The Planner

I had it all planned out.

I got up that morning and thought, “I’ll have my baby in 2 days.” Such a strange feeling to know when you will deliver. My baby was breech so I had a scheduled C-section for that Saturday. The Fam all had their plane tickets. It was all set up. I would work that day, take my CREOG’s the next day, and have our little Genius on Saturday. Then we would discover whether it was a boy or girl. BTW, not finding out the sex of the baby is so much fun... it drives your family CRAZY!

I had clinic that morning and 2 abdominal hysterectomies that afternoon. I remember the first hyst I did that day. She had fat tubes. I'll never forget her tubes. She was a heavier lady, though I’ve certainly operated on much larger women. But she had a thick layer of fat between the leafs of her broad ligament and fat hanging off her tubes. I’ve never seen that before. Anyway it made the case particularly tough.

It was during the first case that the headache started. The scotoma appeared during the second. I stopped by triage before leaving and my blood pressure was through the roof. The urine dip (yes, I dipped my own urine) was a pretty shade a purple protein. Luckily, one of my fellow residents and close friends observed these things and called my doctor. I had no insight. Intellectually I realized I had pre-eclampsia, but it didn’t compute emotionally. It was strange. I was flabbergasted that things would happen out of order. My baby was to be born on Saturday. I realized I was terrified of the “unknown” despite doing 100’s of c-sections my self. Several blubbering phone calls later, they set me up for delivery. The spinal hurt like hell, but my husband and 4 friends who were fellow residents were there to support me. The whole room cheered when he was born. “It’s a boy” some one said. They announced it over the loud speaker on L&D, too. I remember them holding him up over the blue sheet and I thought they should really get him to the warmer. Myself, my husband and my friends (who we’re running various videos cameras) we’re all crying and cheering. It was an amazing day. I had practically lived at this hospital for 3 years, so it was awesome to have my baby among family.

The next day was exhausting, my parents arrived, I was on Magnesium and Demerol. I still managed to nurse and stick with it for 6 months. Half the hospital came by to see me. My nurse finally put up a sign and kicked everyone out (including my mom) so I could get some rest. She’s my hero forever.

Anytime I do a primary c-section, I try to tell a shortened version of this story to my patients. It’s OK to be scared and to cry. Things don’t always go like you planned.

Control Freak and the Uncontrollable Birth

Son on his birthday...already beautiful (if you squint)

At the end of my second trimester, I was a senior resident and transitioned into the chief resident role. Our program had 30 residents, and I took the job seriously. I prided myself on never calling in sick. As I oriented the new first years, I gave them the same advice my chief gave to me on day one: If you are not an inpatient in the hospital, you are not sick.

At 31 and 3 days, I had a headache and was short of breath. I was in clinic, so I took my blood pressure at about 8:30 and it was high. Really high. As a doctor, I knew I should talk to my own doc, who also happened to be my residency director and was down the hall in her own clinic, but I had patients to see.

If you are not an inpatient in the hospital, you are not sick. I pushed through, knowing I could rest during the didactic session planned for all of the afternoon.

During the didactic session, I became more and more dyspneic, even while sitting still. Panic, I thought, and I willed myself to calm down. I wondered if I would make it to the second week of October for my due date. It's because I'm fat, I thought, cursing myself for intentionally getting pregnant at 280 pounds.

After the lectures, at about 4 p.m., I found my residency director and told her about my symptoms and my a.m. blood pressure. She got out a cuff, sat me down and took it herself. It was the same as in the morning, 220/110.

She put me in a wheelchair and sent me directly to L&D for admission, where I insisted on writing my own admission orders. Stupid, but I'm a control freak and writing orders was something I could control.

The BP had improved somewhat by the time I got to L&D. My doc consulted the perinatologist, who examined me and ordered a biophysical profile. The score was OK, so he recommended a 24h urine, a renal consult (I'd been seeing them as an outpatient), steroids and aggressive BP control. No mag yet, he said.

August 7, 2004, day three of my hospitalization. The BPP was not good, and a followup doppler ultrasound showed that the blood that should go toward the fetus was actually reversing flow. The perinatologist recommended c-section right away. I asked if an induced vaginal birth would be OK. He actually laughed.

This is not what I had planned! I'd planned an epidural and a beautiful vaginal, family-centered birth experience in October.

My favorite OB senior resident did the surgery, and my favorite family med intern (who happened to be on her gyn month) assisted. My husband must have wanted to die, but he sat calmly at my side, stroking my face, telling me he loved me.

When they briefly showed him to me on his way to the isolette, he seemed bigger than I'd expected. I heard his cry and immediately gave a prayer of thanks. Two hours later, I got to hold him in the NICU. He was 3 pounds 7 ounces and doing well on a CPAP.

Back in my room, I developed four beat clonus and got to experience mag sulfate for 24 hours. Yeah. That sucked, but now as much as not being able to see my kid.

Husband stayed with the baby and visited me every now and then to give me updates and share the digital camera with me so I could see my boy. Mom and my mother-in-law, both RNs, provided personal bedside nursing.

Another senior resident came and physically removed my beeper from the room. "Don't worry about us," she said. "We'll be fine." And they were...turns out they didn't need me at all. Go figure. And here I thought I was the center of the universe.

I went home on day three, then went with Husband to the NICU every day, 7 a.m. to 9 p.m., to care for our new son. He was a "feeder-grower" and never required intubation, antibiotics or other special care. Sister went nightly at 9 p.m. to rock him and feed him until midnight. On day 28, he came home.

His birth, while scary at the time, is the best thing that ever happened to us. Next week he'll be 4. He's still beautiful... and now bright, funny and well-adjusted. There is not a day of his life that I would trade for anything.

Where on earth is the head?

When I was 37 weeks pregnant with my second child, we moved one block up the street. The day we moved, my husband flew to London on business. This, my friends, is the formula for induction of labour.

I spent the next few days hauling boxes around and arranging furniture. After a particularly vigorous session wrangling the couch, contractions began. When they persisted for six hours, I called Pete and he arranged a hasty return flight.

Once he was back on Canadian soil, the contractions ceased. I was embarrassed and hoped desperately that the baby would arrive in the next day or two so that I might redeem myself. I didn’t want Pete showing up at his office on Monday without something to show for cutting short a business trip.

I was relieved when labour began in earnest two days later. We headed off to bring our three-year-old to our friends' place, but I was so uncomfortable in the car that I asked Pete to swing by the hospital and drop me off first. I brushed off his offers to assist me inside and made my way up from the parking garage alone, stopping every two minutes to lean against the wall and breathe.

Now, I’m a polite and reserved person, even in labour. I don’t scream, I don’t curse and I take pains not to let anyone else feel awkward witnessing my discomfort.

As I made my way into the maternity ward, I ran into my obstetrician, with whom I had an appointment that day.

“I don’t think I’ll be able to come in to see you this morning,” I told him apologetically.

“You have a woman in labour to attend to? No problem, we’ll rebook your appointment,” he replied pleasantly.

“I’m in labour!” I corrected him.

As he looked at me skeptically, a contraction began and I excused myself and turned towards the wall.

He gave me a keen look, murmured, “The leaning-against-the-wall sign,” and directed a nurse to show me into the assessment room.

I lay on the exam table, in the standard light yellow gown, waiting for the resident, with the contractions steadily becoming more painful. When a junior and senior resident stepped into the room, I asked politely for analgesia.

They were busy manoeuvring a portable ultrasound. “First the ultrasound, then the exam, then we talk about pain control,” the senior replied briskly.

“Ultrasound?” I asked.

“We had two undiagnosed breeches recently,” she explained. “So we’re doing an ultrasound on every patient to establish presentation.”

She ran the probe over my belly. With supreme effort, I kept from writhing in agony with each contraction.

She began a detailed teaching session with the junior resident, reviewing the operation of the machine and the findings on the screen. “There’s the back,” she explained, gliding the probe down my abdomen and over my pelvis. Then, muttering to herself, “But where’s the head?”

The nurse, who was clearly annoyed by the residents on my behalf, noted that my face had turned white and announced that she was going to fetch the obstetrician.

“Could I please have something for pain?” I asked the resident again, more urgently.

“Ultrasound, exam, analgesia,” she repeated, irritated. Then, swooping the probe over my belly once more, “Spine . . . where on earth is the head? That is just the strangest thing.” The residents were puzzled.

I knew exactly where the head was. Crowning. I had no choice but to be rude. “I have to push,” I announced. At that moment the obstetrician walked into the room.

“How dilated is she?” he asked the resident.

“I haven’t examined her yet,” she replied. “We can’t find the head on ultrasound.”

He berated the resident for not doing the exam first, and she defended herself, “But I had no idea she was so far along!”

“I’m going to push,” I warned.

As I was rushed down the hall on a gurney to a labour room, I was so focused on refraining from pushing, that it only briefly registered that Pete was not among the mass of people swirling around me. Frankly, that was the least of my concerns at the moment. In Room 11, the nurse fumbled with the nitrous oxide, only to announce that the mask was missing.

Then, with not even a Tylenol on board, with my husband missing in action, I pushed out my son with two pushes.

Ten minutes later, as I lay with a bundled 6-pound 5-ounce Leif Jacob nestled in my arms, blissfully happy that baby and I were well, Pete tentatively entered the room. If he hadn’t said anything, I would have assumed he had had trouble with traffic. But he felt compelled to admit that he had thought he had time to spare, and had popped into Starbucks for a latte and a chocolate croissant as his son entered the world.

(Cross-posted at www.freshmd.com)

Guest Post: Labor lessons

Gosh, it's a long time ago now, children are 25 and soon to be 27. By the time I had kids I had finished a very OB-heavy family practice residency, done lots of deliveries and seen lots of complications including one maternal (with both twin fetal) death. I decided a will was necessary, just in case, and signed the papers the afternoon of the day I went into labor. Both were fairly long labors (19 and 12) hours with pitocin and epidurals when the pit came out, but progressed to normal deliveries. OB was wonderful, she had little kids at the time. What I learned: 1) it's not always good to know what the wiggly lines on the monitor mean, 2) epidurals are wonderful, 3) labor pain hurts and 4) when it's over and you see the baby it's all worth it. Now my daughters are having their own babies and it's interesting to see what has and has not changed.

Best wishes to all,
Mamadoc

Laborious thoughts Parts 1 and 2

Laborious thoughts and sequence of events Part 1:

1) Am I having contractions? It feels like bad menstrual cramps. I don't remember learning that in med school.

2) I'm on call for the gen peds practice right now and in labor.

3) Are these contractions 3 or 6 minutes apart? Perhaps we should go to the hospital now. But first, why don't you set up the pack and play, Honey. OH that's another one .

4) Why am I being escorted to the room where I am told "all the doctors and lawyers" deliver? I am ready for a suite on Kauaii, but alas it is in sunny (hot/humid) Local Hospital room (with a good NICU, which is what every pediatrician wants but wants not to see). Fortunately we find no need for a NICU, no malpractice, no lawsuits.

5) The epidural hasn't helped at all... more anesthetic.

6) Oh (too much). Now I can't feel my legs. Then a quick nap.

7) Wow, having Husband count to 10 while I push actually matters/helps.

8) There she is!

9) Let the breastfeeding begin. (Room in and post "no formula" signs)

10) Life changes as we know it (for the better)...




Laborious thoughts and sequence of events Part 2:

1) What will we do with Precious First, while we're having Second? Grandparents take shifts awaiting the big day.

2) I need two doses of Amp for GBS so no waiting around at home this time.

3) Why is there no air conditioning in this hospital?

4) Wondering why my systolic is down to 75. Glad the senior attending decides to stay.

5) I hope Precious First is enjoying her time with Grandma, french fries and all, and is ready for her whole world to change (for the better, we hope).

6) Were those practice pushes or the real thing?

7) There he is! 9 pounds!

8) Let the breastfeeding begin. (Room in and post "no formula" signs)

9) Get me out of this room so I can see Precious First and introduce her to Second, NOW.


10) Life changes as we know it again (for the better)...

The medical student cervical exam

I was getting desperate while waiting to go into labor for the first time. My due date and come and gone and I certainly wasn’t getting any smaller. In fact, my edema was multiplying every day and looking at my elephant legs was getting a bit old. Not to mention the fact that I had already started taking my maternity leave and stopped working on my actual due date. A date which continued to mock me as each day went by with nary a bloody show or contraction.

When I woke up in the middle of night to feel a steady trickle of fluids, I was ready to do a little jig out of joy. Upon inspection, it looked like what I always imagined amniotic fluid to look like. I mean, I thought I could see vernix. This was a grand slam, home run. Labor and Delivery advised us to come in right away.

By the time we got to the hospital, I had already started having contractions, 7 minutes apart. The senior resident in triage seemed kind and capable. He asked me if it would be alright if a medical student followed me and examined me.

Being a clinician-educator myself, I didn’t hesitate. Sure. Why not? I didn’t work with students at this school (I would feel uncomfortable if there would be any chance of becoming this student’s supervisor someday after him performing a pelvic exam on me).

The resident talked the student through the exam and they took a swab of the fluid to examine it under the microscope together.

A few minutes later, the resident returned and informed us that I was not actually in labor and that we should go home and follow up for our already scheduled appointment in the OB clinic later that day.

WHAT? Was this a joke?

He said that the fluid was not amniotic fluid.

What is it then? I asked in a perturbed way as I lay in a growing pool of amniotic fluid on top of the paper sheet.

It could be urine.

I’m not urinating on myself! It’s amniotic fluid, I’m sure! At this point, I was feeling like I might hurt someone if they didn’t admit me right away and get me some pain meds. Can you check another sample? (said with a wee amount of bitterness)

He looked at me as if dealing with an out-of-hand customer at the customer service counter. Okay, he said, placating me, we’ll check another sample.

This time, he did the procedure and when he came back into the room, his look was sheepish.

Welcome to Labor and Delivery.

Scenes from L&D

Several months prior to birth:
Friend: "I tried to do labor without the epidural, but eventually I gave in and got one."
Me: "Yeah, I know my limitations. I'm getting the epidural the second I walk in the hospital."
Friend: "They may not give it to you right away."
Me: "I don't care. I'll grab an epidural kit out of the supply room as they're wheeling me to my room and put it in myself if I have to."

One month prior to birth:
Me: "Everyone else I know is making a birth plan. Should I make one?"
OB: "Well, what would you put on it?"
Me: "I don't know. I mean, I want all the usual stuff. I want the epidural, whatever. You know, the typical stuff. Whatever everyone else gets, that's what I want."
OB: "I don't think you need to make a birth plan."

Three days prior to birth:
Me: [nudging husband awake] "Hey, I'm having regular contractions, I think."
Husband: "You are??"
Me: "I think so. Sort of. Well, maybe not."
Husband: "Do you want to call the doctor?"
Me: "No, I'm just going to go to work."
Husband: "What???"
Me: "I'll call you if the contractions get worse." [pause] "And maybe you should install the carseat in the car."

Night prior to birth:
I finally crawl into bed, exhausted, after a long day of work.
*pop*
Me: [thinking] "God, I hope that was my water breaking."

Fifteen minutes later:
Me: [typing away on the computer]
Husband: "What are you doing??? We have to leave for the hospital!!"
Me: "Yeah, I just have to finish up and send out some EMG reports I was working on. And I have to call the chief resident."
Husband: "You're leaking amniotic fluid all over the floor!"
Me: "Hold on, I still need to pack my bag."
Husband: "Why didn't you pack before??"
Me: "Don't worry, there's plenty of time. Chill out."

At the hospital:
Nurse: [after exam confirms rupture of membranes] "Well, looks like you're a keeper."
Me: "Can I have an epidural now?"
Nurse: "No, you're only 2cm dilated."
Me: "But... I want it now."
Nurse: "We have to wait until you're 6cm."

Fifteen minutes later:
[Nurse starts running something into my IV]
Me: "What's that?"
Nurse: "Pitocin."
Me: "You're giving me pitocin?! I want an epidural!!"

While I'm in the middle of a contraction, my husband comes to my bedside:
Me: "What's wrong?"
Husband: "I just..."
Me: "What?"
Husband: "I thought you should know that... I have a little headache."
Me: "What??"
Husband: "Well, just... if I seem a little out of it, I just want you to know it's because I kind of have a headache..."
Me: [stares]
Husband: "Okay, I'm going to shut up now."

An hour later:
Nurse: "Your blood pressure is high. We may need to start you on magnesium for pre-eclampsia."
Me: "No! Magnesium can cause pulmonary edema. I don't want it."
Nurse: "You could have a seizure."
Me: "I don't think I have pre-eclampsia. I'm just in pain."
Nurse: "Well, we can try the epidural first and see if that brings down your pressure."
Me: "Yes! Do that!"

Anesthesiologist places my epidural:
Me: [getting nervous] "Hey, if I decide I don't like this, can I ask to turn it off?"
Anesthesiologist: "Yes, you can. But if you do, you will be the first woman ever in all my years of practice who has ever asked to turn it off."
(I didn't ask to turn it off.)

Time to push:
I've let the epidural run down as much as I could stand and I'm feeling every contraction quite strongly. At that point, I followed the advice of my blogger hero Michelle Au and pushed like I was having the biggest BM of my life. And little me pushed that 8 pound baby out in 30 minutes.
OB: "Wow, she was crying before she even came out."
Me: "Uh oh, we're in for it, aren't we?"

The Ob/Gyn, on the other side of the Stirrups

In the summer of 2003, my husband and I finally decided to dip our toes into the pool of being potential parents. A thought, that had up until that time been more terrifying and unpalatable to both of us than we would care to admit today. You see, I was one of *those* people. I had oft proclaimed, loudly, that I was *never* going to have children. Kids were too much work, I was too selfish, and to be quite honest, it was too scary for me, the perfectionist, to comprehend messing up another human being's life. Some of that changed when I met Mr. Whoo. We were so happy and he was so awesome, he made me want to give him the chance at being the great dad I knew he was going to be. The rest of the transformation occurred as I rose through the ranks of my Ob/Gyn residency. It was babies, babies, babies, day and night. I saw the great joys and the every day miracle that was childbirth. I was also devastated with the losses, and frightened to see how badly birth can go in a blink of an eye. Perhaps, most of all, my heart ached along with the infertility patients that I followed along the way. Women and men who wanted nothing in the world more than a healthy, happy pregnancy and take home baby. I saw the struggles, and as I saw their fight for a family, I knew that I wanted a family more than I had realized. In many ways, it was my profession that made me want to have children.

We were fortunate that we didn't have to try very long to conceive. The pregnancy was fraught with complications, some of which I have alluded to in previous posts and comments. To put it succinctly, hyperemesis (puking every day until 37 weeks, living on Zofran), symphysis pubis diastasis (hobbling around as though someone had kicked me in the crotch with a steel toed boot), pre-term contractions (which got me pulled from work, made a pariah amongst my peers, and changed my whole residency experience), depression (a side effect of how horribly I was treated by my fellow residents), and last, but certainly not least, preeclampsia. The last on the list was the reason that my physician made the decision to induce labor. We went to the office on Tuesday with no expectations or concerns, but were greeted with a BP of 160/90, 2 + protein on urine dip. "They are going to induce me," I told my husband. I knew they would, because that's what they would have told me to do for any of my patients presenting the same way. Induction was set for midnight that evening, and away we went to make preparations.

Luckily for me, I was only a mild preeclamptic, so I didn't have to experience the joy that was Magnesium Sulfate. I also was a healthy 39 plus weeks, so not a lot of worry about my baby girl's maturity. I did worry about what every pregnant woman at term worries about...how am I going to get that baby out?? Unlike many mothers, however, I had free access to an ultrasound machine, which I used often. I had been doing fetal growth measurements during down times on our triage ultrasound, and was consistently getting an estimated weight of 8 pounds. Despite my, er, generous "birthing hips," this freaked me out, just a little, because I am all of 5 feet 2 inches, and at term, was as big around as I was tall. There had been several times that I had contemplated having an elective cesarean section, but had finally decided against it due to the small amount of recuperation time that I would have afterwards. My physician was concerned because I was only fingertip, thick, and high (unfavorable cervix for induction) and said that I might be heading for a C-section regardless. I was at peace with that, and went into the whole process almost expecting it.

That evening we took my last belly pictures out in the yard amongst the flowers, packed up the car, and drove in, listening to Gavin Degraw, knowing the next time we were in the car together, we'd be a whole different family. It was weird to deliver in the hospital in which you work. We parked our car in the employee parking garage, and I walked the familiar path to the hospital as I had for the last 2.5 years as a resident, only this time I was the patient and not the doctor. I had already picked out the room that I wanted (lucky number 11) and the nurses had reserved it for me. I know that for other midnight inductions, they would make them sit out in the waiting room until the stroke of midnight, but Mr. Whoo and I walked right in and got sent straight back at a quarter to midnight. One of my favorite night nurses, Julie, had me, and we made nervous chit chat as she did my assessment, drew blood, and started the IV. None of the night residents came to visit (they were the chiefs that were pissed off that they had to cover extra nights of call since I had the audacity to become pregnant), nor did I expect them to. Julie gave me an Ambien, and placed misoprostol around 12:30, turned down the lights and suggested that I sleep. I didn't sleep, though. It was just bizarre and twisted to be the one in the bed instead of the doctor at the nurses station. I could see my monitor comfortably from the bed, and instead of sleeping I passed the time watching for contractions and CindyLou's happy, reactive tracing.

Another misoprostol was placed at 3:30 am, and another at 7:30 am, this time by my physician, who informed me that for all the medicine overnight, I was still only 1cm, and my pressure had been steadily climbing throughout the night. I later learned he was debating magnesium at that point, but was afraid that I would never reach a labor pattern if he added it (magnesium is also a tocolytic, a medicine used to stop contractions) and hinting at a surgical heading to the nurses.

I was already steeling myself for a surgery, but I also knew that I really wasn't hurting all that badly, despite contractions every 2-3 minutes per the toco. Just before noon, I had to use the bathroom, and I knew my nurse was on lunch break. So, rather than bother anybody and be another whiny, needy patient, I unhooked myself from the monitor, stopped the tracing, and hauled myself and IV pole to the bathroom. After using the bathroom, I was surprised that there was still a constant trickling, well after I knew my bladder was empty. It seemed to stop, so I stood up, and proceeded to flood my slippers and the bathroom floor. I schlep-squished my way back to the bed, turned on the monitors, and reluctantly used the call button to let them know about the SROM. They were, of course, thrilled, and started pitocin right away. I was still 1 cm, but now 80 percent effaced (woo, a half a centimeter in 12 hours!).

Almost instantaneously, the contractions felt different, more intense, once the membranes were ruptured. I found that I had to breathe through them, and I started to feel like a big baby because I was only 1 cm and hurting way more than I thought I should. I had heard great things about "the Stadol" from patients and residents alike, so I told Rebecca, my day nurse, "I'd like to try the Stadol." Much like ordering a drink from a bartender, Mr. Whoo later informed me. Obviously, that was a pretty close estimation, because the evolution of feelings went something like this, following the infusion of Stadol: "I don't feel anything." 30 seconds later "Ooooh, now I feel it." 30 seconds later "Ok, now I'm starting to get a buzz." 2 minutes later "Yep, I am hammered, woo hoo!" 5 minutes later "Oh, I don't feel so good. The room is spinning." 5 minutes later "I have a headache." So, yes, I went from buzzed to drunk to hungover in a matter of 10-15 minutes, but the pain wasn't any better, I was just less in control of it than I had been. Around this point, I found myself closing my eyes and focusing my energy inward. Mr. Whoo says there was also a lot of moaning, but I don't remember it that way. Next was the comedy of errors that was getting my epidural. The residents were in a day conference, so the attendings were (unfortunately for me) placing the epidurals. Long story short, my back was kyphotic (very curved) and 2 different attendings tried, and failed, to get a complete block.

My cervix decided that this was the time to get the hang of dilating and I went from 1 cm to 4 cm in one hour, then from 4 to 9 cm in the next 4 hours. Despite the anesthesiologists' best efforts, I. Felt. Everything. Me, the person who signed up for the epidural at 1cm, and never ever wanted to do childbirth without the aid of drugs, was feeling everything. Then, for extra fun, I stalled out at 9 cm for about 1.5 hours. All I wanted to do was push, but I couldn't. By this time, Mr. Whoo's mother was in the room, and I had several different visitors. I don't think I even opened my eyes to look at them. Around 6 o'clock, the anesthesia residents got out of conference, and one of the first years came in and tried to rebolus the epidural for me since I was so miserable...and it worked! I loved that man, and told him so every time I saw him thereafter. After that sweet relief, all I wanted to do was sleep, and, for 20 minutes, I did (likely relaxing enough to let my body completely dilate and for CindyLou to descend).

At 6:30 pm (near shift change, of course) my OB checked and told me it was time to push now. (HA! I wanted to push for 2 hours! Now I want to sleep and it is time to freaking push!) I grudgingly complied, and found that pushing can be the very best part of labor. Due to many days and nights of "pushing with" patients (and giving myself hemorrhoids in the process) I knew exactly how to push. CindyLou was born after just 20 minutes of pushing and a 2nd degree laceration, at 6:56 pm. She weighed a whopping 7 pounds, 4 oz, and she was 19 inches long. She was every bit as perfect as I hoped she would be.

There must have been 30 people in that room, and I didn't care. Two of my OB doctors (day shift and night shift) were there, 2 scrub techs were there, a couple of residents and nursing students were there, the whole peds team was there, and 2 nurses were at my side. Everyone that I worked with and their mother (including Mr. Whoo's mother) was in there, staring at my business, and I didn't care one little bit. It was another surreal moment as they placed that slippery, writhing being on my chest. She was mine. She was ok. She was pink, wriggly, and breathing. (I gave her a one minute APGAR of 9 in my head.) I knew that things would never be the same. And they weren't. They were better.

So, what did I learn as a physician going through pregnancy, labor, and delivery?

1. Knowledge is power. The more you know, the more you may worry, but ultimately it is better to be knowledgeable about your body.

2. Ultrasounds are not incredibly accurate in the 3rd trimester

3. "The Stadol" is good for exactly 5 minutes, otherwise it sucks for pain control

4. Epidurals don't always work, so you better have another coping mechanism in mind as a backup.

5. Contractions can hurt, even if you aren't very dilated.

6. Contractions hurt more after the water breaks, so be kind and don't break water early if you don't have to do it.

7. People can be really mean to pregnant women for a myriad of reasons. Ignore them.

8. Long inductions can be successful vaginal deliveries.

9. Never underestimate the female body's ability to overcome obstacles in labor.

10. At the moment of birth, you won't care who's looking at you.

I use these caveats in my OB practice every single day. I'd like to think it makes me a more aware physician, but I guess you'd have to ask my patients. Thanks for letting me share my (very long) story with you. I'd love to hear what lessons you learned going through pregnancy, labor, and delivery.

Love's labor

The day that my first son was due was also the day that Princess Diana died in France, August 31, 1997. I spent the next week on bed rest crying about the loss of a mother to Diana’s two sons, Will and Harry. Little did I know that I was getting ready to birth my own heir (and later a spare). We had purposefully left the gender of our first offspring a secret to get me through the birthing process. Labor finally came during Diana’s funeral and I got to writhe during the whole ceremony in a hospital bed while the unsynchronized and unorganized contractions did little except flip this baby to the occiput anterior position.

At the time we lived in BFE and I was a pediatrician in a small group practice. I had witnessed several hundred deliveries in pediatric residency. I hadn’t really given a lot of thought to how I wanted my own delivery to go, but I knew some things I didn’t want. I didn’t want a cesarean section. I have a child-bearing pelvis for a reason. I also didn’t want to be in pain if I could help it. I had seen women cuss at their husbands, scratch, spit, and refuse to push. I didn’t want to be out of control like that. I believe in good drugs and an epidural was part of that picture. I knew I was no hero, and would deliver in the same hospital that I worked in. If the hospital was good enough for the parents of my patients it was good enough for me, but I also wanted to keep it together as best I could. First and last I wanted this baby to be healthy.

Part of my initial Obstetric packet was information about writing a birth plan. At the time, I was pretty naive to how detailed some women write their birth plans. Not many mothers had or followed birth plans in the inner city hospital of my residency training. Those that wrote birth plans in BFE probably delivered at the teaching hospital an hour away. Also knowing what I knew about babies and deliveries, I realized that anything could happen, and it was important not to get too attached to my own agenda. I wasn’t the only one in the picture. That philosophy has paid dividends many times over in my life as a mother. The one thing that I really wanted to experience as a new mom was breastfeeding. All of my exposures to hundreds and thousands of germs would pay off by passing on my immune experience to my new son. That was the least elastic part of any plans I had for this delivery. I would breastfeed, end of discussion.

This baby provided me with excellent lessons in flexibility. The epidural didn’t touch the back labor, but it did a great job of turning my legs to jello. At one point my labor nurse (bless her) had me on all fours trying to shake my OP baby loose so I could deliver him. I lost my balance on the jello legs and tried to fall out of the bed. My quick thinking nurse and husband caught me before I went over the rail and pulled out all of my tubes – IV, Foley, and epidural. More lessons came quickly when my mom appeared at 10 cm. My husband and I had made a tentative pact that the delivery would be just us and any needed hospital personnel. At 10 cm and needing to push, I could have cared less if the whole high school football team had been in the delivery room. With the first push, I quickly caught on that the pain and pressure would be over if I could put the pedal to the metal. While Number One Son didn’t flip out of the sunny side up position, I was able to avoid the c-section and delivered his 8lb 6 oz body with lots of pushing and a third degree tear. He appeared with a lusty, masculine cry, and twelve hours of labor melted away into a memory. We had a son!

Breastfeeding humbled me. Latching on made Will claustrophobic – a personality trait he still has to this day. He would cry every time I tried to make him try which made me a teary mess. Next he turned pumpkin yellow with jaundice, and got sleepy enough that he didn’t care much if he was hungry. My ample chest apparatus (to go along with the child bearing hips) missed all the milk-making memos. Maybe all of the tears from the death of Princess Diana soured the whole system. And with no lactation consultant in BFE, I was up the creek. We tried silastic tubing and supplemental nursing systems, cup feeding and so much fenugreek that I smelled like a pickle. After three weeks of trying to starve my sweet baby boy, my husband kidnapped us both and took us out of town so I wouldn’t have to look at my new breast pump and cry anymore. A formula family was born! A more empathetic pediatrician to new mothers was also born as I labored to learn and relearn my lessons of flexibility.

P.S. Harry’s birth was much easier.

My Insanity

This post is a direct response to RH+'s post last week about her sanity. I commented that I'm jealous, but I think this sentiment deserves its own post.

I am jealous, jealous, jealous. Green with envy. Coveting my neighbor's stay-at-home-dad of a husband.

When we were engaged, Husband told me he would stay home when the children came. Then Son came, and Husband backed out of the deal, claiming his ego couldn't handle it. I, and everyone who knows Husband, agrees he would be the best stay-at-home dad ever (no intended disrespect to Mr. RH+). He loves to cook, he loves to engage Son with learning experiences, he loves to plan little outings with him, he prides himself on countering my general messiness with some order in the home.

When we discuss this, and we often do, he tells me that since Son is enrolled in preschool, he doesn't see the use of staying home. Au contraire, mon fraire. Here are my arguments:

1. You do all the shopping anyway.
   
2. You keep the house running anyway.
   
3. You are Son's primary parent.
4. We hope to soon add a second child.
   
5. Even though Son goes to school, the chaos of his before and after school life when you travel is bad for him.
   
6. We can easily adapt to having one salary.
7. You will keep the church, which is your true vocation.
   
8. How about stay-at-home doctoral candidate? Does that sound better for your ego?
9. I can't go on like this.
10. I'm slowly going insane.
    

So, while it seems all about me (like everything else in my life), don't you agree he'd be happier being a stay-at-home dad/husband?

I'm fairly sure he doesn't read this blog. But just in case, could y'all leave some encouragement for him in the comment section? Pretty please?

Yep, I'm selfish. I know, I know.

Reverse penis envy

“Mommy WHY???Why don’t you have a penis?”

Because I’m a girl.

“Don’t you want one?"

No

“Maybe you could buy one?"

No

“If you eat real healthy could you grow one?"

No

“Maybe you can pray for one”

“I DON’T WANT A PENIS!!!”

This was a recent conversation I had with my 4 year old son. Luckily it did not occur in the middle of Target. Despite being potty trained for over a year, and being trained mainly by dad he only recently began peeing standing up. He was extremely skeptical about peeing standing up… but once he figured it out, of course it’s the best thing since chocolate milk. He recently became concerned about why I don’t pee standing up. It truly bothers him. I explained that girls don’t have a penis so we have to sit down. At some point later in life I will explain girl anatomy, but for now I think this should suffice, plus I want to avoid the whole Kindergarten Cop quote as long as possible (MY MOM ‘s a gynecologist and she says boy’s have a penis and girls have a ….) However, he remains quite the penis evangelist. He just thinks I’m missing out on the world since I don’t have a penis.

I have to admit potty training has to be one of the hardest things we’ve done in parenting. He was just not interested. Despite his genius, it bothered him, not at all, to poop on himself. However, I became obsessed with it. After one particularly awful weekend of “training” I had a patient come in saying “Oh, one day my son/daughter just ‘decided ‘on their own at the age of 2 to be potty trained and never had one accident after that”

I actually shot her. I’m writing this from jail.

I’m also prone to exaggeration.

Guest Post: Bad Mommy Days

When the phone rang at 2 am with a first time mom in what sounded like pretty good labor, I wasn't grumpy. They didn't want me to come to the house yet, but I know from experience that they will call back within an hour, ready for me to come.

So I luxuriate in the hour I have to get everything ready for my 5.5-year-old's day. Lunch is packed-- I add a couple of special treats because I know she does not love the days when I disappear without warning. I make her a red paper heart, covered with "I love you" and hearts so she knows how much I think of her, even when I'm not here. I write Spouse/Daddy a note, explaining the lunch, the clothes, the everything, since he only does mornings with Daughter when I am on a birth.

Before 6 am, Daddy takes her to Friend's house and leaves for work himself. Friend will get her up and dressed and fed, take her to camp, pick her up at the end of the day, take her to swimming, and Daddy will collect an exhausted Daughter after her lesson. Daughter will not really see her parents today, and though she will be a trooper-- she has been her whole life-- it will take a toll and she will not enjoy it.

The phone rings again after 50 minutes, and I am off to the birth. Though this is her first baby, she is fast and the baby is born at home, healthy and beautiful, after a 6.5 hour labor. Then the guilt starts to creep, because now I have choices to make. Do I cancel my day at the office, sleep a bit, pick Daughter up from camp? It would certainly mitigate her unhappiness at being foisted off on Friend in the wee hours. Do I leave her at camp, see my afternoon's patients, and then race to get to her before swimming? This leaves me with no sleep, but meeting all of my responsibilities. Of course, I choose the latter.

I race to pick up dinner from one of her favorite restaurants (a bribe, perhaps, to compensate for not being there this morning, for leaving her having to wonder when she will see Mommy again, because sometimes it is not for a day or more, and she never knows). I scramble to meet her at the park so she can eat before swimming. I agree to go in for family swim after her lesson. During family swim, the fatigue hits me. I slam into the wall of tiredness, and I feel the patience run out of my body. Fortunately Spouse arrives to help, but it is still Mommy who reads the bedtime stories, almost falling asleep myself half way through. I collapse into bed and sleep until morning. I wake still tired from the night without sleep, but feeling better.

Then it starts. If there were a soundtrack, it would be the JAWS theme, as the sharks are circling.

Daughter wakes whiny. Her first question, as on most days, is "who is going to pick me up?" It comes in a whine, and irritates me instantly. I calmly tell her that I will pick her up, but that Friend is taking her girls to Something Fun and she has offered to pick up Daughter and take her too, if she wants to go. It is not the distraction I hope for, however, as the prospect of a decision prompts more whining. Hideous wailing as she says "I can't decide!" and seems genuinely miserable about it. I have little sympathy, though, for this child wailing about the misery of deciding between two things she wants to do.

I go shower, to get away. As soon as I turn off the shower I hear yet more howling. Desperate, miserable, whiny howling. I don't dry off, but run into the room dripping to see what horror has befallen her. She is sitting on the floor. Paper is wrapped around her ankle, one of her favorite games, making a "cast." She has the medical tape and kid scissors, but she doesn't want the white tape, she wants plain scotch tape. She won't get up to look for it, and is howling because she can't make the "cast" stay on.

I am livid. For whatever reason, this makes me so angry with her. I am tired, still, and low on patience, and having her howling about something that is, to me, trivial, whining as if it is a Huge Tragedy, well, I can't take it. I go back and dry off, get some clothes on, and come back. I find the tape, but she is too distraught to use it. She is just crying and crying, over the stupid paper cast that she doesn't need.

Suddenly, I am the Bitch Mommy. I am yelling at her, as I tape the paper around her ankle. I don't know even what I yelled, though I know I ended by yelling how much I hate being the Mean Mommy, and the Angry Mommy, and that I hate myself for yelling at her, but that having her whining about something so unimportant made me very angry. I tell her that she does not deserve the Mean Mommy. Then I put myself in a time out, heading to the front porch to look at the paper for 5 minutes until I am calm.

I apologized. I hugged her. She wasn't crying or whining any more, and didn't for the rest of the morning as we got ready for camp. When I went to pick her up she told me that she had made something for me. She went to her cubby and got a piece of paper, on which she had drawn an enormous heart that she had colored in red. I think she was saying that she forgave me, maybe.

I still feel like a terrible, horrible mother.

Lizard is a Naturopathic Physician and midwife in the Pacific northwest.

Comfort

I had to tell a Mom that her son died. He was a grown young man, victim of a freak accident, out of the blue.

From what I could glean, Mom was essentially all alone. It was, or had been, a positive time in their lives. Her son was soon to be married, and they had been enjoying the pre-wedding whirl.

She knew, as they all do when we place the family in the ‘Chapel,’ that it was bad.

I tried to do all the things we are taught about communicating bad news to families – get down on eye level, use unmistakeable words and simple sentences, hold a hand, give her time.

Her sobs, though inaudible, were heartwrenching.

I told her that I don’t think he felt any pain, or even knew what happened. It was true this time, although sometimes I say it even when I’m not sure. It’s the only comfort I can offer.

Announcing Topic Day: Labor & Delivery

On, Wednesday, July 30, Mothers in Medicine will be holding our first Topic Day. On that day, we'll be featuring posts all relating to our own experiences as physician-mothers giving birth. We would like to invite our readers to submit their stories as well: Were you a bad patient? Did a colleague deliver your baby? Did you help deliver your baby? Did you know too much for your own good? Did you bring in the latest literature findings to support you getting an early epidural?

Send your stories to mothersinmedicine (at) gmail (dot) com by Monday, July 28 to be included.

We'll be posting throughout the day next Wednesday so stay tuned!

As always, thank you for being part of this community.

When I retire perhaps I'll be a daycare provider

I took a vacation day from pediatric practice a few weeks ago to accompany Just Four (and 15 classmates) on a trip to the National Zoo. My daughter and I (and 15 classmates) walked that whole zoo up and down. Fun but tiring, and I still crazily fantasize that someday when I retire from general pediatrics I'll be a day care provider. Assuming I receive the proper training, of course.

But for some time until I retire, I'll be a pediatrician and have children in day care, so I will struggle with various options when it comes to hiding or sharing a vast array of pediatric (and other) medical knowledge. Do I let them know that teething isn't the cause of the 102 fever? That one doesn't actually get a cold from being in the cold. That diarrhea is usually contagious but eczema is not.

Do I show them my technique for reducing a nursemaid's elbow? Perhaps it's best to just do it myself--on my own child yes (twice) but on a classmate? I'll presumably gain some cred in the process, as an unintended but welcome side effect. That cred can go a long way when I assure them that my child who was sent home yesterday vomiting raisins is actually fine today and able to stay and play.

And in preparation for my retirement position, I'll take note of all that I can learn from the day care providers. How do they get my children to nap, everyday, let alone getting 12 toddlers to do so, at the same time, under one roof? When I asked, they laughed it off. And when I asked again --it wasn't a rhetorical question-- they explained, "Oh we just tell them it's nap time and turn down the lights and read a quiet story." Ah, that's how they do it. I'll think I'll try that at home.

Someday I'll "retire" and become a day care provider so I can continue the teaching and learning cycle. I'll greet the parents in the morning and late afternoon with information about their precious children. I'll read books to my class, tell them stories, and hear their tales. I'll feed them healthy food. There will be no potato chips in my day care. They learn not to bite each other. I'll teach 16 preschoolers to skip and 12 toddlers to jump. They'll all know how to dance. I'll be tired, but I'll nap too. When I retire.