be safe this summer ladies.

Summer is in full swing and yesterday was the first Sunday of the Pastor’s sabbatical. For as long as we have been married he has worked at our church.  16 years.  For most of those years his weekly day off was my longest day of the work IMG_3307week.  And my days off after being on call overnight were the Pastor’s busiest days.  So this year he gets to take two months off to rest, recover and reconnect.  For the next 8 weeks, Sundays and postcall days will be filled with brunch, swimming, day trips and, hopefully, some other fun adventures as a family.

 

In honor of all things summer….here are the gynecologist’s list of “Summer DOs and DON’Ts”

DON’T go without sunscreen.  Especially you pregnant ladies.  I know what you’re thinking…”sunscreen is for people who look like you and those red headed kids of yours.” WRONG.  Sunscreen is for everyone.  That is, everyone who doesn’t want to get skin cancer or look super wrinkly when they are old.  And, sunscreen is for year round. I thought my dermatologist was going to whack me when she found out I wasn’t using a moisturizer with SPF.  Don’t worry, I do now…every day…I’d like to avoid looking 100 before I retire.  I used to know someone who used hand sanitizer on her kids like a zillion times every day but then those same kids would swim for hours at the peak times of sun exposure turning brown, brown, brown all summer.  Just because you don’t get red doesn’t mean your skin is safe friends.  Tips for everyone: use broad spectrum SPF 30 or higher; reapply every 2 hours; find water resistant formulas.  Pregnant women should opt for oil free (your skin is more prone to break out) and opt for a lotion instead of a spray.  (Never spray anyone’s face…esp your kids and remember sprays make it easier to miss spots!).   And when your baby comes ask your pediatrician about how best to protect that brand new skin from the sun.

DO wear your seatbelt. This seems obvious to me. The Pastor and I took a recent road trip and you’ll be surprised to know that Missouri and Indiana will tell you how many people died in auto accidents that month.  The 10 year old reading road signs alerted us to the number.  Ouch.   But lots of pregnant patients choose to go without.  I wish you could hear how loud I am screaming this at you.  Pregnant ladies!  For the love of all things including your baby!!!  Wear your seatbelts!  Put the lap belt UNDER your belly and the shoulder strap across your chest. Auto accidents are a leading cause of death for pregnant women.  Your uterus, placenta and fetus were not made to sustain direct or indirect trauma from an accident and you can imagine the increase in magnitude if you are thrown from your vehicle because you failed to wear your seatbelt. A quick search of the CDC will tell you that those without a seatbelt are 30 times more likely to be ejected from the car during an accident and 3 out of 4 ejected individuals will die as a result of their injuries.  So let’s all just buckle up, ok friends?

DO use insect repellent. I have no problem with blood and guts.  You know this.  If you follow along, you also know that I think bugs are the worst!  Actual conversation with my dad.  Me: Dad, killed a spider outside.  It was like the size of my face, I promise.  Pastor is out of town, can you spray my house?  Dad:  If it was outside it was one of the good ones. His death will be on your conscience.  But yes, I will come and spray.  (end scene). However, as terrifying as spiders are…mosquitos carry all sorts of diseases including zika virus and west nile virus.  Then there are ticks.  I don’t know if you have seen a tick up close but this image is not for the faint of heart.  Tick borne disease are the ones you learn about in med school that have the cool names and then you learn about them and are terrified. Tips: Use your bug spray with DEET (even you pregnant ladies), cover exposed skin, avoid standing water and if you are out doing some crazy activity like sleeping in a tent (no thank you) make sure you check your skin for ticks.

DON’T overgroom. I’m not even sure overgrooming is a word.  But for today I am making it one and asking you ladies, pregnant or not, to stop it.  Summer is a hassle. Shaving your legs and armpits all the time, wearing a swimsuit; I get it. But let’s not go overboard. Not only are there literally THOUSANDS of grooming related injuries each year, the good Lord gave you pubic hair for a reason.  (I know, commence freaking out that the gynecologist said pubic hair in her blog.  Resume reading when over freak out moment).  And while none of us know the exact reason, it is most likely to keep dirt and other stuff out of your vagina and to reduce irritation of that sensitive skin.  So be swimsuit ready.  But overdoing can result in lots of skin irritation or even infection.

So there you have it.  Summer safety tips from the gyno.  Oh, and in case you were thinking about blowing off one of your fingers with fireworks, here’s an OBGYN joke just for you…

Screen Shot 2017-07-10 at 9.37.38 PM

Summer of fun.

I’m back!  It has been almost a month since my last post.  In that month I have felt TERRIBLE.  At one point I thought I would never stop coughing and that I would get diabetes from my cough drop consumption.  Don’t worry, I switched to sugar free. But now I’m about 89.32% better and have found the time to write again.  (Which is code for I can stay up late and finish things).  And so here we are.

It’s July.  For most people July represents the middle of summer.  Vacations, lazy days at the pool, short days at work.  In medicine July means ALL THINGS NEW.  As in, all the things are new.  New medical students, new residents, new academic calendar. You see, I work in Academic Medicine.  Which means that I work at an institution of higher education where we train medical students to become competent, caring, ethical physicians and then train physicians to be competent, caring, ethical specialists in their chosen field.  Sounds easy, right?  I will try to briefly introduce you to what the summer is like for those of us insane enough to participate in this great adventure of education.

Medical school is 4 years long and almost exclusively completed after a 4 year bachelors degree is achieved.  In the first 2 years students spend their time in courses learning anatomy, the complexity of each organ system, structure and function of the body and its cellular systems, human behavior and so much more.  They come to class, have small group sessions, read and read and read some more and take lots of exams. By the time they come to the third year they are ready to see how all they have learned can be applied to patients and diseases.  Oh and did I mention they also have to pass the first step of the 3 step medical licensing exam? In the third year our goal for a student is to be able to see a patient, perform a basic physical exam and formulate a differential diagnosis.  What that means is that when they hear a patient’s symptoms and know their history they can think about what diseases they are most at risk for and/or most likely to screen-shot-2016-09-25-at-6-38-08-pmhave.  Only once that is done can we as physicians begin to think about what testing and treatment someone might need.  Medical students don’t do anything without supervision.  Sometimes patients will ask if the medical student is going to perform their surgery or deliver their baby. I can answer that with a resounding NOPE.  What a medical student will do is participate in surgery with me where they will learn the hows and whys of that specific operation.  They will check on their patients in the hospital and often serve as an extra set of eyes, ears or hands to ensure that all the details of patient care are taken care of and nothing has been overlooked in making sure a patient makes it safely home after surgery.  In addition to all this they are reading, going to lectures, taking tests.  At the end of the third year we hope they have chosen a medical specialty.  Then they spend their final year of medical school spending time in areas of their chosen specialty, as well as interviewing for a residency position and taking the 2nd step of that all important medical licensing exam series I mentioned before.  So for me July means making sure the syllabus and all the materials our third year students get and use equip them to learn the most they can about women’s health.  It means making sure those 4th year students who have chosen my specialty have the best opportunity to train at the institution of their choice for residency.

July 1st also marks the day new residents begin their training.  These are recent medical school graduates who have gone through a very competitive process to secure their place in a residency training program. Each specialty in medicine has residency training and each specialty decides how long that training should be.  For example, OBGYN residency is four years long. Neurosurgery residency is 8 years long. (no thank you).  While in residency these doctors have a focused practice where they will learn every detail of their specialty.  It is also the time when they are trained to perform procedures and surgeries all in a supervised environment with the intention that at the end of their training they are ready to care for patients on their own.  In the meantime they will spend up to 80 hours a week in the hospital where supervising physicians will provide guidance, support, and supervision.  At the end of those at least 10,000 hours of training each resident will decide whether to join a private or hospital based practice, become an academic physician or, for those brave/crazy enough, pursue even more specialized training.  One of our greatest privileges is to watch those residents graduate and know that they will provide the kind of patient care you would want for your family and friends.

It’s a long journey into a career as a physician.  It can consume more than a decade of your life.  In truth the learning never stops.  For those in OBGYN we have a written and then oral exam to become board certified after residency.  To maintain our specialty certification we read articles and participate in chart reviews each year. We attend conferences and workshops to learn from one another and maintain and improve our skills. We read articles and travel across the country and collaborate to find the most effective ways to educate our medical students and residents.

Screen Shot 2016-09-26 at 12.16.46 PM

So if you see a medical student or a resident, give them a hug or a handshake or a pat on the back.  During a time when there is a lot of uncertainty in healthcare they have made the choice to commit their lives to the service of others. When no one can seem to agree who should have access to care or who will pay for that care, they have dedicated a huge chunk of their lives to ensure that care is available no matter what.  Now if you’ll excuse me, it’s July so I need a nap.

 

i’m not making this up.

A few months ago I was at dinner with friends, one of whom is pregnant. The topic of drinking in pregnancy came up and someone said to me “you just tell people not to drink because you have to, not because it’s really harmful right?” Um…I made that face. That face.  You know. The one where  you couldn’t possibly believe what you heard but, then again, you heard it.  The one where your eyes are big and your mouth is open.  After a pregnant pause I explained that national and now international guidelines recommend against any alcohol consumption in pregnancy.

IMG_5022

We all know that you are never going to get more unsolicited advice than when you are pregnant.  What you can and can’t do including raising your hands above your head or eating peanut butter in the bathtub along with what your baby should eat, how it should sleep, what it should wear and where it should go to college.  Whether or not you should consume alcohol in pregnancy is among that advice.  However, drinking during pregnancy is the most common cause of birth defects in the United States. And while these birth defects are most common among women who drink heavily, there is no safe amount of alcohol consumption for a pregnant woman.  Alcohol use in pregnancy is associated with low birth weight, preterm birth, birth defects and developmental disabilities.  Health care providers are encouraged to discuss discontinuation of alcohol for women who are pregnant and those actively trying to get pregnant.

April is alcohol awareness month. It was established to reduce the stigma associated with alcoholism and increase awareness about alcohol abuse, treatment and recovery.  Excess alcohol use costs the United States about 250 billion dollars per year.  About 5 billion of that is related to alcohol use in pregnancy.  So no, as gynecologists we don’t just say these things because “we have to.”  We say them because we truly want the best outcome for you and your baby.  So if you should find yourself with two lines on that pregnancy test, congrats!  It’s time to take a break from alcohol.  If you are already pregnant and haven’t stopped drinking I would urge you to do so now.  You can tell your grandmother, your best friend, the lady at the grocery store and the dude at the gas station that you are doing everything you can to take care of yourself and your baby.  Really.  We’re not making this up.

the original birth story.

Today is the day we’ve been waiting for.  Or at least I’ve been waiting for.  We light the Christ candle.  It is now Christmas. I don’t know about you but I’ve been anxious for the last 4 weeks.  Anxious to sing the songs and hear the stories and remember the day we celebrate the birth of Jesus.  It is difficult for me to comprehend that God’s people waited through 400 years of silence for the birth of Christ.  I would bet that every time a new king img_2375was crowned, a new country invaded, a new period of famine or drought came they imagined that they were on the cusp of a conquering savior’s presence.  And then they got a baby.

It is easy for us to look at the coming of Christ as a baby and make that sound we do when we see a newborn.  You know it.  You’re probably making it right now. It is the sound of seeing something that makes us feel warm and fuzzy inside.  This is my usual response to Christmas.  The warm and fuzzy feeling of  watching the Nativity.  But today I am keenly reminded of the frailty of Christ’s birth.  In a striking move unanticipated by anyone looking for it, God chose to manifest himself on our planet as the most vulnerable citizen.  We don’t have record of the maternal and infant mortality rate at the time of Jesus’ birth but we can extrapolate based on the earliest data we have available.  Based on early European data and other modeling statistical methods the best estimate is that 300 out of every 1000 infants born did not live to celebrate their first birthday.  That’s 30% of babies.  And their mothers.  Infection and hemorrhage were common.  As many as 25 of every 1000 women died as a result of childbirth during the time that Mary was pregnant.  Compare that to giving birth in the US today where, on average, the infant mortality rate is 6 per 1000 and the maternal mortality rate is about 10 per 100,000 women.  When Mary accepted the call of God to be the mother of Christ not only did she accept the shame that comes with being an unwed mother in her culture but I’m sure she knew the reality that many mothers and children did not survive childbirth in her community.

It begs the question: why would God choose to become incarnate in the form of a baby? Why choose the most vulnerable way to represent himself?  Maybe it’s because God enjoys being subversive.  Maybe it’s because no one would have suspected to look in a crib for a savior.  I suspect it is because He is in the business of demonstrating to us that power
is made perfect in weakness; that He is best found amongst those who cannot raise arms to protect themselves.  Dare I say that if you find yourself looking for a savior who will increase your power, fill your pockets and take down your enemies…don’t look inside the manger.  Don’t look in the manger for a savior who will use violence and destruction and despair to bring about his kingdom.

This Saimg_0059-jpgvior, the one found in the manger, will be “God with you” always.  He will be with you despite your words, despite your actions, despite your selfishness. This Savior will stay close to you in your suffering, He will walk with you in your grief and He will rejoice with you when life is gracious and good.  He will ask you to forgive your enemies, to lay down your weapons, to love someone who believes differently than you.  He is the Light that breaks through all darkness.  If you dare to look for the savior born long ago out in the cold this is what you will find.

May your life be filled with the light of Christ as today we light the Christ candle.  May every baby you see today and this week remind you of the vulnerable God who sends a baby in order to bring peace healing and hope to your life.  Merry Christmas friends!

screen-shot-2016-12-24-at-10-31-32-pm

photo credits: Pastor Jason, yours truly, shiftworship.com, and the internets.

 

love is more than a sentiment.

Well friends, Advent is in full swing and we are fast approaching Christmas Sunday!  And guess what?  Christmas Sunday is….on CHRISTMAS!  Traditionally we celebrate Christmas Sunday on the Sunday that falls closest to the 25th.  But next week we will celebrate the morning of Christmas.  And I’m excited.  But today is the 4th Sunday of Advent.

We light a candle in celebration of love.

screen-shot-2016-12-18-at-1-55-49-pm

In the Advent Scripture from Isaiah today we are reminded that God comes to us as Immanuel.  “God with us.”  We have come to that time in Advent when we begin to really anticipate the birth of Christ. Most of you will be familiar with the story.  Mary, the mother of Jesus, is engaged to Joseph. Except then she is pregnant.  And it’s not Joseph’s baby. You can imagine the drama that this would create. It’s a story we want to romanticize.  We like to paint a picture where both Mary and Joseph are overjoyed at the thought of having a baby but I have to believe that they both understood the hard work, the shame, the isolation they would face.  They had enough faith to bravely accept the ways in which God had chosen to use them and follow wherever this path would lead.

The reality is that God comes to us in one of the most uncomfortable stories of all time. Single mother. Unglamorous birth story.  Weird visitors. If it happened in my hospital today people would look the other way or maybe roll their eyes.  But it leads me to believe that maybe God is at His best “Immanuel” in times when we are most uncomfortable. The difficult part is being able to recognize the Immanuel in our own lives. We tend to move away from the uncomfortable spaces, to stay quiet when we see something that isn’t right, to ask how others are doing with the expectation that they should say all is well.

God loved us enough to have Christ come into the most uncomfortable spaces in our lives. If we are to be His people then we must love in the same way.  There is a lot to be uncomfortable with.  Watch the news, read the headlines, get on social media. Aleppo. Violence against women. More gun violence.  Road rage. Sexual assault on our college campuses. Cold and dark days of winter.  But, because Immanuel, we can speak out against violence.  Because Immanuel we can speak out against oppression and injustice. Because Immanuel we can sit with someone in their despair. The Immanuel allows us to sit in anger, bitterness, sadness and frustration with our lives and He doesn’t move away, He moves closer.

If we truly believe that God is with us today as He was way back then, then you must know that God will move with you into the darkest of spaces and that He calls you to move with someone else in the same way. It won’t be easy.  It will feel uncomfortable. It will mean we have to move out of our daily self-centeredness and begin to notice the world around us. And it will be exhausting. Is it worth it?  Honestly, some days I have no idea.  The Pastor and I have spent lots of time in uncomfortable spaces with people. The return on investment is small; sometimes it’s nothing.  But when I am at my most uncomfortable I want nothing more than to share my burden with another and believe in God as Immanuel. Like Mary and Joseph, we are called into the uncomfortable and God goes with us.

rohr

 

O09.521

If you don’t recognize it, the number above is the ICD10 code for “Supervision of elderly multigravida, first trimester.”  So what is an ICD10 code?  It is the International Classification of Diseases, 10th Edition.  The World Health Organization (WHO) owns the ICD system and it is adopted by the US Healthcare system.  Basically, these ICD10 codes are how we tell coders, insurance companies, government regulators and so many other what diseases or diagnoses a patient carries as well as what procedures were done for the patient.  Each version gets more detailed, and therefore, more complex.

Enough about ICD10.  The real point of this post is to discuss this awful designation of ELDERLY multigravida.  ELDERLY.  Sounds depressing, huh.   So what makes a pregnant woman elderly?  Get this…being over the age of 35.  No, seriously.  35. Most OBGYN’s refer to this as “advanced maternal age.”  It’s nicer.  Apparently the WHO is not nice.  But even then, when did 35 get old?  I just turned 38 and I still feel like I’m trying to figure out my life.

About 15% of women in the US give birth at the age of 35 and older and are considered AMA (advanced maternal age.)  Less than 3% give birth at age 40 and older.  Why the big deal about age?  Well, age comes with some risk.  Women who give birth in the US who are AMA have an increased risk of stillbirth compared to women under the age of 35.  Additionally, women in the AMA category are at increased risk for miscarriage, an increased risk for chromosomal abnormalities, an increased risk for high blood pressure, gestational diabetes, growth restriction of their babies, c section and other complications of pregnancy and delivery.  Once a woman reaches the age of 40 each of these risks sharply increases.  For women over the age of 40 we have special protocols to monitor their pregnancy and recommend they deliver by their due date or sooner.

So why would anyone have a baby after the age of 35?  And who are these nutty women having babies after the age of 40?  Surprisingly, I don’t hear this question a lot.  What I most commonly hear is “when should I stop having babies?”  I always ask the patient if they want my personal or professional opinion, or both.  If you know me, you know my personal opinion.  I love babies…when they belong to others.  Two of them was more than enough for me.  But seriously, what I tell the patient really depends on where they are in life and how many children they have.  When I am seeing someone who is over 35, has no children and wants to start a family I try to carefully counsel them on the small risks of complications for their age.  What about women approaching the age of 35 who already have one or more children and want to have “just one more”…or just two or three more?  Again, I counsel them carefully on the risks of their age.  This includes risks to both the mother and the child.

Last week I was asked “in your personal and professional opinion, what age is TOO OLD to have a baby?”  I loved it.  I told her that personally I am WAY TOO OLD AND TIRED to have any more kids (can I get an AMEN from Pastor Jason??).  Screen Shot 2016-07-10 at 4.44.26 PMBut then I went on to tell her that I think someone should carefully consider whether or not they want to have children once they reach the age of 40.  I think when most women think about having a baby over the age of 40 they think about the possibility of having a child with Down Syndrome or some other chromosomal problem.   But for me it’s all the other risk factors that make me nervous for my patients.  You see the risk of a chromosomal problem is about 1 in 70.  (For more information on screening for chromosomal problems go to a podcast found on perinatal quality.org ) That’s something I can personally live with.  But the increased risk of high blood pressure, diabetes, stillbirth and c section…that’s what gets me.  So what did I tell my patient?  I told her that if she wanted that “one more baby” I would advise her to be done by age 40.  What if she had no children?  Well, that’s a harder conversation for me to have.  I want her to know the risks, but I also want her to know that I support her strong desire to have a child despite life’s circumstances that have not allowed it to happen before the age of 40.

My best advice?  Try never to call a pregnant woman “elderly.”  Secondly, don’t ask women when they are going to be done having babies or if they are going to have babies.  But if you are considering when to begin or when to end your childbearing, ask your OBGYN or your MFM (high risk OB specialist).  I’m sure they will be oScreen Shot 2016-07-10 at 4.43.49 PMpen and honest with you and support you in your decision whether or not to enter the “elderly pregnancy” category.  You see, we all make different choices in life.  When we have kids and how many, where we send our kids to school, what we like on our pizza.  Some of these decisions are trivial, some have important consequences in our lives.  But we all deserve to be given compassion and understanding.  May we strive to understand our opposite, those that would choose a strikingly different path than us.  The kingdom will come near when put aside our differences and see each other as we are: people just trying to make the best in a world full of hurts.