Pandemic Pregnancy

When I became pregnant, COVID-19 wasn’t even a thing. It was mid-December and I don’t recall hearing anything about what was happening in Wuhan until January at the earliest. So it was probably a thing, and there were cases, but the thought of closed schools, clinical work on hold and shelter-in-place were not on my radar. I was honestly mostly focused on the application process for private school for my two oldest kids. They were (and I recognize how ridiculous this sounds) applying for entry to pre-K and K, and my biggest worry was where they would be going to school the following year. Now I’m doubtful that they will even get to attend said school in person, but that’s a topic for another day.

On February 25th I screened positive for Trisomy 21 and perseverated over that for a week until my normal cell-free DNA results.

We slowly began to take precautions at work to screen for COVID-19. It began with questioning patients prior to their visit to see whether they had recently traveled from Wuhan (this eventually expanded to all of China, and as everyone knows that question soon became obsolete). We also asked about cough and fever. Carts with PPE were positioned outside of these patient rooms.

I developed a cough on March 6th, which was terribly awkward to have while everyone was on high alert regarding COVID (for the records, I have had a negative COVID-19 PCR and also negative IgG and IgM antibodies). One of my patients even sent me a personal note saying that he was worried about me because I had been coughing (I wore a mask in every patient room during this time) and seemed short of breath. I had to, with some embarrassment, tell him that I was short of breath due to climbing 3 sets of stairs while pregnant. Fortunately he was a patient I knew quite well.

I had an ob appointment March 10th and my ob was pretty close to 0% concerned about COVID. She told me the reports out of China were reassuring. Pregnant women seemed to fare well and there were no cases of vertical transmission. She also told me to drink a glass of wine, which was interesting because she usually errs on the conservative side (also for the record, I did not drink a glass of wine).

My close colleagues, however, were more concerned and ended up encouraging me to drop one of my higher-risk duties – seeing patients in the hospital. I stopped doing that the week of March 2nd. The week of March 9th I made a huge pivot in my career and left one of the clinics I had worked at for 6 years. Too many things weren’t working out. I was losing staff, knew I wouldn’t have any when I returned from maternity leave again (it was a drawn-out nightmare the last time) and was so exhausted from pregnancy and turning 37 that I knew it was finally time to call it quits.

March was a month of major upheaval. Our world paused in March – with school canceled starting March 12th (initially only for two weeks but that eventually progressed to no school for the rest of the school year) and shelter-in-place coming 5 days later. Everything was being canceled. It was such a crazy time.

We largely stopped seeing patients in person, with my last real clinic held on March 16th. Everything has been virtual since. To be honest, it’s been challenging. Some conditions in dermatology are easy to treat virtually (acne, for example). Other things, like checking over someone’s skin to look for skin cancer, are impossible. I have been seeing 1-2 patients a week for skin biopsy and evaluation of more serious rashes, but always wearing ample PPE (I have my own that I cycle through). We have just started talking about opening up clinic more robustly, and I am concerned about the plan (or lack thereof). It doesn’t sound like anything is changing, other than spacing out clinics and appointments to encourage social distancing. Of course, we are asked to wear PPE, although it is unclear whether this is readily available.

Normally, I wouldn’t be too concerned. But last week, at my follow-up ob visit, my doctor was suddenly very concerned. She told me there had been new reports of COVID-19 found in placentas, IgM antibodies in newborns, vertical transmission (from mom to body), second trimester miscarriages, stillbirths and premature births. The numbers of reports were small, but there was definitely more alarm. Moms are tested at the time of delivery at our hospital and COVID-19+ moms are recommended to separate from their newborns. Having had three kids, I can’t imagine how heartbreaking that would be.

In sum, I’m starting to worry about ramping up capacity to see more patients. I’m not reassured by the plan currently in place and now I’m much more anxious about doctoring while pregnant. At the same time, I feel a bit silly, because I don’t work in an emergency room or ICU, and certainly don’t do any high-risk procedures (any biopsies I do near the face are usually relatively quick and nothing compared to an intubation). I also feel a strong obligation to my patients. I know how scary it can be to have a spot that you are worried could be a skin cancer, or a rash that keeps spreading. Our patients have been so wonderful these past few weeks, understanding that we are taking every precaution to keep them safe, but I certainly don’t want anyone waiting months to be seen. Since I am taking maternity leave, I would be gone until early 2021. Finally, I care deeply about my colleagues. Although they might not be pregnant, they could have co-morbidities or take medications that make them immunosuppressed, live with elderly parents or in-laws or immunosuppressed children and spouses. I don’t want to burden anyone else with having to see my patients because it seems to imply that my pregnancy is more important than their personal circumstances.

It’s an uncertain time for all and I don’t envy our management who has to make some tough decisions moving forward. For now, I’ve reached out to my ob to see if she can give me some clarity on making a decision. If need be, I’ll reach out to my colleagues to see how to best mitigate risk. I’m taking leave at 35 weeks so essentially only 13 more weeks to go. Hoping those 13 weeks are as smooth and uneventful as possible!

This is how it often is

We met on her second day of hospital admission. She was in her early 30s with a newly diagnosed leukemia. Her symptoms had been mild to start, and now she was here, admitted with cancer, about to begin chemotherapy. She had a six year old daughter at home. The walls were filled with artwork, family photographs, the annual Christmas card.

This is how it often is. You don’t have cancer until you do. The symptoms are mild at first – “I thought I had a terrible virus”, “I was so run down but I had been working so hard”, “My back was aching something terrible but I had just started CrossFit”. You’re living your normal life until it shatters.

I am a dermatologist who sees patients in the hospital when they experience side effects from cancer treatment, or have had a bone marrow transplant with skin complications, or have skin disease in either setting. This is not the role we usually envision for dermatologists. When I was an intern at a renowned academic teaching hospital, the ICU attending skipped over me while we were reviewing a chest X-ray on rounds. “You don’t have to know how to read this – in a few months you’ll just be doing Botox.” I was sleep-deprived, short on caffeine and the low woman on the totem pole, so I swallowed my tongue and folded it up as an anecdote I would later share with my own residents. As one of my mentors always says: you have to show skeptics your value, not tell them about it. Eventually they’ll come around.

The things I love most about medicine – the connections I have with my patients, the trust they have in me, the things I learn from them – are sometimes the hardest part of medicine. Patients often share their hopes and fears. They tell me things they have only told their closest families and friends. I had unprotected sex with someone who wasn’t my husband. I tried to kill myself. I don’t want to die. I never wanted to have children. I grew up in foster care and never had a family who loved me. It’s heavy. There is never any judgement, just a deep understanding of how complicated our world is. There is so much loss and pain, and on the flipside so much beauty and love.

Many times, my patients are soon in remission. The cancer was removed surgically, the cancer treatment worked, the bone marrow transplant gave them a new chance at life. I often don’t see these patients again, but some continue to visit me each year for a routine skin check, or because of a new rash. Those are joyful visits. I receive updates on wedding anniversaries, growing children, grandchildren, vacations – general life excitement.

Other times they never leave the hospital. Or they arrive to the hospital a different person. The complications pile on, everything goes wrong. Soon there is a planned discussion between oncology and the patient’s family. How aggressive do they want to be if new complications arise? Is it time to transition to comfort care? Whereas the first time we met they were sharing photographs of their families and explaining the artwork on the walls, they are now hooked up to machines and unable to communicate beyond a blink. I still talk to them when I enter the room. I repeat who I am and what I am doing – “I will be taking a look at your skin. Your oncologist is worried about the new blisters on your legs. Is it okay if I lift up your sleeve?” The syllables fade into the air, surrounded by assorted alarms. I finish my exam, say good-bye.

The next day we arrive to round and the family is huddled around the bedside, family members spilling into the hallway. The daughter is there. This is usually a sign that the patient has a few hours to live. It is a terrible moment for physicians. I wish I could shield my residents from it, in the same way I yearn to shield my children from the terrible things that happen in our world. We move on to the next patient but there is a heaviness in the air. A six year old is about to lose her mother, a husband is about to lose his wife, parents are about to lose their daughter. The hospitalization ends here but the repercussions of this loss will resonate for eternity. Eventually it will be explained as my mother died when I was six, but there were days and weeks and months and years leading up to that moment which were filled with all of the details that make our lives rich.

I sign into the hospital’s electronic medical record at home that evening to finish notes. I see that our patient has died. My children are sleeping in their beds and my husband is working on a deadline next to me but a mother has died. I move on to the next task, almost in slow motion. This is how it often is. You don’t have cancer until you do. You’re breathing until you’re not. You’re alive until you’ve passed.

What I’ve learned is this: there is nothing to do but to keep moving. Cherish the small things in life, keep your family close, take care of your health. Tomorrow is not a guarantee, trite as it may sound. Wealth and accolades will not shield you from disease and death. At the end of the day, we are all left with nothing. Ashes to ashes.

To my fellow physicians-I see you in the trenches, trying your best to keep your academic hats on while retaining your humanity. To patients everywhere-your doctors truly care about you. They think about you long after you’ve left their office and often long after you’ve left this earth.

I still remember my patients who have passed. I keep the trinkets they gave me, write down their quotes and life lessons, and have stored away the memories we’ve shared. Medicine is broken in so many ways – out-of-touch administrators with unreasonable demands, insurance companies refusing access to care, astronomical cost – I could go on and on. But all is not lost as long as the purity of the patient-physician relationship remains.

Maternity leave in review

In two days I’ll return to work after my third maternity leave. That’s one job, three pregnancies, three maternity leaves and three “first days back at work”. My first post on this blog was about returning to work after my second was born (see October 2016 archives) and now here we are again! In honor of this occasion, I wanted to spend some time (kid naps allowing) to reflect on the past few weeks.

This maternity leave started earlier than planned when my contractions started the morning after my last day of work. I had been expecting at least a few days (if not weeks!) of extra time to wrap things up, but baby had other plans. I subsequently spent the first 3-4 weeks wrapping up work. I know that sounds really terrible, but it was actually okay. Everyone knows that newborns don’t sleep, so it gave me something to do in the wee hours of the night, and it was something that would definitely prevent me from dozing off with the baby. I am also fortunate to have a lot of support staff and they helped me make phone calls to patients (since that’s not something that can be done in the middle of the night!).

My husband didn’t take his paternity leave right away, so it was a bit of a whirlwind. Even though we had family helping out, if I had to do it again I would ask him to take a few weeks off in the very beginning. It would have been immensely helpful to have a bit more overnight help those first few weeks and I would have probably been able to take some daytime naps without the baby! It seemed pretty stressful for him to work while so sleep-deprived and this definitely led to more bickering than usual. Fortunately, things improved with time (and sleep!).

We briefly had a night nurse helping us out…until she fell asleep holding the baby. I couldn’t believe it. As my husband always says “why are people so bad at their jobs? You have one job – learn how to do it right!” So I guess another thing I would do differently is not hire a night nanny. Yes, it was helpful to have someone hold the baby for a few hours overnight, but I did enjoy doing the bulk of evenings since so much baby bonding happens during that time. I also found that I didn’t rest easy when she was over, perhaps because I was worried about the above. Fortunately, our little guy persevered and now his sleep isn’t as atrocious (although it is definitely nowhere near ideal for having to go back to work!).

My older kiddos have done really well with their new little brother. Toddler Y (our middle child) had a tough time those first few days, but now he is sweet as pie. One of our major challenges when I return to work will be carving out individual time for all three kids. Right now, the older kiddos have independent activities on Saturday mornings, and I plan to build onto that time.

One of the highlights of maternity leave was seeing a lot of family. My mom spent a few weeks with us right before and after Baby Z was born – not quite as long as the last time, but just the right amount of time during the hardest days. We also had both of our families visit on separate occasions and I was able to visit home twice (the last time for 3 weeks!) during maternity leave. The kids have a blast around family, so it was so nice to see everyone on multiple occasions.

Another highlight was meeting an awesome group of moms with kiddos around Baby Z’s age. I have excellent mom friends whom I met shortly after my first was born. Some had second babies so I didn’t feel the need to branch out much with Toddler Y. But this time around I knew that Baby Z would need some baby buddies and went out of my way to meet people. Well, this group of moms is just awesome, and it’s been great getting to know them.

On an organizational front, I did a TON around the house. I cleaned out the whole attic, donated and threw out a bunch of items from all throughout our home (trying to get a head start on minimalism for 2019!), made headway on two home improvement projects we have been working on, had the guest room painted, reorganized the guest room/soon-to-be Baby Z nursery, cleaned out the entire shed and organized all of the kitchen drawers. I gave away a ton of baby things we no longer needed, worked on Baby Z’s scrapbook and first-year album and also researched and toured a slew of private schools in the area. I did much of this with the baby strapped to my chest, but needed a bit of assistance for the manual labor.

Of course, the highlight of maternity leave was the hours upon hours I got to spend with Baby Z. I wore him almost constantly in a sling (now carrier) during the daytime hours. He often slept in bed with me overnight (not necessarily by choice, but we made sure the bed was as safe as possible for infant sleep) and he accompanied me to appointments, a handful of work meetings and a slew of errands. He’s an excellent eater, and I will forever be grateful to my employer for allowing me to have all of this time with him.

When I return to work, he will be about 4.5 months old. I know international readers will balk at how little that is. However, having had all of my children in the US, I feel so incredibly fortunately to have had 4.5 months of paid maternity leave, as well as the assurance that my position is stable. When I return, I’ll be able to set time aside as I wish to pump and to adjust my schedule as needed to make this year as manageable as can be. In fact, I’m returning part-time this month, and I am so very grateful to be able to rev up gradually.

I will always be sad about leaving my baby. What will it be like for him to not be strapped to my chest all day? (Honestly, probably not as bad as it will be for me!) I will worry incessantly about something going wrong while he is out of my care and I will miss his little noises and tiny fingers and sweet smile. I will stress out trying to give everyone attention in the few hours we have before work and after work/before bed. But I have faith that it will all be okay. Not easy, but okay.

Many moons ago, when I was obsessing about going back to work vs not going back to work (not really an option for me at the time but an interesting hypothetical argument) and then obsessing about daycare vs nanny, the one thing that stuck with me was reading that kids will thrive with a decision as long as the parents are happy with that decision. So I always focus on the positive aspects of my job and the positive aspects of their relationships with other caregivers.

I also have this to get me through: my older kids are alright. They’re happy little clams, in preschool now. My oldest is four. If we repeat his life cycle 4 more times, he’ll be twenty – an adult! In other words: time flies. As my children have grown, I’ve had (some) opportunity to think about who I am independent on them, how my husband and I interact independent of them, what I will do once they leave. Yes, I am not very far in and they are still very, very small and very, very dependent, but there are snippets of time when these opportunities for thought arise. When they have arisen, I have always been very happy to be working. This is what has worked and been okay for me, but it may not be the best case scenario for anyone else, and that’s okay too.

So in less than 48 hours, I’ll be waking up and changing out of my pajamas first thing. I’ll put on make-up, grown-up clothes, triple check my bags to make sure I have my work things plus my pump things, and then I’ll leave my sweet little baby behind. First I’ll have to convince my older kids (who have been out of school for three weeks!) that getting dressed and leaving the house early is also a good idea. I am not sure which of those feats will be harder! And in a few weeks time, doing this will be the new normal, and these lovely (and hard) maternity leave days will be a distant memory!

The Blob Trimester: Baby’s Z’s 1st 3 months

As my youngest (baby Z) is one week shy of 4 months, I find myself fondly reflecting on the fourth trimester haze. If you are not familiar with the term “fourth trimester”, it is common terminology for the first 3 postpartum months. Due to human anatomy and the limitations of the birth canal, human babies are born neurologically premature. Thus my rationale for (very affectionately) calling my newborn a blob.

Let’s put it this way: newborns would never survive in the wild. They can’t hold their heads up, they can’t make meaningful movements with their arms and legs, they can barely see, and they are easily surprised. They can only communicate via crying and they spend a great majority of their days sleeping, drinking milk, peeing and pooing. This is one reason why the fourth trimester is so challenging for new parents: you are suddenly in charge of keeping a small, defenseless human alive. No pressure!

Prety daunting, huh? Couple this with the fact that new parents are chronically sleep-deprived (newflash: babies don’t know the difference between day and night, so you may find yourself pulling a lot of all-nighters), moms are experiencing a hormonal hailstorm (why does everything make me cry? why am I suddenly so angry at my husband? why am I so worried about every damn thing?) and everything you previously knew about yourself has gone out the window (so long hobbies, singular focus on career, social life). Given all of the above, we might as well also call this time period the sob trimester.

Never fear, however. Between 3-4 months, everything gets easier. Yes, there are still challenges (hello 4 month sleep regression!), but your little blob has turned into a reciprocal mini-human who tracks your movements, produces wide-toothed smiles and even cackles with laughter, which makes the experience much more rewarding.

For the sake of preserving my own memories, here’s a recap of Baby Z’s first 3 months:

  • Birth: By far the best of three (third time’s the charm!). Baby X was induced and we barely made it to the hospital with Baby Y. For Baby Z, we went to the hospital as soon as contractions started and were told to walk around until they intensified. We did this for quite some time, even coming home to shower and re-pack, so by the time we returned to the hospital, it was go-time but not baby’s-about-to-fall-out time. I was able to get an epidural (thank you, modern medicine), labor peacefully and when it came time to push, he was out after basically 3 pushes with no tearing involved.
  • Sleep: We purchased a Snoo for this guy, but I wasn’t quite comfortable having him sleep in it from day one. The rocking seemed a bit intense for me and I capped it (there is a function where you can limit the motion) and have kept it as such to this day. In the beginning, he honestly mostly slept in bed with me (my husband would supervise so I didn’t roll on him) and we also lay him down in the Snoo (without turning it on) or put him in the Rock n Play (which he honestly never liked very much and also isn’t safe for unsupervised sleep). We hired a weekend night nanny for those first rough nights and she fell asleep holding the baby on the third night she worked for us! As my husband would say: WTF? YOU HAVE ONE JOB!!! That was pretty traumatic, but baby was okay and we gently told her we were no longer in need of a night nanny. I have to be honest: the sleep was pretty rough early on. He would spend a few hours up each night and I often had no idea what to do with him around 2-5am. My husband was also saving his paternity leave so I tried not to bother him since he had to work the next day. It was pretty intense. I tried to establish an early bedtime for him, but he went to sleep around 11p for a long time! Just recently (close to/when he hit 3 months), he started falling asleep around 9. Early on, he would be up cluster-feeding for quite a few hours (e.g. 8p-11p/12a) but more recently he would do a longer stretch, waking up either at 1a or 3a. So most nights he’ll wake up 1-2 times. The first nap was also the first to fall into place, as it usually does. It’s the one I can actually set him down “drowsy but awake” for! At the moment, we are traveling (good-bye Snoo!) and have him in a Pack n Play. I have to say that he’s not loving it. Last night, he was up every 2 hours, and spent the bulk of the night in bed with me. I’m not sure if this is a Snoo transition issue, a travel/change of environment issue, or the start of the 4 month sleep regression, but I don’t like it.
  • Temperament: When we first brought him home, we were a bit concerned he would be colicky like Baby X. Turns out he was just a normal newborn who wanted to be held, cuddled and carried pretty much all day. With every need attended to/preempted, he’s happy as a peach. He likes tummy time, mat time, play time (songs and the occasional book when he gets his own) and of course still loves when we tote him around all day. So far, he’s a happy, go-lucky baby who can also entertain himself independently (for now, this mostly involves staring at something in the distance).
  • Feeding: Baby Z latched pretty easily. I had one of the nurses remind me of the appropriate position when they are little blobs and can’t hold up their heads, but he quickly got the hang of it. I don’t have him on any particular schedule at the moment. He should technically be eating every 3-4 hours, but sometimes it’s less. Of all the baby things, nursing has always been fairly easy for me. Yes, it was always painful in the beginning. I enrolled in a lactation class prior to the birth of my first, worked with lactation consultants in the hospital the first two times, and also had private lactation consultant visits after the first two were born. These steps allowed me to feel more comfortable nursing. And yes, I worried ALL all of the time whether they were getting enough to eat, especially my first. Was he colicky because he was hungry? Were those tears of starvation? Did he want to nurse all of the time because he wasn’t getting enough milk? I also always pumped just enough and was worried each time about how pumping at work would turn out. Yet I was able to nurse the first two for 15 months and pumped until they were 11 months, using up my freezer stash for months 12 and 13. We’ll see what happens with this guy. I’m a bit worried because I had 187 oz and 300 oz of milk saved up for my first and second, respectively, when I went back to work, but currently have only 55 oz with only a few weeks to go (poor third child!). But I am telling myself that the freezer stash really only helped me to stop pumping a bit earlier, so it isn’t the end of the world that his is so limited. After all, every lactation consultant I’ve spoken with has said you only need enough milk for your first day back (and this is true).
  • Developmental milestones: Baby Z was quick to roll from tummy to back. I know I sound like a delusional mom saying this, but he was doing it month one and still does it to this day. He’s flailing his arms around and kicking his legs much more now. He sees well, follows you around with his eyes, smiles and laughs, has coo-ing conversations, and has started to grip things and bring them to his mouth. Actually, everything is starting to wind up in his mouth – his hands, the carrier strap, teething toys, etc. He can also reach out with his hands to swipe things hanging above him on his playmat or on one of his chairs. His neck is pretty strong and I will often place him forward-facing in the carrier (if it’s not naptime) because he likes to observe the world. He’s actually starting to show interest in food already, which seems early to me, but I’m looking forward to introducing solids.

I honestly can’t believe he’s almost 4 months and am definitely patting myself on the back for getting through those tough first few months. Work is just around the corner (a story for another day), but I feel very fortunate to have had this time with him.

 

Not a sleep whisperer

I spend a good chunk of my day convincing little humans that sleep is a good idea. The other day, as I was prematurely patting myself on the back for getting all 3 kids to nap at the same time, my two oldest decided they were simply going to skip their naps. Of course, they were little (cute) monsters by the end of the day.

Right now, I’m struggling most with my middle child. He has recently started to extensively delay bedtime. He wants ten stories, ten songs, a million cuddles. Every time we acquiesce, he asks for more. After all of the above, he started asking for more lights on (we already have a nightlight). So we started with one, then two (after all, if he was truly afraid we didn’t want to be the mean parents who ignored this). This was enough for a bit but then the demands escalated. He wanted all the lights on but then also wanted us to hold him to sleep. The thing is, we’ve been down this path before. With both of our older children, we’ve always given in, and then regretted it some time later. Who doesn’t love the feel of their young child against them, all chubby cheeks and fat fingers, warm breath on your shoulder, kissing your cheek and saying “I love you, mommy”. I mean, what could be more precious? But it is hard to tack on an additional two hours for bedtime after a day packed with activities and attention doled singularly on the children. That extra times leaves us extra wiped, so we bring even less to our relationship, our home, and our work. And I am a firm believer in children needing to get a good night’s (or nap’s) sleep! When our kids put themselves to sleep, they fall asleep more quickly and wake up better rested.

This is on my hand because my middle child just cried himself to sleep for nap time. He only cried for five minutes or so, but it of course broke my mama heart. In truth, if I didn’t have a third child currently strapped to my chest for his own nap (we are visiting family and my oldest is sleeping in my room, where the crib is), I would probably just hold the kid to sleep. Again-who doesn’t love that feeling? So there’s the added guilt of attention being taken away from him by the baby. But we did try the “cuddle to sleep” method the last two days and he just ended up giggling, playing, and essentially doing everything BUT sleeping.

I reached out to our sleep consultant this week (honestly, at this point I should just have her on retainer) and she advised that if the gentle approaches weren’t working, to firmly return to business as usual. She advised either letting him cry or spending less and less time in the room with less and less physical or verbal interaction. The latter sounds like it would be torture to do, so we have settled to let him cry. Bedtime has improved dramatically (still delays, but not as many demands and we haven’t had tears for a few days). Naptime has proven to be more difficult, perhaps because there is less sleep inertia and it involves taking a break from playtime. I joked with our sleep consultant that I should print out a frame with “When in doubt, cry it out” for the nursery, because this seems to be what we resort to after a few days of failing at every other approach. Her philosophy, at least with our family/children, has always been: if baby/toddler/child is dry, fed, healthy, has gone to the bathroom and if you’ve addressed all of their fears, questions, and concerns, then there’s no reason why they shouldn’t be able to sleep by themselves.

I recognize this is a very Western philosophy. It is very foreign to my mom, who always had children in bed with her. In truth, our youngest (almost 4 months now) has spent more time in bed with me than I’d like to admit. This is mostly because I’m so exhausted when he wakes to feed that I accidentally fall asleep with him. I sleep alone (poor hubby has been banished to the guest room for this reason), with no extra pillows, blankets, or throws. I wear warm clothing so as not to cover myself and make sure the baby’s unswaddled and in the very center of the bed. It always fills me with great trepidation, despite all of these measures. For us, the main reason we haven’t intentionally shared a bed is fear. The second reason is that it’s been really important for my husband and I to have adult time after the kids go to sleep. We are not perfect in this regard, as I often allow housework or work work to bleed into our time, but it is theoretically more possible if there is no child in our room.

I’ll end on a positive note: my 4 year old has become a much better sleeper with time. He was our crazy colicky baby who refused to sleep on his back and had us up every twenty minutes as a newborn. We held him to sleep for naps until he was almost 3! But now this very same child will tell us he’s tired (before nap or at bedtime) and then go to sleep by himself. He sometimes needs a bit of encouragement when it comes to changing into PJs, but then he’ll happily settle in under the covers with his stuffed animal and put himself to sleep with no extra support. If you had told me this four years ago, I would have never believed it. It’s amazing how children change over time.

One of the greatest challenges of parenthood has, for me, been sleep. There are a good days and bad days, but definitely lots of sleepless nights, sleep regressions, and changes – potty training, separation anxiety, nightmares, travel, teething, etc., etc., etc., which seem to knock the schedule right off its track. But one day, these little humans will become (really) big boys, and then I will probably be nagging them for sleeping TOO much. Funny how things work. For now, I’ll try my hardest to revel in the baby snuggles and to try to focus less on the naptime/bedtime snuggles. However, I will never sleep when the baby’s sleeping, because when else would I get anything done!?

The Village

I was recently surprised to learn that I had lost my desire to move back to New York. As recently as a few months ago, when people would ask me whether I envisioned myself staying in California forever, I used to respond with “Probably, because I don’t think I can convince my husband to live anywhere else.” Now I pause, because the answer is that I can’t quite imagine living anywhere else.

When and how did this drastic shift occur? I left New York when I was 18 years old. To be honest, I was thrilled to do so. I lived in the suburbs outside of NYC, had moved during my freshman year of high school (NOT a good situation), and was excited to “discover the world”. I floated around New England for college and medical school, and spent a requisite year living and working in NYC. When it was time for residency selection, my husband (also an East Coaster) and I were adamant that we needed to get out of the cold. He wanted to work in California and I was game to live in California and so I applied and was accepted.

We flew to the West Coast with one suitcase. (I can imagine myself telling this story to my children one day, at which point they’ll roll their eyes at this particular sentence.) We had less than $5,000 combined in our bank accounts. My husband was unemployed (“between jobs”) and I was days shy of starting my intern year. We rented a small unit in a house of four units total and decked it out in IKEA furniture. My husband bought a Samsung flat screen TV which we still own 8 years later. We weren’t married yet but reasoned that we needed to move in together because the rent was too expensive to swing two apartments. When he proposed to me, the engagement ring was the most expensive thing we owned. We didn’t have much but we were so happy.

In the past 8 years, we’ve spent 5 of them living together (we were apart for 3 years while I completed my residency), got jobs, got married, bought a house, tucked away money for retirement, had 3 kids, tucked away money for college education, and created the life we always wanted – one we could have never quite imagined when we landed in California in 2010.

Yet there were bumps in the road. I started my first job out of residency in 2014 and had a baby 3 months later. I’ve had 2 additional children since. I had no idea how difficult it would be to raise a family away from our families. It often felt impossible. I vividly remember those first colic-filled weeks with our oldest. We had help for a few of them but were on our own most of the time and I cried constantly. When I went back to work I was convinced there was no way I could juggle motherhood and my career without help. Most of our acquaintances at the time were my husband’s friends and, although mostly good people, they just weren’t my people. Is that a terrible thing to say? I hope not. You know that feeling when you just click with someone? When you can tell them anything – lay all your cards on the table, be completely vulnerable – and they will accept you wholeheartedly? Let’s just say I didn’t get that vibe from his people. And that’s what I struggled with the most – not having someone I could text frantically when our first was up at all hours of the night, not having someone I could ask to watch him for an hour while I took a breather, not having a tribe to commiserate with.

So I put myself out there. I met a group of women I now call “The Mommies”. My first mom friends! Now, the group has changed dramatically these past 4 years as moms move away and group dynamics shift, but we have each other’s backs, an ongoing calendar of events, never-ending birthday parties, and most importantly the knowledge that we have known each other since our little ones were just months old. I rekindled friendships with people from my intern year and became closer to co-workers with young children. I met more moms through preschool and subsequent “new mom” groups as more children joined our family. We acquired a network of people who have helped us out in some capacity around the house – gardeners, painters, nannies, cleaning crews, etc. Today, our nanny saw that I was clearing out our shed for some upcoming work and (unsolicited) called her husband to see if he would be willing to pick up all of the items we were throwing out to save us the hassle. He came by an hour later and I was so happy I could have cried. With such distance between ourselves and our families, these random acts of kindness mean everything.

I also have to admit that there are serious perks to living in California: great weather, tons of diversity, generally liberal politics. It’s also true that we both love our jobs and our house. But the game-changer for me was truly the evolution of our community and little village. We’ll see how we feel as the kids get older and schedules become more demanding but, for now, I am truly loving where we live, and this is the first time since 2014 that I’ve been truly able to say that.

Chaos coordinator

I’m 3 weeks into having three children (one day I’ll get around to sharing the birth story, but for now I’ll just say: the baby was not born in the car and I was able to get an epidural, which is seriously the best medical innovation to date) and it is absolute chaos.

Let’s discuss some of the ridiculous things that have happened since bringing our baby home:

  • Our middle child, Y, bit new baby’s Z finger when he was only a few days old. Seriously kid!? Fortunately Z was okay, but it was a clear sign that Y was not going to warm up to him easily. We’ve since made sure that Y has a bit more one-on-one time with everyone, and we continue to call him our baby. He has since only given him lots of kisses, so perhaps our approach is working.
  • Z was not sleeping at all the first few days (and, truth be told, is not sleeping great now, but I’m giving him the benefit of the doubt since he’s still a newborn). I should clarify: he would sleep just fine as long as he nursed the whole time and/or I held him. We ended up hiring a night nanny, who came highly recommended by two friends. We had her spend 3 weekend nights with us so we could be as well-rested as possible for the big kids during the day. It was incredibly helpful (even though I still had to wake up every 2-3 hours to feed the baby), but on the third night we caught her catching a snooze with our baby on the couch next to her! As my husband would say: “Seriously!? You have one job.” So we don’t have a night nanny anymore. But Z is cooperating and starting to sleep a bit at night. We can usually get one or two 2-2.5 hr stretches. I believe there was one night when we got two 3 hr stretches. Glorious!
  • I took Z out with me to a store the other day, when he was 2 wks old. I’ve been trying to lay low and not exert myself too much (also trying to keep Z away from germs), but I have unfortunately had a few time-sensitive errands to run. On this particular day, Z bawled his eyes out in the car (his M.O.). After we parked, I was trying to load up the stroller quickly so that I could pick up the wailing newborn. I thought I had closed our SUV’s trunk, and didn’t see that it had ricocheted back to half-open due to an umbrella stroller wheel sticking out the back. Unfortunately, I wasn’t looking up when I walked behind the car again and I ran straight into the side of trunk door. It was a pretty good blow, but when I touched my hand to my head to feel it, I was still surprised to see my hand coated with blood. OMG. My husband was at work, my mom was at home with Y, and I was bleeding from my head in the middle of a parking lot 30 minutes from home, with a wailing newborn still buckled into his carseat in the car. The whole thing was ridiculous. I ended up keeping my appointment at the store (I’m sure the woman working there thought I was insane coming in with a newborn with a blood-soaked Kleenex pressed against my head, asking whether I could use their bathroom to clean out my wound). I called one of my surgical colleagues right away and asked whether she had time to squeeze me in that day because I was pretty sure I needed stitches. And that’s how my quick errand turning into an afternoon spent in my clinic getting stitches. Silver lining: at least this happened on my scalp, where the scar will be hidden by my hair, and not on my forehead!
  • Negotiating 3 sleep schedules has been tough. As I mentioned, Z is not sleeping great. X has woken up really early a few days (e.g. 5:30am). I wouldn’t care if he could just sit quietly in bed, but he usually uses the restroom and calls someone to wipe him (so that’s one adult who needs to wake up) and then he goes back into his room, usually noisily, and wakes up Y (since they are now sharing a room). I also wouldn’t care about this if Y was a morning person, but he likes to sleep in, so this automatically makes for a cranky pants morning. Y still takes long naps (3 hours) so we pick him up after a half day of “preschool” and let him snooze at home. Honestly, it would be much easier to have him stay at school all day as opposed to driving to this school three times per day (drop-off for both kids, pick-up for Y mid-day, pick-up for X end of day), but the times we’ve tried a full day of school (including today) have been an absolute disaster. Y is a zombie and in a TERRIBLE mood, so it’s honestly more miserable than taking an extra drive mid-day. Just a few nights ago, I had finally settled Z out of my arms and into the Rock ‘N Play. Then, all of a sudden, I hear crying coming from X&Y’s room (it’s around 9:30pm so this shouldn’t be happening since they had fallen asleep some time before). I check out the Nest Cam and see that Y is standing up in his crib bawling. Oh no. If he wakes up X, we’re going to have a problem. And why is he up crying!? I rush into the room to make sure he doesn’t have a dirty diaper or a fever. Negative on both counts. I carry him out of the room to comfort him and then tell him calmly that he’s going to have to sleep in his crib tonight. That doesn’t go over very well. Ultimately, I let him cry it out in his crib and spend the whole time praying that X doesn’t wake up. By some miracle, he does not, and Y settles to sleep after a few minutes. And, of course, Z wakes up just a bit after that.
  • Family outings are a nightmare. I’m serious! It takes forever for us to get out of the house and we seriously need a rolling suitcase as opposed to a diaper bag whenever we leave. My mom has been in town, so right now we have a 1 adult to 1 child ratio. However, when she leaves, we are going to be in big trouble! X and Y always seem to dart in different directions. Z has blowouts literally only when we are out somewhere! And without fail someone will throw a tantrum.

In sum, things are crazy. I feel like I am barely surviving when all 3 kids are home. That being said, I would choose to have a third child a million times over. I love the chaos and would honestly love a fourth child (crazy, right? Pretty sure there’s no way to convince my husband that this would be a good idea). I also know that these days are fleeting. In just a blink they’ll be teenagers, looking for ways to escape into their rooms. So I’ll enjoy the endless cuddles, each boy vying for mom’s attentions. And I’ll even take the tantrums, tears, and sibling rivalry.

How I do it

I can’t get into Instagram. Like other social media platforms, I follow a handful of friends, family, and acquaintances and post very sparingly. I don’t post a lot because I’m fairly paranoid about privacy (all I can say is: thank goodness it did not exist when I was in high school – I would be mortified to have those memories immortalized) and I honestly just don’t have time for it. I’m constantly in awe of people who capture and share so much of their lives. How do they manage to do it? I have no idea.

I worry about young women following certain “influencers” (what does that even MEAN!?) who post regularly on working motherhood, work-life balance, etc.  These influencers leave out so many important details of their lives when they post. They talk about being imperfect but then always post “perfect” photos. I couldn’t believe it when I learned that some people hire photographers to take their pictures! What happened to authenticity!? How can these people write about “keeping it real” when someone’s following them around with a camera? I’d love to see more influencers post while wearing yoga pants (not actually used for exercise, mind you) with their unwashed hair pulled up into a tight bun because they haven’t been able to escape for 15 minutes to take a shower in 3 days.

These influencers also rarely address the role of privilege in their lives. Did they come from money? What role do their husbands play in their financial success? Have they faced any hardships? What does “hustling” mean in the context of not really having to work?

I would be a terrible Instagram influencer because I don’t sugarcoat things. I am very upfront when I give advice to young women who ask me about work-life balance. So I’m writing this post today to share the authentic side of working motherhood, how I’ve been able to balance both aspects of my life, and how I’ve learned to be at peace with my decision.

1. How I decided to keep working full-time after my first child was born: I actually didn’t have a choice.* This is not a glamorous answer, but it’s the truth. My husband supported us through medical school (full disclosure: my parents also supported me quite a bit through medical school, before my husband and I were married) and residency. Once I graduated and had a real job that brought in actual income (sorry residents!), it was my turn to support our family while my husband started his own company. I came home from the hospital after my son was born and announced that I never wanted to go back to work (I loved my job and still love my job, but those postpartum hormones and attachment to your newborn are strong forces!). My husband, who is very loving and supportive, looked at me and said that wasn’t an option. Ultimately, he was right. We had a mortgage, lived in a high-cost of living area, and both had to hustle to set our family up for success, because we were not about to inherit millions of dollars any time soon (or ever, having both come from humble backgrounds). So 4 months later, I went back to work.

I vividly remember new moms I met during maternity leave saying things like: “I can’t imagine going back to work and leaving my baby with a stranger”, “babies need their mothers”, etc. and feeling so incredibly hurt. I never once congratulated myself in front of them for going back to work, or made any arguments as to why working motherhood was “better” (is there a better? I don’t think so – I truly believe every parent tries to do their best within their means). Although I was hurt at the time, I think they were trying to rationalize their own choices, and I don’t fault them for it. I now have almost 4 years of perspective to see how that decision has impacted their relationships and careers, and I also see that our kids don’t differ in any appreciable ways, despite mine having had >1 caregiver. So the first thing I tell young women is this: you have to do what’s best for you and your family. How much choice you have in the matter will depend on many personal circumstances, but you can never go wrong if you love your child and try your best. And don’t listen to anyone who tries to tell you there’s only one right way to do things – they are trying to convince themselves, not help you. 

2. How I “do it all”: Today, a weekday, I organized a play date with a close friend and her kids. I ran errands, prepared dinner for everyone, read a story to my son’s preschool class, and spent some time calling patients with results, speaking with other doctors about complex cases, and working on administrative projects. My friend sent me a text saying “Wow – super mom! You crushed it today!”. Yes, I was pretty productive, but I also have a lot of privilege and extra help, so it’s really not that impressive.

First of all, I have a very rewarding and flexible job. I love what I do and who I work with, I have great benefits, I have a lot of autonomy, and I have the opportunity to do some work from home. I’m not in the hospital taking 24 hour call and I’m not working a dull, minimum-wage job. So how did I get here? Well, I have always been driven, but I also had parents whose main goal was to set me up for success. They were present, supportive, loving, and sacrificed their own livelihood to put me first. This allowed me to focus on my education, to attend an Ivy League college, and to ultimately graduate from medical school and enter into a competitive specialty. I worked hard, but I also won the lottery by being born into an amazing family, and also encountered a lot of luck along the way. There are many bright and promising people who are not so lucky, or whose lives are transformed by tragedy. Second of all, I have an amazing husband. He is very affectionate, closely involved with the kids, does groceries 90% of the time, and cooks pretty much every night (my cooking tonight was indeed an anomaly). He has also been very successful in his career, and this has set a solid financial foundation for our family. I truly won the husband jackpot. Finally, we can afford to hire help. We have our oldest in a nurturing, full-time preschool (and his brother will join him in a few weeks) and we also have a full-time nanny. Without family in the area, I can’t imagine doing this without our nanny. She has been a true lifesaver, taking great care of our kids, tidying up our home, doing our laundry – I could go on and on. And because our jobs are flexible, we don’t utilize our childcare resources to the max, so we are still able to be their primary caregivers.

Now, there are certainly many people who are much better off than we are, and our arrangement may also not work for everyone. But the advice I usually give is this: split the household responsibilities with your spouse. If you can afford it, outsource household work you don’t enjoy or find fulfilling (e.g. washing dishes, cooking, etc.). If you can’t afford it or can but wish to reach financial independence more quickly, figure out what you can do without. Can you ignore the laundry piling up for a few days? Can you leave dishes in your sink? In sum: try not to sweat the small stuff so that you can focus on what you truly love, which for most people is spending quality time with their kids. Doing it all is really just a matter of how much you put on your list. Put less on your list and you’ll automatically do much more!

In sum: I don’t think my situation is all that impressive. I continued working because I had to (but 4 years later am so incredibly happy that I did, because I truly do believe I have the best of both worlds now) and I “do it all” because I was privileged enough to have been set up for success and I can outsource some household tasks and afford quality childcare. And this is precisely why I would have a terrible public Instagram account – the truth is not very awe-inspiring, but I do think it’s important for young women to hear it so they are not discouraged by “perfect” lives on social media.

*In truth, there were things we could have done to make my staying at home feasible. My husband could have stayed at his well-compensated job, we could have moved to a lower cost-of-living area, we could have relocated closer to family. Ultimately, however, we chose to remain on this trajectory because we liked where we lived, I had a great job, and my husband had a lot of opportunity with his new endeavor. It was not an easy decision, and I shed a lot of tears, but I don’t regret making this decision.

 

A-holes on airplanes

My kids were much better behaved on our trip back and we had a much better flight with an extra set of hands (thanks to my husband who flew out just to fly us home). I should mention that the flight ended with my oldest projectile vomiting, which was not, as I assumed at the time, motion sickness, but was actually a horrible GI bug that he is still grappling with and that I am desperately hoping no one else in our home contracts. But that’s a story for another day, because first I’d like to talk about a-holes on airplanes.

I have flown a ton with my kids in the past 3.5 years. I have been fortunate to encounter nothing but gracious people, who have tolerated some tears, tantrums, and other infant/toddler behavior on our flights. The kids are actually great travelers, and I think this is part of the reason we have never encountered animosity on airplanes – they don’t scream/shriek the entire time, they are not rude, and obviously they are incredibly cute and win everyone over (biased mom here). Part of the reason we get a lot of sympathy is also that my husband and I always come equipped to entertain them, and we hustle the entire flight to keep them as calm as possible. We don’t let them run around willy-nilly, we are mindful of how their movements and noises affect surrounding passengers, and we try to have new/engaging/interesting items on hand to pique their interest.

However, we did meet our first disgruntled passenger on this week’s flight. We boarded the airplane first, and barely noticed an overweight, older gentleman board a few minutes later. He was seated two rows in front of us. Because we had boarded so early and the majority of seats were empty/passengers were still getting situated, I let my youngest sit on my oldest, start hugging, and begin to play as I set up our seats (safety harnesses, waters, books, wipes, etc). They were basically hugging and making noises. My youngest was saying things so that my oldest would copy him, and they were having a blast. Cue grumpy old man: “I’m sorry, but that is unacceptable behavior.”

I was taken aback – was this man talking to me? It sure looked like he was staring in my direction, but what could be unacceptable behavior? Well, never fear, he proceeded to explain: “It is unacceptable for you to let them hug and yell and cause a commotion for everyone.” First of all, the cabin wasn’t even 25% full. Second of all, who gets angry at playing toddlers who are literally just sitting in their seats!? We hadn’t even been on the airplane for five minutes! If this guy was already annoyed, he was definitely in for a treat during the 5+ hour haul.

I was honestly speechless. I was also slightly embarrassed (was I an oblivious parent? Had my kids actually been loud/obnoxious and not cute/endearing?) and wanted to stay calm for my kids. I was also worried that he would start cursing in front of the kids or become otherwise belligerent. And I didn’t think there was much point in arguing with someone who would yell at a pregnant lady traveling with 2 toddlers – what were the chances he would honestly empathize? Plus you see all of these viral videos these days of families getting kicked off flights for the smallest things, and I did not want any trouble on this flight. My husband, who was sitting across the aisle from us, had zero of these reservations.

He got into it with this man, telling him not to talk to me like that, asking if he had ever flown with children, and on and on. The grumpy old man yelled something back about common courtesy/being nice and I pretty much zoned out and tried to distract my kids, while simultaneously asking my husband to calm down. It was an ugly scene and I was not in the mood for confrontation.

I felt pretty crappy the rest of the flight. We worked as hard as we usually do to keep the kids calm, but it felt different – like we were somehow acquiescing to his demands. I was grateful that both of them napped and were generally in stellar moods. I also felt very grateful to have my husband there. I don’t know how the scene would have played out if I were solo, except that perhaps more passengers would have come to my immediate defense. A few gave us smiles of solidarity after it happened, told us the grumpy old man passenger was a jerk after the flight landed, and also commended us for having well-behaved kids. We were grateful to those people for their small acts of kindness. And a special thank you to the passengers across the aisle from us who handed me a barf bag when they saw my oldest vomiting and me searching frantically for something to contain it.

And if you find yourself on an airplane with parents who have young kids, try to have some empathy. I get it – you paid for your flight, you’re tired, you want to sleep/read/watch a movie/etc. But guess what? It’s not a private jet. Most (I can’t speak for all) parents are trying their best to keep their kids contained and respectful, but kids aren’t robots. These families have also paid money for their seats – in our case, we purchased four of them – and have the right to talk, walk around within reason when the seatbelt sign is off, and so on. And no matter how little you think you’re relaxing by the kids being in your mere presence, the parents are relaxing 100% less trying to entertain them. Moral of the story is: try not to be an a-hole on airplanes. After all, isn’t that what common courtesy is all about?

Toddler tears

Tonight is our last night visiting our families, who live on the opposite coast. We fly out here often (and vice versa) so that our children can still be close to their grandparents, even though we live far apart.

I tucked my kids into bed tonight and reminded them that I would wake them up early in the morning (“tomorrow”) to fly back home. My oldest seemed to process this information quickly, but then called me back into the room a minute later. “What does tomorrow mean?”

“Tomorrow will be when you wake up,” I said. His eyes welled up with tears and his lower lip quivered. “But I don’t want to go home!” he said. “I like being at grandma and grandpa’s house. I don’t like our house and I don’t like my school!” For reference, he is 3.5 years old and has never expressed a dislike of our home nor his preschool.

His words broke my heart. The back-story here is that I myself often wonder if we’re doing the right thing living far away from family. I have discussed moving back home countless times with my husband (ad nauseam really) but he’s adamant that we are building a better life for our kids by staying where we are, and in many ways I think he’s right.

I didn’t feel a desire to flock back home until after I had kids. My husband and I both left home at 18. We come from involved and attentive families who sacrificed their own quality of life to provide us with everything we needed, and we subsequently both attended the same Ivy League college. After college we went our separate ways but found ourselves living in the same city (not near our parents) a few years later. 9 years after college, we moved together to the opposite coast because it’s what we wanted to do. We had both flirted with the idea and thought it would be a great time to try it. We ultimately stayed because my husband achieved some career success locally, even though, had I been single, I would have likely left the state. After our first was born, we stayed because we had a house and great jobs, and we have stayed since for similar reasons: it’s comfortable, we have short commutes, we have great careers, we love the area.

I grapple with staying a lot (my husband, who is very rational and pragmatic – as I have mentioned – does not). I often wish we had extra sets of hands to help out with the kids. We are on our own in terms of childcare, with the exception of that which we pay for. I also think the kids would grow to be more well-rounded if they had different caregivers intimately involved in their care. We have a lovely nanny, and she has been around since my first was born, but as much as we trust her, it’s just not the same as family. My closest friends are also here, and I find it so time-consuming to make adult friendships, especially with kids and working full-time. I also think about the fact that our parents are getting older. These are the years they will enjoy with their grandkids – when the grandparents are young enough to spend quality time with them and the grandkids are young enough to love spending this time with them, before they become self-absorbed teenagers. If anything happens to our parents, will I regret not living closer when it mattered the most?

More and more of our friends and acquaintances are moving out of state, for one reason or another. Some days I yearn to be one of them as well – packing up the house, putting it on the market, starting our lives elsewhere. But really I would only move back home, which is funny because I didn’t particularly love growing up here. As I’ve mentioned, my parents were great, but I moved when I was about to start high school, and this put a bit of a damper on everything. Adolescence is tough! I actually disliked my house for the longest time, but now that I’m an adult who has purchased a home in a high cost-of-living area, I can’t help but think: it’s so large! Look at all of this space and land! What a steal!

I am sure my oldest will wake up feeling fine tomorrow morning, but I don’t think my own feelings will be forgotten so quickly. I don’t know what the right answer is, and I don’t want to pressure my husband into making a decision until I am certain it is the right choice. And so I’m stuck in limbo, flying back and forth, feeling not-quite in each place, trying to put a positive spin on the situation for my kids. It reminds me of a few lines I read in the book “This Is How It Always Is” by Laurie Frankel:

“This is how it always is. You have to make these huge decision on behalf of your kid, this tiny human whose fate and future is entirely in your hands. Who trusts you to know what’s good and right and then to be able to make that happen. You never have enough information. You don’t get to see the future. And if you screw up – if with your incomplete contradictory information you make the wrong call – nothing less than your child’s entire future and happiness is at stake. It’s impossible. It’s heartbreaking. It’s maddening. But there’s no alternative.”