From PCOS to Parenthood: A Candid Journey Through Fertility, Birth, and Motherhood with Michelle Powers, CNM

0:00 Hello, today I have with me Michelle Powers. Michelle is a certified nurse, midwife and the mother of two, and today she is here to share her fertility and birth journey with us. Michelle, welcome and thank you for joining me. Hi everyone. Thanks Kelly for having me on. As Kelly mentioned, my name is Michelle. I happen to be very privileged to work Within the birth field. I'm a certified nurse midwife, which means I have a master's of science in nursing, and I get the privilege to take care of women across the lifespan, which includes gynecology as well as obstetrics, prenatal care and, of course, doing deliveries within a hospital setting. I am the very honored mom of two boys.

0:41 My oldest is Nate. He was born in December of 2018. And my youngest is Samuel, and he was born in December of 2022. So he's approaching, like she is, five months now. So a little bit about me and how I very much got to become a mom of two. I was on a perfect journey. I was not one of the lucky friends of ours or patients who got to spontaneously get pregnant. As Kelly mentioned, my infertility journey is one that's pretty expansive From the get-go. I had the mom when I was a teenager who said it's weird that you haven't gotten your period You're 15.

1:26 This is strange. Whereas I thought it was great, who wants that? My friends are miserable. But she took me to our local pediatrician, who referred us to Duke University where I got to know somebody who was very advanced in the field for managing Polycystic Ovarian Syndrome, or PCOS. Now, more and more, over the past decade or so, lots more of information has come out about PCOS and its impact on the lives of women across the lifespan and across the age. But, most specifically, one of the things that we talk about PCOS most commonly for is infertility, or trouble getting pregnant.

2:07 The biggest reason that happens is because, even though there are many women who have PCOS who maybe get a regular period, and there are those of us who don't But more importantly is that we do not ovulate. So ovulation is the process by which the body or the ovaries spontaneously release an egg, and if you, as the female partner in a relationship that is planning to get pregnant the female that is trying to get pregnant are not releasing eggs, then there is no genetic material to form an embryo or to form a pregnancy. You're missing half, and so, although there are more studies, medications and suggestions out there, a lot of us women with PCOS tend to seek reproductive services or infertility services.

2:57 Being somebody who lives in the Northern Virginia area, i was very pleased to see that we had a high resource environment and high resource community. So I was able to get evaluated and it was not easy. We attempted to do some low intervention infertility work. First We tried intrauterine insemination, which is non-surgical It's where my partner of choice, which happens to be my husband his genetic material was, with a procedure, kind of put inside of my body so that an egg and sperm could meet to create an embryo. We tried that about five times, all without success. So during that took about a year And even before that all the testing and some weight loss and some medication attempts he had visits, all this type of work up were probably about two years into it and still not pregnant.

3:47 There's definitely some really low lows during that time. Feeling especially as somebody who has the privilege to work taking care of women who are pregnant, it was really hard to see all these successful birth stories, successful pregnancy stories, when I couldn't have one of my own. But through that, with counseling and support from my partner and my village, we eventually decided to make the leap from IUI or intrauterine insemination to a procedure called IVF or in vitro fertilization. This did involve a surgical component. This is where, after medication that I was taking as well as injected, my ovaries on ultrasound demonstrated that I had lots of eggs that were mature And so with surgery, they took the eggs out of my ovaries and put them into their science lab And, with the genetic material of my choosing from a male partner, which again happened to be my spouse, my husband they created embryos in their reproductive lab.

4:44 So this is where they joined the egg and the sperm outside of my body and fed these embryos, and we got daily updates about how the eggs were doing, how the embryos were doing. Statistically, about 50% of the eggs collected die before sperm can be successfully inserted into creating an embryo. So we were lucky enough to follow that statistic and they harvested 20 eggs from my body and we ended up getting 10 healthy embryos. That's a pretty normal statistic to get double the eggs and only have so many embryos that are healthy. We were very lucky to feel safe enough in our health history to not need to do further testing on the embryos, and so we froze nine embryos and that 10th embryo became our first pregnancy, and I luckily had a very safe and healthy pregnancy.

5:35 We found that it was more that I didn't release an egg, but my uterus did okay and kept a healthy pregnancy. I did get hypertension with my first, and so I had an induction of labor at 37 weeks and delivered Nate. That was very exciting and we loved everything about it. And then with Samuel or Sammy, our youngest, second time around was a little bit easier less medications, no surgery, since we had frozen embryos through our reproductive endocrinologist, our infertility team, we were able to just go in a little bit of medication and tell them our desire or plan of when we'd want to have that embryo put inside of my uterus And luckily, again that worked out very successfully.

6:20 Another healthy pregnancy. This time we had gestational diabetes that I needed insulin to control, and hypertension, and so again I got induced at 37 weeks and had baby Sammy. I did have two vaginal deliveries, one with each boy. I did not have any postpartum complications other than just continuing to need medication to manage my blood pressure. For about a month postpartum With Nathaniel, my first Nate, i had pretty severe postpartum depression. I sought counseling and I got put on a mood stabilizer called Lexapro. I am still on that medication today and I did continue that medication through the pregnancy with Sammy and that really did seem to help my postpartum course this past time. I think that's a lot about me.

7:01 You're like that with a lot of information. Yeah. I want more though. Let's talk about your births. So you got induced. When did you find out you had the gestational hypertension? Yes. So with Nate I was 36 weeks pregnant and didn't feel great, and my husband also happens to be a family nurse practitioner. And so I said, hey, do you have your blood pressure cough? I don't feel great, i'd like you to take my blood pressure. So he takes it to the manual cuffs and it's mildly elevated. And he says, yeah, but I don't think this is the right cuff size for you.

7:41 And I looked at him and I said 10 bucks, as I get induced in less than a week. In case anybody wants to know how that worked out, i was right, anyone's keeping tabs. And so at my 37 week visit, my first blood pressure was elevated and was met criteria. Now, by chance, i happened to be being taken care of by the practice that I worked for as a certified nurse midwife. So I went about seeing my patients on my schedule and four hours later took my blood pressure again in the office. It was still elevated, and so we decided that for safety, we would call up labor and delivery and see what they could do. And so I found out at about 37 weeks in one day, because it was a Monday And my gestational age weeks changed on Sunday And we were admitted Wednesday evening and I delivered Friday morning.

8:28 Amazing. Just go on and work through that hypertension. Work the next day delivering babies, delivered babies and then had another half day. Came home, installed the car seat, grabbed some Chick-fil-A and headed in. Awesome, So most classic provider story ever Yeah. So just to clarify on the recommendations, when you have a high blood pressure that is within the range that's not severe range that needs to be treated right. So you have to have two that are four hours apart. Yeah. So the diagnosis of gestational hypertension is you have blood pressure readings, at least two of them, two data points where either the top number is greater than or equal to 140 and or the bottom number is greater than or equal to 90.

9:20 So, like a 136 over 92 still rules in, a 144 over 88 still rules in. And the reason that we recommend having two at least four hours apart or longer, right. So if it was just an office visit and they were seeing you back in like a day or two again that may still rule you in is because part of gestational hypertension, and really part of hypertension and pregnancy, is that it can really call labial, right, it is not unheard of to have a pressure that is elevated and may be something that we say, oh, this meets a certain criteria we have for potentially a diagnosis, and then have two hours of normal and then all of a sudden have another one.

10:04 And that's because it's not chronic, it's not something where your body is changing forever. It's being impacted by the pregnancy and the placenta and the gestational age And it's saying, hey, i'm okay, but I'm not great. And when that starts to happen, the safest recommendation is delivery, because that truly is the cure right Now, depending on your gestational age medication, or watch and wait, maybe a safe alternative, once your full term, which is 37 weeks or greater in your pregnancy weeks. at that point there's only risk right, and so the recommendation then becomes move towards delivery in a safe manner versus waiting it out.

10:52 So then, the difference between that gestational hypertension and we need to move now is if you have one of those really severe range like potential to have a stroke or a seizure range. Yeah, it's usually more about mom, right? I mean, we know as any, as any pregnant woman who's even kind of happy about being pregnant, pregnancy is not easy. It is not for the faint of heart. But most of us at least, once we hit a certain point, the pregnancy say okay, i am excited about the outcome of this pregnancy, i am desiring a healthy outcome of this pregnancy Once there comes a point where we actually are about mom.

11:34 At this point, although, yes, a maternal seizure the pregnant woman has the seizure or things of that nature could impact baby, babies actually tend to do okay, they're well protected It's mom who actually potentially is the greatest risk to her health. And we've come so far to grow a healthy baby. We want that baby to have its mom, we want this family intact and complete. And so if we are recommending either an expedited path to delivery, whether that's preterm or full term, or potentially even bypassing an induction due to significant maternal factors and clinical findings that dictate that a two to three day induction may not be safe from mom's outcomes and therefore a C-section or a surgical delivery is recommended, that all comes down to maternal health.

12:23 And so when we're talking about that, we're talking about blood pressures that are 160 over 100 or higher, and those tend to be much more consistent. They tend to be it's not that you go from 160 down to 120, right, you go to 160, you're like 158. Woo, right, like it's not the same, where you're like, oh, i'm 138 over 98 and then I'm 112. Like, that's justational. All right, fine, mild hypertension, okay, no, when you've got your severe range pressures, there's actually some lab values that tend to dictate that there's been some other potential internal changes to mom's organs. And we're, for better or for worse, we're racing a clock, right?

13:03 We know that in labor and delivery, in pregnancy, even things can change on a dime, right, we have women who have excellent fetal movement and then don't. We have women who are having no bleeding, and they're having bleeding, and same can go with hypertension. Once you've hit a certain maternal factor or eternal clinical symptom severe range pressures you're racing the clock. Pressures are one thing. Lab values on top of bad pressures are a whole different ball game, and so we're monitoring all of that. But the answer is that we want your family to be intact, from munchkin to mom to dad, so you can all go through the drama together, right? But in order to do that, sometimes we have to give recommendations that feel intense and they feel sudden and they feel severe, and especially when they say but I felt so good during pregnancy.

13:53 I know, and I love that for you, but your body has changed its mind for better, for worse. Your body has said I'm so glad, you feel great and your pelvic pain isn't so bad, but your blood pressure is through the roof, so I need to come out And there's nothing to do about it. It's not that they ate the wrong food or they should have waited to get pregnant for six more months or anything like that. Right, this is a pathophysiological reaction that some women have to pregnancy, and as long as we are super close to full term or full term, we have a baby. Yeah, that really sums it up well. I was thinking about how I feel like people need to hear this over and over, and, over and over again, because I mean, there's so many factors that go into a healthy pregnancy and we have the technology to be able to intervene when necessary and thank goodness for that And it isn't always what we wanted, but the outcome is what we want.

14:46 We want the healthy baby, we want a healthy mom. Right, and I think that now I'm not saying that bedside manner doesn't matter by any means. Oh, it does, right, and a situation is key to success. But, that being said, i totally understand. I mean, 37 weeks feels early, right, even for the person who potentially is tired of being pregnant. The odds are family wasn't planning to come into town, maybe the car seat isn't even purchased yet, because they thought they had two to three more weeks, right? Heck, first time moms assume they're going past their due date. So here we are, taking this presumed expectation that they have set specific things in motion by and brushing it all away, and it can feel very overwhelming to say no, i'm sorry, but you need to be admitted and we need to work towards your birth now.

15:33 And all they think is but that wasn't the plan, right? Oh, i know, we know it wasn't our plan either. It makes you feel any better. It also wasn't my plan for my patients. But when there's no other choice, usually people come around right And again you just. It's that explanation of you're right, your baby is okay And I'm so glad your baby is okay, but I can't promise that you will be okay if you stay pregnant And if you're not okay. As the vessel, as the carrier of this munchkin, then by default, your munchkin's not okay. Your situation was the gestational hypertension, so you didn't have severe range, and so then, once you got to full term, the recommendation was to deliver. So how did that go for you? after having all of the experience with moms and delivery, what was your experience like?

16:18 It wasn't terrible. Actually I didn't mind an induction, only the fact that I had given a what to expect on an induction spiel for the past 10 years of my life. It was very helpful. But I will also say that I deeply respect the impatience. I definitely had that. As much as it is so fruitful to do the what we call ripening stage of an induction, which feels so slow. It was necessary But it does. You feel like you're just sitting there. It's really tough because it feels very clinical. You've also been told that this is necessary for safety. Why are we taking our time with it? So there's a whole mix of emotions.

17:01 But that part wasn't terrible. I did do a cervical ripening balloon. I didn't mind it. I thought it was fine At that point. I think it was more. It was either cervical ripening balloon and bounce on the ball and deal with some pressure or potentially go another six to 18 hours chilling before we started pitocin And that I just I could not mentally do that. I would take the pressure. So we did. So we got admitted late on a Wednesday evening. I was lucky enough to be about one centimeter. We started with ripening medication called cytotech or mesoprostol, and so I took that medicine by mouth and then they used a what we call a mechanical dilation or mechanical ripening device called a cervical ripening balloon.

17:45 That applies pressure to the cervix and helps soften it and open it. with a little bit of that pressure, especially when baby's head is not really well in the pelvis yet, which is common for first time moms that what we call descent, or the head moving lower down, takes usually later in the process or the progress of labor for a first time mom, and so that balloon applies that needed pressure to the cervix, kind of start to melt it open. I always talk about to my patients the cervix being like that soft mound of clay on a potter's wheel right And so that soft clay. The idea is that with gentle pressure from your thumbs it will open into a bowl or a plate right. The cervix is kind of the same thing.

18:25 If you have super cold clay that's not warmed up yet, you're not going to be able to apply just gentle pressure and get it to mold into that opening. You have to work it first. And so, similar to a cervix, we have to soften that cervix, we have to get it warmed up, we have to ripen it in order for when we start medication for contractions, which is putosin synthetic oxytocin that the cervix is ready. The cervix has done its job to start to soften so that as we apply kind of that pressure, we're putting pressure on the gas, we're starting to get your uterus working. The cervix is more agreeable to open and dilate. And so I did the cervical ripening and then we started putosin And then I was very nervous as a first time mom, not necessarily actually about pain.

19:14 I also had an excessive amount of fluid, which is normal with giant babies and potentially PCOS moms, and so I had a lot of fluid and so I was very scared of having to go to the operating room after they broke my water potentially an emergency and having to go on to general anesthesia. So even though I was not uncomfortable yet, i opted for an epidural at about four centimeters before they broke my water so that if something happened I could stay awake during the surgery. So I got my epidural. It was excellent, best choice. My husband and I were very thrilled with that part of the labor. They then broke my water and basically from between Thursday at about 4pm when they broke my water, i made pretty decent change.

19:55 I did get an IUPC, which is a way to monitor contractions from the inside versus the outside of my abdomen, to make sure that I had the right amount of putosin, that I needed a little bit more specific data collection to help with some unique care planning. And then I was obsessed As a bedside nurse. Kelly's going to be very offended by this, but I was obsessed with making sure I got turned every hour. So I would set an alarm and I would hit my nurse call light. Please don't do that to anyone. I just have neuroses, please don't be me. So I would set an alarm. And finally my husband and my bedside nurse, who were lovely, stole my phone and she set her own alarm so that I wouldn't be waking the entire room up every hour on the hour to get rotated.

20:38 So it was big believer in my spinning babies and my movement with my peanut ball, especially after my colleague who was my doctor at the time, said oh, munchkin feels asynchritic, oh, and then I went off the rails. I was like oh, every 45 minutes. So, nope, gotta do it. So don't be like me. I promise it's fine. The nurses know what they're doing, trust them. But I loved getting moved. I did all the positions, side to side, upright, the whole kit and caboodle. And then my provider checked me and she's like okay, you're complete. You're like plus one. This is great, you're going to start pushing, i'm going to go take a shower and then we'll deliver before eight o'clock. And I said awesome, sounds great. So I brushed my teeth with my little spit bowl because I can't move with my epidural.

21:19 I'd be like get ready My mom and my sister there, it's pre-COVID. Obviously We're very peaceful. I pushed twice and my nurse says you have to stop pushing. And my instinct goes why? The baby's heart rate is fine, because why else would anyone tell you to stop pushing? What's going on? And she goes you're going to have your baby without a provider in the room. And I was like but I am a provider. She was like no, not the same thing. I was like okay. So I got to sit there for another 15 minutes just chilling as my child is crowning and I'm feeling nothing because there was no one in the room. My doctor was in the shower, luckily, obviously didn't really care because it was fine. So, yes, i had two colleagues in the room when I delivered, because it was change of shift, because of course it's like 730 in the morning.

22:00 So I had my night nurse, my day nurse, two docs and it was great. I was very fortunate to only push for about 20 to 23 minutes, which is very unheard of as first time mother. Again, i don't know why I was lucky enough to do that. It makes me feel better. That was not the case with the second one And so, but it was great. And he came out screaming, crying and he went straight to my chest. I had a very standard second degree laceration which they repaired very nicely with my epidural intact. So I didn't do anything but some gentle pressure, which was very nice. No abnormal bleeding went up to postpartum. He got a little friendly when listening. In case you don't know, babies are kind of stupid.

22:42 They're real cute but they're real dumb And so he decided to have some breathing issues. He decided to try holding his breath, which is kind of frowned upon, and so my postpartum nurse freaked out. So he got a chest X right. It was fine. So of course Nikki was like do some skin to skin? I was like that's my plan. So he did sit into skin and then he was totally fine And we went home at 48 hours postpartum and it was great. It was everything I wanted, in the sense of I loved cuddling him. It was great. My family was amazing. It's a lot of work. I did not realize how much I didn't know, considering I had been so immersed in the birth world and the birth community for so long and had dedicated theoretically, my career, my professional life, to this, i felt very surprised by what I didn't know, and that probably was the biggest cause for my post-partum depression.

23:33 I just didn't know what I would need and I thought I did. I thought it was just some support here and there and just cuddles and time away from work, and I am too extroverted for that. So I actually more visits, and not again. I didn't need them to hold the baby, but I needed people time. I needed people physically in my line of sight, and with paternity leave, as short as it is, that wasn't really a thing, and so I was quick to realize how lonely I was, and so once we figured that out it got way better, but took hitting some rock bottom there. There's only so much reality TV you can watch before you are probably close to clinically insane. And so, you know, got into counseling, made better arrangements with friends and colleagues and my family to have somebody pretty much there.

24:22 And again, it wasn't that I needed someone to hold the baby, i just needed someone to interact with me as an adult. And so, you know, i learned even more about myself, for sure. But no post-partum complications after that With Sammy. On the other hand, i had some early bleeding, very much convinced myself while working me I had had bleeding while I was on call, definitely believed I was miscarrying. I was frantic. I was on with a colleague of mine and I was like you have to, son of me. She was like there's nothing I'm going to be able to see. You are six weeks pregnant. And I was like you have to, son of me, you have to tell me what's going on. Which, of course, resulted in no information because, as it should, but freaked out, had convinced myself and my village that this had not been successful and you know we were going to have to make arrangements for another transfer and you know all this stuff.

25:14 So kind of trudged my way at about seven weeks, to my scheduled appointment with my infertility provider and was like this one I had a ton of bleeding, it lasted for like two days. You know, i know what you're going to find. They were like oh my gosh, you should have called. We're so sorry. Let's just, you know, confirm that there's nothing left in the uterus. I was like, of course there was heart tones. So here we are, mm-hmm, yep, i did a lot of swearing that day, as did my provider, because we were both very shocked. It was great. But, mm, yes, that was really good thing. I did my Lex pro that day. That was very strange And my first lesson in no pregnancy is the same Right, i say it so I'm blue in the face with my patients and yet I needed to apparently learn that lesson firsthand.

25:57 So already starting very different with Sammy and because of my PCOS and my body mass index, there's a recommendation for an early glucose screening to make sure that I don't have either type two diabetes or what we call pre gestational diabetes. I did great, rocked it, super excited, feel like we're doing great gloriously failed my 28 week blood sugar test. I was immediately diagnosed with gestational diabetes, didn't even have to do a three hour, just really went for it. And the thumb in common. One of the symptoms or part of the metabolic triad with someone who has polycystic ovarian syndrome or PCOS is something called insulin resistance. This is where your pancreas works.

26:38 It's that you make insulin. It's that your cells don't necessarily have the most intense response to insulin, so insulin is supposed to be a little bit like a lock in key. Insulin is supposed to talk to the cell, open the cell up so that sugar from the bloodstream can go into a cell, so the cell can utilize it to carry out its cellular functions. Well, with women who have PCOS, we have something called insulin resistance. It's like there's something where the key doesn't fit into the cell lock every time, whereas often or as routinely as we want it to. So more sugar stays in our bloodstream for longer, therefore potentially increasing our risk for adipose tissue or fat or a larger BMI. But it also makes it much more common for us to have gestational diabetes and pregnancy, because it's basically our natural state.

27:20 Our natural state of insulin resistance is, on some level, diabetes, and so it wasn't surprising, but it was definitely different. I started with oral medication that didn't do a lot, so went to insulin pretty quickly and needed a hefty amount of it to keep things under control, even with strict diet and exercise guidelines, measuring my food, the whole thing, which was definitely different. I only needed injections in my first pregnancy to get pregnant. I definitely didn't need them any other time. So back on. Injections was fine, but different, especially having a four-year-old who's like mom, why are you giving yourself a shot? Let's have that conversation 900 times, thank God, they're so curious, and so we would have to teach Nate every day this is mommy's medicine.

28:07 No, you don't need a shot, it was on replay. But part of that definitely led to some concerns for Sammy gestational diabetes. When you're on medication, the recommendation is to consider an induction of labor between 38 and 39 weeks, and that's because at some point we do worry about not only fetal size. But the other is that there's risk to maternal and fetal cardiovascular systems. When you're on that type of medication. At some point there's a risk that it stops working really well, and the more high blood sugars you have, the more likely you are to potentially have vascular damage from the pregnant woman's side, as well as potentially that sugar passing through the placenta to munchkins, veins and arteries and also potentially causing damage or trauma there.

28:51 So I knew that going into it And I thought, okay, well, i'll be a couple extra days pregnant. And then blood pressure went up again. Sure, not surprising, we'll argue. It was stressed. This time We'll say it wasn't pregnancy. My own mental health This time was a little bit different with Sammy. The pressure started mild range. So for gestational hypertension, same kind of criteria blood pressures couple hours apart, meeting criteria, no problem. We kind of knew that this was coming, so we just kind of moved the date up a couple of days in order to have an induction date. My village was ready. We knew this was happening, so we got to go hang out with grandma and grandpa. My husband and I got admitted. While in labor my pressures did hit some severe range.

29:31 I did not necessarily need IV hypertension medication, but I did need oral hypertension medication And I did continue it for a month postpartum as my blood pressures remained elevated. Nothing about that is abnormal, unfortunate. Only because again just feels like a lot, but that is pretty common with hypertension of pregnancy. Just because, yes, the cure is delivery, that doesn't mean that your body suddenly doesn't know that it wasn't just pregnant And so it's those pregnancy hormones and all of that that can still persist and perpetuate those elevated blood pressures. So nothing totally out of the ordinary. The next biggest thing I learned, though, with Sammy, was that gestational diabetes?

30:13 especially when you have abnormal fastings, which is the first blood sugar you take in the morning after not eating anything. When those are consistently high, it can decrease the amount of surfactant, which is kind of like a lung goo that your body makes, that we all have. That babies need to make in order to help their lungs inflate and have that oxygenation exchange. So in the bronchi, in the avioli, which are the branches of the vessels inside of our lungs. That's where oxygen is exchanged from the lungs into the blood and then carried to the organs And so that surfactant helps with that process. And in a pregnancy, in a growing baby, the surfactant and Munchkin's insulin are actually made by the same pathway And so if a baby has to start potentially making its own insulin prior to delivery, its ability to make surfactant or enough of surfactant can be jeopardized or diminished.

31:10 So that's what happened to Sammy. So we delivered at 37 and a half weeks vaginal delivery and other induction slower than I would have expected as a second time mom, but tell that story. But Sammy ended up going to the NICU. He initially just needed some observation in the nursery. I was taking a pretty decent nap and I kind of knock on my door from a colleague saying that the NICU provider once talked to me and lovely, lovely man, i worked with him as a nurse, midwife, knew him well And he says hey, and I thought biscuits okay. And I said hey, yourselves. And he says so remember how he made that joke that, like you wouldn't need to see me after the baby was out because you'd be full term.

31:52 I said sure do. And he said I'm admitting your baby And I said okay. And so Sammy went upstairs to join the NICU crew. He was on nasal cannula oxygen. He got a nasal gastric tube for a couple of feeds because he needed so much oxygen. He was there for a total of five days two and a half days of intervention, two and a half days of no intervention to just pass all the quote, unquote tests based on their protocols. And then he finally got to come home and has been amazing ever since. But I definitely didn't expect that, you know, especially considering he was smaller than his brother. We felt like we had controlled everything else. We did not expect a respiratory transition concern, but very grateful that there was a NICU with our hospital planned birth to alleviate those concerns in the safest, best way possible.

32:39 So in Sammy's induction I was similar. I was not one, and so again we started with cytotek. My blood pressures were not severe range at this point. My lab values were normal, so we felt like we had the time. So we started with cytotek. I ended up getting two doses. I yes, of course opted for the cervical ripening balloon. Again, i took the pressure and moved on And then similarly got on Potosin, had my water broken and with time and effort got to 10 centimeters. It wasn't necessarily that it was much slower, but it definitely felt slower for whatever reason. This time around My epidural didn't work And so I got an epidural at about four centimeters prior to my water being broken And I thought I felt pretty good.

33:24 But then they broke my water and placed my bladder catheter and I felt it all And I just kind of ignored it. I just thought it just maybe hasn't set in right, haven't had enough time since they placed it, and as I started to dilate more and contractions came on, it really wasn't covering it. So we tried giving more and more medicine. That didn't work. We tried replacing it. That worked a little bit, and so ultimately by the time it wasn't necessarily abdomen or back pain, but it was very pelvic and hip pain and definitely felt the pressure to push the burning ring of fire. Lots of tears between myself and my partner just because it was so different With Nate.

34:08 I really truly felt nothing. Pushing was such this blasé experience. The whole thing was blasé. I really was like, oh, you could probably cut me open and I wouldn't feel anything. Okay, and Sammy was definitely not like that. There was significant discomfort that led to just fatigue and processing difficulties. It was really hard to regulate myself, pet talk myself up for two reasons. One is it hadn't been my plan. My plan was not to experience an unmedicated labor course And my previous experience was just so different. I only had one experience with anesthesia. It was so excellent that anything but that I wasn't mentally prepared for. Luckily, all is well that ends well, pushed, very efficiently.

34:51 Yelled at my provider After delivering him thought I might get fired because of the things I said to her. Not, her. She's not the one that's going to be upset about that. Nope, she laughed it off like the gem that she is, the treasure. But, yes, yelled at her very strongly, yep, one of the excellent night nurses yelled at her, screamed her. She got in my face and told me to calm down, which was very helpful and necessary. So, really good colleague, bonding right there. Really, yeah, it was great. But no, i mean all in all, in terms of you know, in the grand scheme of things, as I my husband is probably listening can hear, i couldn't reproduce the pain. If I wanted to, i couldn't. I couldn't talk about the emotions.

35:32 For sure, i remember what, how strenuous it felt, and feeling and turning to my partner for support, even though he is, as I am well aware, working in the community. He can't do much for me, right, and so, even though he was so willing and graciously to accept that burden that I was trying to put on him, he felt just as helpless as I did, and so, although we both felt safe in the encounter, it was processing those emotions. I can feel those, i remember those moments, but I couldn't tell you what the pain was like. I couldn't describe it. Now I have no idea, you know, and that is good, i think. The halo effect. Right, i mean I. I mean I remembered on some level in a sense, that I remember I couldn't stop right. I had to push, I needed it to end, but there's nothing I could do right now that I feel like I could reproduce this, that same intensity.

36:18 I feel like when I stub my toe, it gets close. Yeah, there are certain things you're like, oh yeah. Or like I have like severe diarrhea and a stub toe at the same time. Yes, So that is still true. Yeah, oh yeah, gastric, upset is probably as close as you're going to get. Yeah. But the bone pain for me is like a stubbed toe. But you can't. You can't make it stop. Yeah, but the the rectal awareness Yes, there is only only gastric upset really does put you right back in it, right, because it is sometimes that intense and that's unforgiving. But you know, again, in that sense all went very well. I was very comfortable with the management plan. I was comfortable with the induction plan.

36:59 For better or worse, i knew when I was getting myself into if the epidural was not working, was not to participate in, or things I had prepped for mentally. I had prepped for the cervical ripening balloon. I had prepped for exams. I had prepped for artificial rupture of membranes or an amniotomy, which is where the provider breaks your water. I had mentally prepped for all that. I had coached my husband through all those expectations, you know. So that part had certainly helped. Now, part of it's because it's what I do for a living. The other is, even he had some experience, right. I mean that roughly the same type of scale happened with our first. So even though sure did, i wish it had gone faster, yes, but it wasn't terrible. So you said that pushing was different with both, and I hear you coach people all the time in pushing.

37:43 So did you practice what you prepped? So actually, yes, i really did on some level. My husband always says, not with the Sammy, but with the first one his biggest takeaway of almost like shock and awe other than like birth as a general, all-encompassing thing, was how quiet I was with pushing. He was really surprised And part of that was because all he's seen is some maiden Hollywood movie about a woman screaming as she births a baby, right. But he also just didn't realize the type of like inner focus that it can take. And so I did. I said to myself, with pushing with Nate, i said, okay, what would you tell a patient? Okay, so you would go into this position, you would try and relax your face, you would try and take all that energy, even if you can't feel where you're pushing it.

38:32 You would visualize abstractly forcing that energy into your bottom right And being pregnant constipation very common side effect, right, Very common complaint. I put myself back there. I said, okay, the last time you were constipated, sitting on a toilet trying to have a bowel movement, what did that feel like? Where were you pushing that energy towards? And I did, i kind of talked myself through it And I tried in that sense, even though I know there were certain recommendations made, because I remember hearing them. Whether or not I took their recommendations, i don't know. I think I was so focused on being like, okay, this is what you would tell a patient.

39:12 Does this work? And partly it was for my own kind of science. Experiment is what I'm saying to a patient that can remotely relatable or successful. And the other was well, at least I've done enough deliveries where I said it over and over again, something clearly works. So let me at least try my own advice and see if it works. And it did. I mean, there is a way there without an epidural. The vaginal canal, you know. And ultimately, when we're talking about birth, the birth canal, the nerves are not placed super great right. So you have to nerve innervation deeper, into more, the like what feels like rectal tissue or very like low posterior vaginal canal, so towards your spine.

39:53 And then there's nerve endings around the labial and at the clitoral hood right, and those are for multiple reasons. One is survival instinct, right. You need to know when you have to have a bowel movement. That's how you excrete waste. You can't keep your waste inside your body or you get sick, right? So you have to have something that triggers your body to tell you to release the waste or have a bowel movement For labia and clitoral hood. Part of this is safety, right, you want to know when something is getting near a vulnerable part of you, right? Mucous membranes. Obviously, in a social context, a different, you know, argument of awareness and vulnerability. And also for those of us in a consensual relationship that is looking for pleasure from sexual inner course, having some nerve endings in that area is also helpful.

40:36 But otherwise the rest of the canal is not awesome for any of that, much to the dismay of providers, potentially women of all ages in a consensual relationship, it doesn't do a whole lot. And so sometimes, until the baby is low enough in the birth canal to innervate or push on those nerves that innervate more of the rectal tissue or the posterior vaginal canal, or right as baby's head is starting to stretch, open the labia and potentially push pressure against the clitoral hood, a lot of it is guesswork, right, and none of us, ideally, have pushed something out of our vagina, granted, right? Ideally, that's the idea, right, even if it's experimenting, right, those of us who use tampons or diva cups.

41:21 No one's trying to expel something from there, right? However, on a regular basis. We're attempting to expel something from our butt. So the encouragement is push into your butt. And it's not inspirational and it's not pretty and it's not kind. And there are so many other kind of things I say to patients about how they're amazing and their birth story, and this, that and the other. Then we get to that point I'm like, oh, by the way, we're going to meet your kid, but push into your butt, yay. But it does work, amazingly enough. It does work And that's what I did. I tried to keep my face as relaxed as I could, took my big, deep breath, held my breath deep in my lungs, trying to use that as my powerhouse, my power source, and just focused on if I were trying to have a bowel movement, what would my body be doing to push, even if I couldn't feel it, where would my energy be going?

42:06 right, And patients say it all the time like I don't feel, like I'm doing anything, and I'm like, no, i promise you're doing all the right things, and so it really can be that abstract, but that's successful. Now, pushing with Sam is a little bit different. I very much knew when I was 10 centimeters. I had kind of gotten a little bit of extra medication in my epidural that kept me a little bit comfortable from eight to 10 centimeters, especially in a sitting up position versus a lying down position. When I remember looking at my nurse, kirsten, i said if I am not 10 centimeters, we are going to the operating room. I am done. Luckily I was 10. Excellent, and that's because the pressure was very suddenly overwhelming. I had gone from being like, okay, i can breathe or wiggle through this to I don't know if I can stay sitting, even though I'm not actually able to move my legs, and so there was a very much that sudden gastric upset, feeling like, oh, i need to wiggle in hopes that I get to a bathroom soon.

42:57 So that helped. That immediately gave me a sense of awareness. It immediately gave me a sense of direction to encourage where I or to help lead me and where I'm going to apply my energy and my force. The other thing that happened was we being complete and being uncomfortable very quickly got me into the pushing position I felt most successful and most strong lying flat on my back. That's a me thing. I enjoyed the idea of kind of like that row machine pulling back equally on my knees. Not everybody feels that way. When I talk to my patients about pushing, i ask where do you feel the strongest, where do you feel like you, mentally and emotionally, had the most success in your pushing? And if that's on your side, hands and knees flat on your back, whatever that may be, that's what I'm going for, because, again, if it is that abstract kind of discussion, regardless of my sensation, if your effort is going to be better because you feel successful, then we're going to utilize that emotion and push through it.

43:50 And so for me personally, i felt most successful on my back. So I got me into that position and as soon as we pulled my knees back, i started heaving something. It was the most intense pain I've ever felt in my entire life And I couldn't do it. I couldn't do it. I was like, oh nope, i need a vacuum, i need to. I can't do this. And so then we tried again because I was like, nope, i can pet myself up, just kidding, i can do this. Couldn't do it. She was like, okay, you're done, you're getting an epidural bowl. I was like I just had one two hours ago. She was, i don't really care, we're trying, we're doing this again. I was like, okay, so I got a little bowlless, gave it up 15 to 20 minutes, pulled my legs back And although it was intense, i could easily pep talk myself through it, i could harness it. It was no different than just like a really nasty workout.

44:31 You're just trying to push that last hill or those last crunches or whatever. I could find a natural, a personal pep voice to go through it. And pushing was efficient, thank God. But that direction was just more intense And it was different because the awareness was just so much more that, even though they were counting and coaching me and encouraging me, i definitely not in a bad way, but didn't need it because I was very aware, like I knew exactly how close I was, i knew what, probably how much of his head was out. And part of that is because, after one child and working in the field, there's a certain awareness that I expected like, oh, if I'm going to have pain, this must be what correlates with what.

45:11 And it was quite obvious when we went from okay, still completely inside the vaginal canal to, oh, probably almost to eyebrows, to, okay, the head and the shoulders are out, because it was. It just all felt very different And so in that sense those phrases and terms that you hear are out there right. So you feel pressure, you feel that almost spontaneous urge to give into that pressure Again, kind of that gastric distress, kind of almost having the poop sweats I had a mentor once call it where you're like you're starting to shake and wiggle if you don't get to a bathroom to a very intense almost burn. So the idea of almost that skin stretching to accommodate the head being just those nerve endings are just so friable in that sensitive tissue.

45:53 And then such this overwhelming relief as the largest part of him, his head, kind of came through And even with the shoulders again still needed to give a push. There was just just as a push, all like the circular part, right. So the head pushes on every nerve ending, all evenly. The shoulders only push in like two places. So it's much easier. And again, i didn't actually have any pain. They didn't have to give me local lidocaine for my very small repair, so I'm not sure why there was just this one section of my pelvis that didn't seem to get that anesthetic relief that we had hoped for. But again, I only pushed for about nine to 11 minutes, thank goodness, which can be normal for a second time, mom. So it wasn't totally surprising, but I was very ready to be done And again that part was different, although I still same idea of push into, give force towards your bottom, but instead of kind of this abstract mental picture that I was building for myself inside my head with my pep talk, i had physical factors that definitely triggered and helped with that direction very efficiently.

46:56 So everything after the birth was pretty straightforward, right. He reacted, cried, didn't have to go to the NICU. Yeah, so he didn't cry right away. Yeah, so Nate did. Nate cried great, right. Sammy didn't cry right away, which we were not totally surprised with. His abcaras I think were five and eight. But I was on Lexapro my whole pregnancy And so we weren't totally shocked that he maybe was a little bit respiratory lazy. He did pink up. We didn't call NICU or the pediatrician team to the bedside right away. It was not at a half an hour of life. We both thought he was a little grumpy. They came and assessed him, cleared him And then actually right before we went out to postpartum, the pediatrician that group that we see did rounds again, cleared him, went up to postpartum.

47:40 And at this point I've done skin to skin, which I didn't really do well with Nate. I was all too happy to have dads just my aunt now and grandma now to hold him, and so I didn't necessarily do a ton of skin to skin with Nate right away. And so I was really, really adamant about doing skin to skin with Sammy And so I had been doing skin to skin basically for almost two hours straight, other than some assessments here and there. And so we got up to postpartum and we decided that Sammy was going to go to the nursery, i was going to take a nap and Danny was going to head home for a nap in a shower, and it was while he was in the nursery he spontaneously desat it And they got some gunkies out of him right, got some niobiotic fluid. He didn't get a good squeeze.

48:20 There's only nine to 11 minutes of pushing, so again normal. They thought he was okay. But obviously after he desat it spontaneously he had to stay in the nursery for I think four hours. That's what our NICU neonatologist was going to give him. And within not even a full four hours he had spontaneously desat it. So they said no. So I got to snuggle him for five or seven more minutes before they took him to admit him to his new hotel in the NICU. And again, i had no idea until the neonatologist sat down and kind of talked to you about his theory for why Sammy didn't transition very well. I had no idea that they were of similar pathway for fetal development. That was crazy, amazing to learn and helped certainly my patient care on a whole different level. And although NICU was kind of scary, first and foremost they're amazing.

49:04 I got way more sleep than I would have expected, which was kind of nice. And they don't mess around. Up there Those nurses are. They run a tough ship And you know what Good They don't mess around a thing or two, and so they get those babies right. Those babies are good with sounds and lights and beeps and they'll sleep through anything. They don't care how many times you change their diaper Again. They'll sleep through anything. They get them on a feeding schedule for you. They literally like how often would you like to feed your baby? And I was like well before we left the feeding I am not somebody with PCOS who does breast feeding. I am not a great candidate for that And it does not help my mental health And they're like okay, so like 8, 12, 4 and 12, and I was like sure, no, no, that's what he was on when he came home And I was like this is great, it's the best thing ever, this is awesome, you know.

49:53 I mean I felt like I didn't know how to increase feeds with Nate. It was a big learning curve for me, considering breast feeding is the majority of the information you get. Formula feeding is not always discussed as well as it maybe should be, and so I didn't really know how to do it And it was really a trigger for me, thinking about Sammy's growth and development. And I didn't have to worry about it, nikki just did it. It was great. So, although I'm not saying that everyone should encourage to have a Nikki baby, it's great, that's awesome. Yeah, that's kind of how I thought that life was going to be, because I had been postpartum nurse on a not baby friendly unit when my daughter was born, and so I was just really expecting things to be on schedule immediately. But nope, that's not how it happened with my first baby.

50:34 So you did mention something that kind of came up for me when you're talking about how this affected, and was it the blood sugar to the insulin resistant that they were kind of made by the same? Yeah, so I guess, yeah, in fetal development the baby ideally doesn't start to make their own insulin until out of the body, right, or out of mom, i should say right as their own person, because it has to right, and so, because it's now doing all the things on its own, and it's not that it doesn't make insulin, it just makes a very small amount. Notice that the priority is almost like 80, 20. So 80% of this pathway is supposed to make surfactant and 20% insulin until certain triggers happen extra uterine life.

51:19 But when you have fastings that are uncontrolled and so they're elevated, right, that means that the longest duration of time where you're not checking your blood sugar, which is overnight, is Most likely also elevated. So here you now have no exercise to lower it. Potentially, even Your liver is continuing to try and make sugar because it doesn't know any better. Right, because that's what your does. Your liver does at night to try and keep you alive, is feed you, because you're not feeding yourself. So here you have this potentially 10 to 12 hour period where you have elevated blood sugars and that sugar is crossing the placenta and baby's body.

51:59 That pathway gets triggered because it feels like suddenly it's supposed to be doing something based on physiological changes of that influx of sugar sooner than it's supposed to. So suddenly that pathway becomes maybe 5050, 50% insulin and 50% surfactant. But that change in that decrease formation or decreased amount of form surfactant can Impact lung maturity long term. So the way it was explained to me was that even though Sammy was 37 weeks in the couple of days his lungs were maybe closer, like 35 and a half weeks. That's interesting to me, because what came up for me when you were telling me about that was like, oh, she's gonna have to get beta methasone.

52:40 But then I was like, wait a minute, she's Diabetic, so Diabetes is causing this. So then, like, the beta methasone can increase the blood sugar, and then so Obviously that wouldn't help. So not only would, yeah, and the other was that, at the point where you don't know till you know, and not in a bad way. But there's always a chance that, even with this potential pathway changing in its percentage of Successfully created surfactant versus insulin until munchkin comes out, even if you know it's a risk, it doesn't necessarily mean a transition issue. Right? That's like being able to forecast whether Every 36 week is gonna need the NICU admission versus a 41 week, and we know that's not true.

53:24 There are plenty of 36 weekers that kick butt and there are 41 weekers that need extra support. And so, even if there was concerns, there's no clinical advice or clinical data to support getting either surfactant or beta methasone during pregnancy, because, until you see that it's an issue, it's not an issue. Yeah, that makes sense. The other thing I was gonna ask you about was you had mentioned with your first pregnancy that you had Extra amniotic fluid and you were concerned about them breaking your water. So you've got the epidural. I know why you did that, but you really want me to say those big scared words, don't you? I do, i want people to understand because, okay, because we don't know, we don't know and so Yeah all right, so I will do that for you.

54:09 I really I assumed you were not gonna want me to say it. So There is, although ideally a low risk, there is a risk, whether even in spontaneous breaking of water, but usually, more specifically, when there's we call artificial rupture of membranes, or where the provider, while in a Labor course or in a hospital situation, breaks the bag of waters, breaks the membranes of water. There's many reasons that this is clinically recommended. Usually it's a it's an augmentative intervention, so the idea is that it's going to progress the labor course. The idea is that it's pushing you closer and closer towards delivery. So with my first with Nate in hindsight being 2020, we assume I had gestational diabetes with him.

54:51 I just so happened to pass the test like I just got lucky that day, because, between PCOS, insulin resistance and most likely undiagnosed gestational diabetes, extra fluid or poly hydrame neos is Very common. It's sometimes what we see when we're Hmm, could there have been some gestational diabetes and we missed it? and so that extra fluid. The concern is is that when they break the bag of water, there's always a chance that in a River rafting type experience with that big flow, that big gush, that forceful release of this pent up Fluid that it may pull something like the umbilical cord with it. So the umbilical cord is floating around in there right, for better or for worse babies tangled up in it.

55:35 Baby's not. It's a play thing. Yeah, it's just. They just coexist. But when the water comes, if the cord were to flow with it almost like a pebble or a leaf in a stream, if the cord comes Forward in front of the baby's head and then, as that fluid drains, baby's head settles down against the cord. Now the cord is trapped and that's what we call a cord prolapse, right, prolapse being that has fallen out or in front of something, and the cord being the umbilical cord. We don't want pressure on the umbilical cord. The umbilical cord is the pathway by which the placenta and mom Communicate to baby their oxygenation needs, their nutrition needs.

56:17 So if we have basically what's become a Turnicate, right, you have baby's head putting, slowing blood flow through the umbilical cord, therefore Slowing the deliverance of oxygen to munchkin. Well, munchkin's not gonna love that. It is considered an obstetrical emergency. There is no way to dislodge baby's head and push it back up. That is not a thing that we can do, and so usually the recommendation is an emergency C-section and the reason we say emergency is because, obviously, the longer baby goes that oxygen, the more likely there is for risk now Or other things we would do in that moment if sounds clinically to reduce the risk of baby truly getting no oxygen while we got baby out.

57:02 Of course, usually these things are found very quickly. Baby's do great Doesn't mean it's not scary and intense, but babies usually do fine. And so I was very fearful of this and, knowing that it was a risk, even if a small risk, i wanted to make sure that if I had an epidural I would be able to be awake for an emergency C-section and not put under general anesthesia, because if you have a cord prolapse you can't sit up for an Because you're just applying more pressure to the cord. So I wouldn't have been able to sit up again epidural, so I would have had to stay lying down, potentially with my hips elevated, to try and let gravity pull the baby's head back from the cord, things of that nature, and so that's why I did it. So I mainly had was doing it out of, even if there was a low risk, any risk.

57:46 I wanted to try and prioritize Certain outcomes right, and it wasn't even that I was against breaking my water. With that risk, knowledge right, i agreed with breaking my water as a step towards progress. I agreed with the intervention. It was more that knowing this intervention was needed and being okay with it. If there is an outcome that's unfavorable, how do I maximize the goodness of that outcome? right and for me, that was being awake, and so I wanted to eliminate a certain risk of Not being able to be awake. Yeah, and it's easier to do interventions when you have an epidural too, just because you're not gonna be fighting us. Yeah, you don't care if my hands in your vagina for a long? time, yeah, yeah that's what, friends, that's what the intervention is is.

58:29 My hand goes in your vagina and I pushed the head up Yeah, super lovely, real cool. We got real close. That's right. We got real close to real fast a lot of times right there in the weirdest way. Yeah, i'm like sitting on that. Yeah great, We ride in the bed to the OR together. So fun. The last thing that I wanted to ask you is if you could go back and talk to Michelle at any point in this process, or prior to this process, to tell you things that you wish you have known. What would you tell Michelle? So probably twofold. So the first one is I would probably not wish for it to be over as soon. Don't be wrong. I deeply. I'm so glad I didn't go to 39 weeks pregnant.

59:10 I was not a nice pregnant human Like I love being a mom, but I was not a nice pregnant human Like I just wasn't. So I'm sure all of my family and friends were very glad that I was induced, but I also, because I wasn't the nicest pregnant human, not so much with Sammy but with Nate. I just felt that I just had to get to the finish line, like I. Just I had to do it, i just had to get there. I just had to have this baby in my arms. Now, part of it was my infertility journey. I was ready for this prize. I was ready for the safe outcome. I was ready for this thing that I had been fighting for and climbing these mountains for For two plus years. But I also felt like I rushed it. I felt like I because I was a provider and I was rushing it. I didn't necessarily enjoy prenatal care. I didn't enjoy the ultra sounds as much as maybe I should.

59:51 I didn't like do a prenatal massage. I really enjoyed my baby shower. But again it just felt like it was this thing to like cross off the bucket list, and so I kind of wish that I had mentally slowed down maybe a little bit during my first pregnancy. I definitely did that on my second and I enjoyed it more a little bit. So you know I was still a cranky pregnant woman But I at least I slowed down a little. I mean, like I got a massage regularly, i like saw a chiropractor and you know I obsessed over the pictures and the ultrasounds and you know I went to my prenatal visits and I asked questions even though I didn't really need to and you know I just kind of faked it till I made it, which was a little bit nicer. The other is actually less about labor and delivery, and not because I I know about labor and delivery or anything going into it.

1:00:32 I honestly had scheduled a c-section with Nate because he was trending so large that I was like you know what, if we go to 39 and a half weeks, i'm not even playing this game. And having an elective c-section for giant baby, i'm not risking this, i want to save my vagina. I don't want anything to get stuck or injured. No, we're done. And then when I had to be delivered because of clinical changes my blood pressure early, we decided to give it a shot because that was more average, right, and he was still 8 pounds, 6 ounces. He was not cheap or thin at 37 weeks by any means. But I really wish that someone had said to me Michelle, nobody talks about formula feeding.

1:01:12 I was so open from the get-go with my providers, my colleagues, with my village that I was formula feeding like. I was like Please do not send lactation into my room. I don't want to hear it. It's a waste of their time. They have way more important patients to see than me. Like they do not have to write a note on me. Please just don't even make it a thing. Right? I had decided before 20 weeks with Nate that I wasn't doing it. Between my PCOS and what I thought I was going to need, mental health wise, i just couldn't do it. I needed to be able to allow my village to care for my son in times of feeding as well. But I wish someone had said to me like they're not gonna know how to teach you. They are so focused on breastfeeding. We got home from the hospital at you know whatever 48, 49 hours post-delivery, and no one had told us to increase the amount we were giving him.

1:01:58 We were still giving him less than a fluid ounce, because that's what they told us to give him, so that's what we were giving him. And so he was screaming every 20 of 30 minutes Because he should have been at two to three of his every feed at that point. And you know, if you ask someone in hindsight, they're like well, of course, why wouldn't you? that's what it, you know, and I'm like great. But that's because now this is five years later and there's this movement and there's all these new discussions and social media posts and Influences and people who have taken upon themselves to make discussion of motherhood easier or at least more realistic Since COVID happened, because I think finally, mom's like oh, look it, we have time because you're home and you can watch children And I can go.

1:02:39 That's thanks. And but I wish someone had said to me do some research. Because also, really, i did none. I just assumed that I would get some sort of sheet or Catalog or something that said like hey, this is what you increase, right, because if you ask somebody in breastfeeding, like, of course, you increase it by five to ten minutes every side, every see dead. And they have all these instructions and you're like, okay, and now with formula, and they have like nothing, you know, and in your discharge paperwork that they like give to every patient that is sponsored by the hospital, it's a four cents blurb and there's eight pages on breastfeeding and you're like I know nothing. And so I wish there had been more Advocation or empowerment from my village or from myself to say just Google it right, whether it's Mayo Clinic, whether heck, you go to similaccom because there's a whole website about how to formula feed and how to pick which formula And how much they should be eating and how to store it.

1:03:34 And I mean, i had to do so much research in the first 48 hours being home That I swear I could write a dissertation now. And so I wish, in that sense, because I really think that was just one cornerstone That I really feel, for whatever reason, feeding with my son, with my first son, became such a chore emotionally and physically That I really feel like it was one of the major Triggers for my post-traumatic depression. And so I and that's why I said I was I knew it was gonna be a trigger for Sammy, and so the fact that the NICU took so much of that off my plate Just by happenstance was such an incredible relief, because even all the research I had done, with all the forms I had printed, all the laminated papers and posters I had all over my house ready to do this, it was still nervous about it, because you're basically told here's a baby, love it, feed it and change it, and I felt like I couldn't do one of those three things.

1:04:28 I did not have to feed my first baby, so I was so worried about it with my second, and so that's the one thing that I wish someone had said to me was like, listen, i don't care what you're gonna do, but if you're gonna do this throughout, here's one option it's gonna do this route. Here's one option. Hopefully, this takes you for the first seven to ten days of newborn hood, until you can get your head on right and figure out What you actually want to do, and so I wish that's what I wish yeah, and I think that that's one of the most common causes of postpartum depression is not knowing how to feed your baby, whether it's formula or breastfeeding, because it's it's hard. Yeah, well, on, it's hard and it's again. Literally, it's one of two things you're supposed to do, right, supposed to love it and feed it. Literally, that's it. Yeah, and even on some level, love can be a hundred different things to you and your family. right, it's basically give a shelter and feed it and suddenly you feel like you can't do one of those two critical survival things.

1:05:12 Yeah, it's a little bit of a little stressful. You can torment you. Yeah, yeah, hmm, yeah. Was there anything else that you wanted to talk about? Are we my two hours of podcast? No, i think. I mean I think overall labor and delivery, part of my, my clinical changes, my practice changes as a provider, now that I have experienced birth and postpartum depression and the ups and downs and Everything in between, the gray area of pregnancy and, you know, motherhood, i would say that, for better, for worse and all of it, trying to be flexible, i'm not saying don't have preferences, i'm not even saying don't have priorities. Right again, feeding was a big one for me, formula seeding, making sure that I had a built, you know, certain parts of my village.

1:05:55 I my priority is, my second was having a really nice stroller, because I wanted to be more active in my second postpartum Course and I just didn't like my stroller in the first one. I mean I get having priorities and making those priorities come to fruition, but for better, for worse, something will go wrong, and and wrong is not necessarily mean dangerous or a bad outcome. It just means something will not go the way you expected, whether that's the you get peed on, pooped on, whether it's a nikkia admission, whether it's a c-section versus vaginal, whether it's timing of delivery, whether it's breast versus bottle, whether it's boy versus girl. Whether it's whatever, something will not go according to your planned or expectations, and so allow yourself some grace.

1:06:35 You were allowed to have emotions about something going wrong. You can be Super bummed and disappointed that you're getting a c-section, but so thrilled that your baby is healthy. It is okay to exist, and I dichotomy of emotions, and then it's not something that we tell moms or women enough. It is okay to live in a place where you feel both evenly. You can feel Frustration and joy. You can be so excited that you're a mom and so super frustrated. The breastfeeding is not going well. There's a day or tiger episode about that two. Yeah right, No, you can everybody needs to bitch because it is okay to cry That breastfeeding is hard or that you now have to formula feed instead of breastfeed, but excited that you figured it out Right.

1:07:20 You can be thrilled that your baby is gaining weight, but really upset that your baby's not sleeping, right. I mean, all of these things are normal and you don't just have to feel joy. You're allowed to feel both strongly and discuss both and articulate and vocalize both, and You should be celebrated for feeling whatever you feel. Yeah, yeah, have your feelings. That's my takeaway. Have you feeling? love it. Michelle, thank you so much. I always learned so much when I Listen to you. I love the way that you describe things. Thanks, all right well, i have your feelings and gastric distress, yes, you.