TRANSCRIPT EPISODE 36 – All About Pregnancy & Birth With Dr. Nicole C. Rankins

Transcript episode #36:ALL ABOUT PRE-ECLAMPSIA AND WHAT YOU
NEED TO KNOW TO REDUCE YOUR CHANCES OF
GETTING IT WITH DR. CECILY CLARK-GANHEART

Transcript

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00:00                                     On today's episode of the podcast, I'm talking about preeclampsia with Maternal Fetal Medicine Doctor Cecily Anne Clark-Ganheart. Welcome to the All About Pregnancy & Birth podcast. I'm your host, Dr. Nicole Calloway Rankins, a board certified Ob Gyn physician, certified integrative health coach and creator of The Birth Preparation Course, an online childbirth education class that will leave you feeling knowledgeable, prepared, competent, and empowered going into your birth. Quick note, this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at www.ncrcoaching.com/disclaimer.

00:45                                     Hello and welcome to another episode of the podcast, episode number 36. I am so glad that you are here today. Today's episode is the second of two episodes that I'm doing related to preeclampsia. The first was last week. It was a birth story from a very strong woman named Tomeka and a devastating complication from preeclampsia with her son, Jace. She unfortunately had a stillbirth. It's a heartbreaking episode, but you'll learn a lot if you tune in. That's episode number 35. Now, this week on the podcast, I'm bringing on a high risk pregnancy doctor to really break down preeclampsia. Dr. Cecily Anne Clark-Ganheart is a maternal fetal medicine specialist in the greater Kansas City area. Her areas of focus include maternal complications of pregnancy, really optimizing outcomes for women who have problem pregnancies and using lifestyle medicine before pregnancy to reduce the risk of pregnancy complications, particularly among women with obesity.

01:55                                     Her hope is that by improving mom's health status prior to pregnancy, that will lead to better pregnancy outcomes for both moms and babies. Cecily and I talk about all things preeclampsia today, what it is, how it affects moms, how it affects babies, who's at risk, the symptoms and ways to reduce your risk. You are going to learn a ton from this episode today. Now, before we get into the episode, really quickly, let me remind you about my free live online class, How to Make Your Birth Plan the Right Way. In this class, you learn exactly what you need to know to make a birth plan that really works to help you have the birth that you want. I go beyond what you typically find related to birth plans. As Billy, someone who's gone through the class said, I love how you dive into the why behind the birth plan checklist that are very typical. Now you can register for the class at www.ncrcoaching.com/register. I only do the class three or four times a and space is limited. So go to www.ncrcoaching.com/register to grab your spot today and that link is in the show notes.

03:06                                     Nicole: Okay, so let's get into the episode with Dr. Cecily Anne Clark-Ganheart. Hey Cecily, thank you so much for coming onto the podcast and helping us understand all about preeclampsia.

03:19                                     Cecily: Thank you. I'm happy to be here. Thank you for having me.

03:23                                     Nicole: Yeah, well let's how bout we start off by having you tell us a little bit about yourself and your work and your family.

03:29                                     Cecily: Yes, so I am a maternal fetal medicine physician, which is also known as a high risk obstetrician or perinatologist. All of those terms are interchangeable. And so what I do if I work with women who either have a high risk condition because of their personal health or that their baby has a high risk condition. And so I'll work together along with their obstetrician or care provider to help maximize and try to improve their pregnancy outcome and that's what I do for the majority of the time. I also see women, prior to pregnancy who are interested in conceiving but may have a high risk condition either because of their weights were weight loss, would benefit them or some other condition and try to help them address that prior to conception so that they can maximize their health.

04:26                                     Nicole: Yes. As we were talking about before we started recording, I'm going to have to have you come back on and talk about some of those preconception issues and weight loss specifically. That would be great.

04:35                                     Cecily: Yes. I think I would love to do that just because I think a lot of people don't recognize how important it is to maximize your health prior to pregnancy.

04:44                                     Nicole: Absolutely.

04:44                                     Cecily: And so especially if you're planning a pregnancy, you can definitely help improve your health before that happens.

04:51                                     Nicole: Yeah, yeah. And what about your family? You want to tell us a little bit about your family?

04:55                                     Cecily: Yes. So I'm married, my husband and I, we live in Kansas with our two sons, both very active. My oldest son is into baseball and baseball season is wrapping up, so we're always running around there. And then my youngest son has decided he's a skateboarder. That's new to us because neither of us know how to skateboard but it definitely helps to keep life interesting.

05:25                                     Nicole: For sure. For sure. Yeah. We're a two girl family, so yeah. Yeah. All right, so let's get into preeclampsia. How about we start off with just basically what is preeclampsia?

05:37                                     Cecily: So how I like to explain preeclampsia is that it's basically high blood pressure when you're pregnant. So think of it as if you didn't have high blood pressure before pregnancy and then later on towards the latter part of pregnancy, your blood pressure starts to rise. Traditionally we say if your blood pressure increases to either the top number, which we refer to as the systolic blood pressure of 140 or the bottom number, which is referred to as the diastolic number is greater than 90. And you have to have that on two separate occasions, not just one time because you were nervous or whatnot, but elevated blood pressures are kind of the hallmark of that. We also describe it as having protein in the urine. However, we don't hang our hat on the protein requirements anymore. It's really about what are your blood pressures doing and then what are some of the other effects that it's having on the rest of the body in the pregnancy.

06:39                                     Nicole: Okay. Now what is the difference between preeclampsia and say just gestational hypertension or hypertension that develops in pregnancy? Like what's the spectrum of all of that stuff?

06:51                                     Cecily: Right, so there's several different spectrums and classifications and what not. So gestational hypertension, again would have the blood pressure criteria that I discussed before, but it does not come with protein in the urine. First is when you have preeclampsia, you have different stages of Preeclampsia. You'll hear people talk about preeclampsia with or without severe features, which was traditionally referred to either as severe preeclampsia or mild preeclampsia. Once you get past the protein component, both of them, those, the distinguishing factor is whether or not you have other signs of organ disease. So in addition to protein urine, your kidneys can start to fail or not function as well. You can have problems with your liver, which can cause changes in your lab values or actually cause pain, headache, blurred vision, new onset nausea, vomiting. These are items that would move you into the class of severe. And it's important to note that you can have severe features even without protein in the urine. And so this is why we have now recently, but I say we the American College of Obstetricians and Gynecologists, we've moved to now not requiring that you have to have protein in your urine. For us still to take this disease seriously.

08:26                                     Nicole: Oh, and I guess real quickly, what's the cutoff for what's considered severe blood pressure?

08:31                                     Cecily: So severe blood pressure if you did not have any symptoms and you haven't been diagnosed by symptoms, blood pressure criteria alone is a top number, again, the systolic of 160 with the bottom number and or, so you don't have to have both I should say that bottom number being 110 the diastolic. I'm sorry, I forgot to mention also along that spectrum of Preeclampsia, you have even more severe conditions such as eclampsia. So really you forgot about that too. But eclampsia, so what preeclampsia means is before seizures and eclampsia means seizures. And so this is seizures not due to a separate medical condition. This is someone who has no other reason to seize other than the preeclampsia has now moved into rclampsia. And then you'll also hear people talk about something called HELLP Syndrome. Which is manifestation along that severe range, but that's when you're starting to have breakdown of your blood cells.

09:36                                     Cecily: That's called homolysis. Elevated liver enzymes. That's a marker of liver dysfunction. And then the low platelets, which you may hear people throw out and call the term Thrombocytopenia, but that just basically means low platelets, platelets are designed to help our bodies clot.

09:55                                     Nicole: Okay. Now how common is preeclampsia?

09:59                                     Cecily: So preeclampsia, different estimates put it anywhere from 3% at the low end, up to 10% occurrence in pregnancy. I was going to say, I feel like we see it all the time so I don't know if we're just behind on our estimates and need to do updated population search, but according to the published literature, that's what the rate is. But I feel like every other person has preeclampsia.

10:24                                     Nicole: And we should say that the severe form with seizures and that is not very common.

10:33                                     Cecily: No, that's going to be where that's going to be less than 1% of people are going to experience that and some of that decrease hopefully with seeing the severe form comes with proper management. So the only cure for preeclampsia is delivery. However, we have to balance how severe your preeclampsia is with how far along you are in the pregnancy. Because while I'll often talk to patients and co-manage people who have been diagnosed with, we're just going to call it mild preeclampsia, with a milder form of preeclampsia, and they said, well, you know, why can't you just deliver me now? And I'm like, well, because you're stable, we're monitoring you closely, baby's stable and it's actually better benefit for your child to get further along in pregnancy. Versus someone who comes in seizing because of their preeclampsia. Well, it's no longer safe to keep you pregnant. And so I think you know, are fortunate because if you do start to progress and show signs where it's not safe for you to continue pregnancy, that's a lot of times when your obstetrician is going to recommend delivery. And so we're not necessarily seeing some of that progressiveness of the disease.

11:53                                     Nicole: Yeah, I think this is an important point to mention is that the treatment is very individualized. So you may hear one person get delivered at one point in pregnancy, another person, a different point in pregnancy. It's not a one size fits all.

12:08                                     Cecily: Correct. Yeah, there's so many factors that come into play. But the common goal is to make sure that we are balancing risks to mom because we need to have healthy moms, right? So they can be around to care of their children. So we do not want to put the mom at unnecessary risk, but we want to balance those risks with also the risk of the baby because gestational age is a huge determinant of longterm outcomes, you know, in childhood and adulthood. So we're trying to balance those things. And just as you mentioned, that's gonna look like different things in different patients.

12:50                                     Nicole: For sure. For sure. Now, what are some of those problems that preeclampsia can cause for moms? We talked about obviously eclampsia, the seizures, but what else are the big things that can affect mom?

13:02                                     Cecily: So stroke is a big thing. So just in general, like you said, you said seizures already. We have strokes, you can get fluid in the lungs. That's called Pulmonary Edema. You can have heart failure whether or not that's just the preeclampsia itself or because of poorly controlled blood pressure, you know, which came first, but you can definitely have heart failure. We talked about liver failure bleeding, I mean worst case scenario, even death. Stroke is something that we really, I mean all of those obviously are bad complications but not controlling the blood pressure which then can lead to stroke, which then can lead to death and you know, permanent disability and things like that is really especially of concern. And the thing people don't realize about preeclampsia is that yeah, you have the classic symptoms, the headache and the blurred vision and all of that. You definitely need to seek your care provider, get your blood pressure check, make sure you don't have preeclampsia. But there are definitely a subset of women who just come in for a labor check or came in because of decreased fetal movement or whatever. We take their blood pressure and we're all like, how are you still sitting here? Your blood pressure is 80 over, you know, 110 and so aggressive treatment of blood pressure definitely has been shown to improve maternal outcomes and prevent some of these more serious complications for mom.

14:29                                     Nicole: Yeah. And we don't want to scare you by telling you the things that you know can happen, but we want to be realistic and help everybody understand that preeclampsia is very serious and unfortunately on our side, not all obstetricians take it as seriously as we need to take it. I think we have a little bit of work to do in that regard, in that respect. In terms of the managing blood pressure issues specifically, I don't know if you would agree with that, Cecily, like how we're trying to push for more like not, you know, getting rapidly treating those blood pressures. So we just want to make you aware so you can be informed and you know, ask the questions and take care of yourself when you need to.

15:08                                     Cecily: Right. And it's definitely one of those things. Definitely don't want to scare you from not being pregnant at all. That's not the goal. But I do want people listening to get a sense of just the self-advocacy. It's one of those things where like, yes, it's unfortunate that you may not necessarily be able to walk into any ER in the country and know that protocols will be followed, but by you also just being aware, you don't necessarily need to know the numbers. Anyone who's pregnant, I do think you should know the signs and symptoms of preeclampsia and hopefully your provider's going over that with you and we'll talk about those in a minute. We'll talk about that. But just knowing that if you go to your care provider and you normally have normal blood pressures, however you see on the measurer that your blood pressure is 150 over 90 and no one addresses that, I want you to feel empowered to say, oh, what was my blood pressure? Oh, that's not normal for me. You know? Sometimes it's just, in the business and in the hustle and bustle, people may just have things may slip their mind, but yeah, you're noticing it. At least bring it up and if your care provider repeats it or whatever and they at least investigate it and then you guys come to a conclusion, so be it. But at least it was addressed. And that's kind of all I want to take home message to be.

16:35                                     Nicole: For sure. Absolutely. How can preeclampsia affect babies?

16:39                                     Cecily: So with babies, there are also a host of conditions. One preeclampsia, I think one of the biggest things is whether or not you have to deliver preterm or prematurely, earlier than what you would have had to. Because as I mentioned before, that is a significant determinant. It goes into, you know, future outcomes. So preeclampsia that has to be delivered before 20 weeks. You're going to potentially look at some very serious complications of prematurity. If that does not occur, you know, just in general having the smaller babies. So we call that intrauterine growth restriction is the medical term, which basically means that baby is not reaching its full growth potential or you know, the baby's too small all the way up to. Unfortunately, sometimes we do see stillbirth from preeclampsia, especially if it's severe complications, etc. People will have stillborn aside from having preterm delivery or too small babies. So those are some of the things we see. There's also a condition called placental abruption, which kind of is that the interface where both maternal and maybe complications where because you're getting bleeding behind the placenta that then will decrease mom's blood count. But it also, it can affect like oxygen status and caused some complications for the baby too.

18:05                                     Nicole: Yeah. So we think that preeclampsia affects the placenta essentially, which then in turn affects the baby. Is that fair to say?

18:12                                     Cecily: Yes. Yeah. Yeah.

18:14                                     Nicole: Yeah. Okay. So what are risk factors, and let's just do like three big risk factors for preeclampsia.

18:21                                     Cecily: Your strongest risk factor is going to be prior history of preeclampsia. So I like to tell people, and you know, just obstetrics, pregnant patients, Ob is a field where the past sometimes does predict the future very well. So if you had a history, like you've had a history of preterm delivery at increased risk of that happening. Again, if you've had a history of gestational diabetes, you are at increased risk of that happening again. And just like that preeclampsia, if you've had preeclampsia before, you are at increased risk of having that happen again. Outside of preeclampsia, other factors include being either obese or overweight, chronic medical condition, so we can kind of just lump all those together. Like if you have high blood pressure or hypertension, diabetes or kidney disease, those are risk factors and then multiple gestation, in vitro fertilization, IVF, those as well. And I guess this is more than three. Sorry.

19:20                                     Nicole: No, we're educating here. Let's go for it. Yeah.

19:24                                     Cecily: For first pregnancy, so people who have their first pregnancy are actually at higher risk of having preeclampsia and then sometimes we also forget about the kind of age as a factor. So younger patients actually like in their teens actually have a higher risk and also patients who, I guess we were referred to as advanced maternal age are also going to have an increased risk of preeclampsia.

19:48                                     Nicole: What about race or ethnicity?

19:50                                     Cecily: Yes, sorry. So I did not mention race. Black race is a risk factor for preeclampsia, at least to my knowledge, unless you've read something more recently, I don't know that we have actually elucidated why that is. So like studies will say this and you know, we'll get into aspirin probably later, but when we're looking at who can we try to help reduce the risk of preeclampsia for, but biologically, I don't know why that is. We've seen that in stats, but just myself, I've not come to any plausible reason why after controlling for other things like socioeconomic status, obesity or you know, other comorbid conditions, you still end up having black race as a risk factor for preeclampsia.

20:46                                     Nicole: Yeah, and I'm, that has to do with chronic stress and racism within our healthcare system, I'm sure that certainly plays into it as well.

20:55                                     Cecily: That's true. That's true. And there's something that unfortunately it's just difficult to measure from like a, you know what I mean? Quote unquote scientific method standpoints. But there's definitely something systemic. Do you know what I mean? Multi-factoral. That's odd because it's hard to say it's law, it's just hereditary. Do you know what I mean? Like exactly like to say that for a lot of things, but when you start digging deeper you find out, well is it really hereditary or is there something else. So hopefully we can start to tease that out. Especially with the attention that's coming to the disparities in maternal mortality, I really hope it helps, makes the healthcare system at a whole take a hard look at itself and really see what our personal biases, how they are actually influencing outcome and why and really start to tease that out more.

21:57                                     Nicole: I absolutely say that really all women, you have to be extra vigilant about advocating for yourself. Like you know she talked about earlier, we want to advocate for yourself, but there are certain groups who may have to advocate a little bit harder for themselves just because of the difficulties they run up against. And black women in pregnancy is one of those groups where you just may have to advocate harder for yourself than other women. And that's just kind of the reality of it.

22:24                                     Cecily: It is. And what I tell, you know, all of my patients is that when you ask questions, I think sometimes people are afraid or nervous to ask questions of their physicians or care providers. And so whenever someone sees me, I give them a chance. I'm like, are there any questions? And if I see that kind of pause, I'm like, go ahead and ask. I said, now you may or may not like my answer, but ask that question because that's what we're here for. There's no silly question. You know, that's what you're there for. They're supposed to be the knowledgeable expert on whatever it is you went to see them for. So definitely feel empowered that it is okay to ask questions.

23:06                                     Nicole: And if you're not getting your questions answered, then please feel free or please not just feel free, but find another provider who will answer your questions.

23:14                                     Cecily: Yes, that's what I say too. If you're not satisfied, definitely you should search and find someone who meets your needs.

23:21                                     Nicole: Yeah, for sure. Okay, so what are signs and symptoms of preeclampsia?

23:26                                     Cecily: So signs and symptoms and there are a lot, so we may repeat these a few times. Classically you'll notice, people talk about headache and so you know headache can be tricky, right? Because people do get headaches and pregnancy but I mean a headache that is unrelenting, it won't go away. You are having to treat yourself with Tylenol, you know every couple hours. It's just there. It's pounding. Blurred vision. So visual changes or what we call the fancy term is Scotoma but it's they're like little black spots is kind of how people describe them. Little flashes and your vision. New onset nausea and vomiting, particularly in the third trimester. And so notice I said new onset nausea and vomiting. Because typically you know we have early in pregnancy where many people complain of different nausea, vomiting, etc. But usually that gets better. And so if all of a sudden your near the time of delivery and it's not just that you ate something that didn't taste great, it's I am constantly now nauseous around the clock. I haven't felt this in two months. That is something you need to take up with your provider. And again with the vomiting, if that's starting again on a regular basis, that's not normal.

24:52                                     Cecily: When we talk about pain, so there is something called epicgastric pain, which if you just want to touch your abdomen now and kind of trace your hand up the center of your belly, it's like right under where your breastbone would be just a little below that. That's epigastric pain and then if you just move your hand over from there to the right, that would be right upper quadrant pain. So not necessarily you picked up something and you stretched wrong, but that's you're just not doing anything and you have this kind of just internal pain and then it can even get to the point where if you touch that area, it's sore, it's like tender when you touch it or someone else touches it. Those are all signs, no swelling. We don't use welding as part of the criteria for severe preeclampsia, but certainly having a significant onset of new swelling needs to at least, again, be addressed by your provider. Or if you're weighing yourself at home and in a week you put on seven to ten pounds, that's probably water weight. And so preeclampsia is associated with like retaining water and swelling. So again, not saying we use that to make a diagnosis, but this is something that should be noted, right? No one pregnancy is gaining 7 or 10 pounds in a week.

26:16                                     Nicole: Exactly. Yeah. And one thing I also find, it may not be nausea or vomiting, but some women will just say, I just do not feel right. Like something feels off. I don't feel like myself.

26:30                                     Cecily: Yes. And that's an excellent point. Some of the earlier descriptions talk about just a general feeling of unwellness something is off. And so those are all reasons that you definitely to discuss with your provider. What I tell people too, and it's something that always makes me scratch my head. But you know, I'll have a patient who comes to see me and just for their scheduled ultrasound, but then they'll tell me about the symptoms that they've been having for the last three days and I'm like, so if you're starting to have these symptoms, please call your provider because I can't tell you how many people are like, well, I have an appointment at the end of the week. It's Monday. Well I already have an appointment Friday so I'm just going to wait until Friday to talk to them about this. I would definitely say if you're having signs and symptoms like this, you should call your provider and see if they want to see you sooner than that.

27:22                                     Cecily: The other thing is if you have any of those risk factors that we mentioned before, sometimes having a home blood pressure cuff is a good idea, so certainly I recommend that for all of my patients who have hypertension or high blood pressure. Even before pregnancy, I'm like, you know, you should have a home blood pressure cuff. You should just have a general idea of what your blood pressures are doing. And so that is also something because if you, you know, have a headache but you're assuming your blood pressure is functioning correctly...

27:54                                     Nicole: Take it in. I always say take it in and have it calibrated against what's in the office. Yeah.

27:58                                     Cecily: Yes. And I don't like risk cuffs. Those are not accurate. So we want to make sure you have a cuff that is appropriately sized for your arm. But assuming all of those things are true, if you have a home blood pressure cuff and you have a mild headache, just kinda curious what your blood pressure is and it's 90 over 50. You know, still call your doctor and talk to them about it, but they're probably going to tell you not to come in and they'll probably give you some other tips or whatever. Versus if you are taking your blood pressure and you're seeing it at home creep up, you definitely know that, okay, this is not something you should be waiting until the next visit to talk to them about. Like you need to definitely call your provider and a lot of providers if they know their patient has home blood pressure cuffs, will give you different cutoffs to just check your blood pressure once a day. You know if you have, especially if you have a high risk condition just so that you can be at the forefront of knowing if something is wrong because we probably only see you once a week towards the end of pregnancy.

29:00                                     Nicole: Exactly.

29:01                                     Cecily: A lot of stuff can happen in those six days when we're not seeing it.

29:04                                     Nicole: Yeah, and that's the thing like preeclampsia guys, it can evolve over time. It doesn't necessarily like some of the symptoms may start and then over a few days things will start to progress. And again, we don't want to alarm anybody. Most of the time you have a headache, you take Tylenol and it's fine. So we don't want to scare you, but just want you to be aware so you can know those things to look for just in case.

29:30                                     Cecily: Exactly, exactly. And then hopefully some of this will make sense. If you do have a provider who is kind of monitoring you for gestational and or preeclampsia and they're asking you to take your blood pressures at home, you know, hopefully you won't say, Oh, why do I have to do that? Hopefully it will all make sense. They're trying to get more data on you rather than the 20 minutes that you're in their office.

29:56                                     Nicole: Exactly. Yeah. Okay. So we talked already about how the only treatment for preeclampsia is delivery, but what are things that women can do to reduce their chances of developing preeclampsia in the first place?

30:11                                     Cecily: So we'll talk about aspirin. But I do want to just say in general about improving your health prior to pregnancy. This doesn't mean you have to, you know, be the gold standard of health before you try to conceive. But if you are obese or overweight, try to see if you can have a five to 10% weight loss before the pregnancy. If you have a history of diabetes, so preexisting diabetes and you know it's poorly controlled because your hemoglobin A1C which is a marker of what your blood sugars have been over the last three months, is that an eight or higher, you know, work on getting that down. If your blood pressure's poorly controlled and you rarely take blood pressure medications, etc, you know, make sure that is controlled. All of these things are going to help maximize the likelihood of that healthy pregnancy outcome.

31:10                                     Cecily: But what we are recommending kind of widely to people who are either at moderate risk for severe risk of preeclampsia is low dose aspirin. And there was a trial called the aspree trial. Basically there's been others, but that was really a big well-designed trial that showed that giving women anywhere from in their trial, they used number, they did closer to like 160 milligrams of aspirin a day. But ranges that you'll see us prescribe are anywhere from the 81 milligrams a day up to 162 milligrams a day depending on your condition. That has been shown to decrease the risk of preeclampsia and women who were at high risk of disease.

31:54                                     Nicole: Gotcha. So number one, get in this, and this is just in general for pregnancy, get in as healthy of a state that you can before you get pregnant and then talk to your doctor about the possibility of whether or not you're a candidate for aspirin. We're not going to go into all the who is and who isn't. That's the conversation you can have with your healthcare provider.

32:15                                     Cecily: Yeah. And have it early on. The only thing I'll mention is that for it to be beneficial, we believe you need to start it before you're 16 weeks pregnant. So you know if you're asking in the third trimester, you've kind of missed the boat for this pregnancy. At your first prenatal visit make sure to bring this up is what I would recommend.

32:36                                     Nicole: Okay. Awesome. Now, let's just finish up just asking you a few questions about you and your work. So what would you say is the most rewarding part of your work?

32:49                                     Cecily: I think, you know, I just enjoy being able to work with women and obviously their pregnancies and help guide them through and help support them during just a time of uncertainty. What I say is that you know, many people, pregnancy is just a time of joy. But when you receive a diagnosis that you weren't expecting, we all go into pregnancy with this ideal picture of what we think it's going to be like. You know? And so when that ideal picture is either tainted or now deviated, I enjoy being able to still assist women and having an optimal outcome even though the circumstances around that outcome may be stressful.

33:38                                     Nicole: It's certainly rewarding for sure to help women through what can be a difficult and challenging time when they weren't expecting it at all. On the flip side, what's the most frustrating part about your work?

33:50                                     Cecily: You know, I think I'm probably like most clinicians in the fact that I definitely think documentation and charting, etc are important. But I think that administrative work is becoming greater proporation of our time during medicine. Most people that I know that are in medicine in general enjoy treating patients. That's why we went into medicine. But I feel that just even from the time that I've finished residency to now as a practicing attending, I've noted just the amount of paperwork or you know, discussions with insurance companies, peer to peer reviews, all of these different things seem to take up increasing amounts of time in our day. You have to really try to prioritize making sure you get in that patient time. And so I would say I'm probably no different than any other clinician in that aspect. Just how some of the administrative roles are, are becoming more of an impedement to really spending the time that you want with the patient.

35:00                                     Nicole: Yes. Y'All have no idea how I'm, and we're not trying to like turn this into a complaining fest, but like how many like check boxes and things you need to fill out in the electronic medical records so it doesn't beep at you or click at you or whatever and then paperwork and then the insurance company denies this and you have to get on the phone with somebody who's not even an obstetrician to get something. All this stuff can kind of weigh when you, so I totally, totally get that for sure. Now, one thing I heard you talk on another podcast about how you chose midwifery care during your pregnancy. Why did you do that and how was that experience for you?

35:41                                     Cecily: Yes, so for my first son we had an Ob Gyn and she was fantastic, Dr. Scott and then in fellowship, this was the first time that I had honestly been exposed to midwifery services. So in residency we did have a midwife group that was starting, but they didn't have their own patients yet. They mainly were in our triage area and helping them provide support there. When I was in DC for fellowship, this was the first time that I really was exposed to, you know, all midwifery practices, etc. And so I just really wanted to try the experience and see what the difference was if there was a difference. I have heard a lot of things about the dangers potentially having a non-certified midwife or, well you may hear referred to as a lay midwife versus in our hospital all of our midwives were certified and you know, were following Ob Gyn standard guidelines.

36:47                                     Cecily: So I wanted to try that. I was also interested in having a natural childbirth and so, you know, I thought that they may have a little more time to spend in labor kind of, do you know what I mean? Like with the ball? Some of those techniques that I know myself obviously as an obstetrician that, you know, I just don't necessarily have that sort of time to spend with the patient like that during labor in terms of like the ball and all of those things. And I do check on my patients frequently. But I just know that me, myself personally with the other tasks that I have to do with and have that time, so that's kind of what led me to try that. And I did have a wonderful experience both times, honestly. So when I was with my Ob Gyn, I had a great experience and I had a great experience with my midwife.

37:36                                     Cecily: I think for me, the experience of having both was valuable because it really, let me understand more of the scope of practice so that when I as a high risk obstetrician have a patient referred to me, whether it be from an Ob Gyn or from a midwife, I feel like I'm now more familiar with what should stay with a midwife and what should really go to an obstetrician. I don't know that I would have that sort of, I would have just kind of a blanket answer, right? But I don't think that I would have the understanding if I hadn't have had that experience, I felt so I think it's helped me both personally and professionally.

38:19                                     Nicoel: So you're definitely supportive of obstetricians and midwives working together to provide the best options and care for women?

38:28                                     Cecily: I do. I really think it be collaborative. I think, you know, some of the gear and P and models so that it can be a very beneficial collaborative relationship. You know, sometimes we'll see in the media going back and forth with one group talking about the other and the other group vice versa, talking about, you know, we're here, if we're involved in the care of women, then our common goal, should be optimal outcomes or mother and baby. And I believe we can do that together.

39:02                                     Nicole: Yeah. Yeah, we're definitely better working together. It shouldn't be this sort of tension at all. And there are lots of folks, I work with midwives in my hospital and we work very well together. So there are certainly models that exist. And then just a couple last quick questions. How have your personal experiences as a mother influenced your work as a maternal fetal medicine doctor?

39:23                                     Cecily: I think it's definitely helped me to kind of understand. Obviously every person reacts to a diagnose different, you know, so you can tell two people that they have preeclampsia, same gestational age and they're going to have two different reactions. So you can never kind of predict. But I think it just gives me more compassion and more insight into, well, what happens if this would have been me during my pregnancy? You know, how would that affect me? I think it just gives me more compassion and I also think it allows me to do a better job of also explaining things because it's kind of like, well, what would I want to know? So whenever I do a consult with someone, I always make sure to hit the points that I would've wanted to know. And sometimes by the end of it they're like, wow, you answered almost all of my questions. Like you actually explained it. I understand what's going on. And so I think that has helped me, you know, as well, just that influence to help me to deliver better patient care.

40:31                                     Nicole: Yeah. Not that obese who haven't had children are bad by any stretch of the imagination. But I think I hear that over and over again for women who are obese. Once you have children, it helps you to be a better obstetrician.

40:43                                     Cecily: Yeah. Yeah. I think just because there's something that you would not have anticipated either being a concern or something being important. So you actually experienced that, you know yourself. So I think, yeah, especially, birth plans. I think before I had our first child, I was always kind of like, why are birth plans a big deal?

41:07                                     Nicole: Like, yeah, I felt that way too.

41:10                                     Cecily: And then after actually, you know, going through labor and having vaginal deliveries, I can see, you know, still for myself, for my second child, I didn't make a birth plan per se. The only thing was I wanted to try nitrous oxide. That was my thing. I was like I want to try nitrous oxide. But I didn't have a plan per se, but it made me understand why this is important for someone who chooses to make one. Honestly, I didn't understand that before.

41:36                                     Nicole: Yeah. So what is your favorite piece of advice that you'd like to give to expect to moms?

41:41                                     Cecily: I think one, just be kind to yourself in terms of there are a lot of things I think we go into pregnancy with kind of ideal expectations and sometimes it goes perfectly according to plan, but other times it doesn't. And I'll see a lot of people who for some reason blame themselves when there is an outcome that's not expected. So for instance, someone goes into preterm labor, that's because I worked out, you know, or if only I would have done this, you know, is it that canola oil that I cooked with? And this is why my baby has a birth defect. And so the thing is when you have a pregnancy complication, it's not your fault. And so what you need to do is just lean on the support of hopefully have a support system of your family or friends and then also discuss that with your care provider. I mean, we're here to help try to maximize those complications or things that have went unexpectedly, still into outcomes, but just you're not at fault if things planned. It's not your fault.

42:53                                     Nicole: Yeah, absolutely. I like that a lot. So thank you so much for coming on. This was a ton of useful information and like I was saying, you're going to have to come back on and talk about some of the other things that you can do, which kind of feeds into where can people find you?

43:10                                     Cecily: I'm on Instagram, Facebook and I have a website. So they all kind of center around my interests, weight loss, especially prior to pregnancy, trying to help people improve their health status prior to pregnancy. So the name is all the same. It's @fastingworkgirl that's all one word. And so that's my website. That's my Instagram and Facebook there. I talk about health and wellness, but also using intermittent fasting as an approach to obtaining health.

43:42                                     Nicole: Okay. Yeah. So just real quick, how much weight did you lose personally yourself with intermittent fasting

43:48                                     Cecily: With intermittent fasting? Close to 60 pounds, around like 55 pounds with intermittent fasting. So yeah, I mean it's worked personally for me and I still continue to do it just for general health and wellness.

44:00                                     Nicole: Yeah. So she's working on some things like that. And how to help women get an optimal shape, you know, with their weight before pregnancy and then postpartum weight loss. So we'll certainly have to have you back on and talk about some of those things too.

44:12                                     Cecily: Yeah, great. And I would enjoy that.

44:14                                     Nicole: Yeah. Okay. All right. Well thank you so much again for coming on. Appreciate your time and you have a wonderful day.

44:21                                     Cecily: Great, thank you. You as well.

44:25                                     Wasn't that a great episode? Tons of useful information. After episode I do something called Nicole's notes where I go through my top three or four takeaways from the episode and here's Nicole's notes from this episode today.

44:39                                     Number one, if you're early in pregnancy, ask whether or not you're a candidate for aspirin to prevent preeclampsia. The American College of Obstetricians and Gynecologists has something called a committee opinion that discusses low dose aspirin use during pregnancy and it covers who is a candidate, which women should be on aspirin to help prevent preeclampsia. And I'll link to that committee opinion in the show notes.

45:03                                     Number two, be sure you know the signs and symptoms of preeclampsia. Preeclampsia can come on at any time during pregnancy. It's far more common in the third trimester and actually most of the time it happens in the third trimester that you should really be aware of the symptoms because although most of the time it's not serious. As we learned in last week's episode, in rare circumstances it can be quite serious, so no, those signs and symptoms, increased blood pressure, headache that's not relieved by Tylenol. If you have new nausea and vomiting that you didn't have before, changes in your vision. If you have significant new swelling with those other things or a rapid weight gain, that will also raise some red flags potentially. Also, you may just not feel right. You just may feel like something is off, so when those happen, then call your doctor or midwife. Most of the time it's not anything but you want to check in to be sure. Now I don't want you to obsess about this. I've seen some women who were taking their blood pressure like five or six times a day and that's excessive. I don't think you need to do that, but you should be mindful of the symptoms, kinda have them tucked in your back pocket and if you have anything that pops up, then bring it to your provider's attention.

46:21                                     And then number three, and this is the take home message that Dr. Clark-Ganheart wanted to convey and it's one that you hear me say time and time again, please, please advocate for yourself if something isn't right then speak up. If your questions aren't being answered, then speak up. If you need to change providers to get someone who is answering your questions then do that. The reality is that sometimes women need to be insistent to get the appropriate care. So don't be afraid to advocate for yourself or if you have trouble doing that because I get it. That is not always easy to like speak up quote unquote against a doctor or bring those kinds of things up then have a support person. Have a partner, have a friend, have a family member who can advocate for you on your behalf.

47:10                                     All right, so that's it for this episode today. Be sure to subscribe to the podcast in Apple podcast or wherever you listen to podcasts. And I would love it if you leave a review in Apple podcast especially, it helps other women find the show and I just love reading what you say about the show. Very often I will read reviews and give shout outs on the podcast. And don't forget about the free LIVE online class on how to make your birth plan. Women really love this class and find it incredibly useful. Go to www.ncrcoaching.com/register to save your spot. There's limited space and I only do it three or four times a month. So sign up today and that link is in the show notes. Now, next week on the podcast I'm going to talk about amniotic fluid. Where does it come from? What's considered normal? Why is amniotic fluid important for your baby's health? So come on back next week and until then I wish you a healthy and happy pregnancy and birth.

48:09                                     Today's episode is brought to you by Women's Wellness Coaching by Dr. Nicole Calloway Rankins. Head to www.ncrcoaching.com to check out my free one hour mini course on how to make your birth plan, as well as my comprehensive online childbirth education class, The Birth Preparation Course with over eight hours of content and a private course community. The Birth Preparation Course will leave you knowledgeable, prepared, competent, and empowered going into your birth. Head to www.ncrcoaching.com to learn more.

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