Liz: Hello!

Lizzy: Welcome in!

Liz: Hello everybody. We have Dr. Katie Maloy joining us today, who's going to talk about maternal health and pre pregnancy, post-pregnancy, and during pregnancy. We have a bunch of reader questions or follower questions, which are great.

Lizzy: And also a lot of our own questions because these questions never end, no matter how many babies you have. 

Liz: Do you want to talk a little bit about how you know Katie? 

Lizzy: Sure. Katie and I are freshmen year college roommates. She is from Michigan and we met on the first day of college, in Maine. And she has gone on to be an OB GYN and has answered every question I've ever had about pregnancy, anything vagina related, basically, and if you've had any question, a female question, and you're within 15 feet of me, she's received a text and she answers everything so graciously and kindly 

Liz: She's the sweetest. 

Dr. Maloy: Hi! Good morning!

Lizzy: Good morning. How are you?

Dr. Maloy: We have a snow day here, so we are pivoting to plan B. 

Liz: Oh my gosh. Are you okay? 

Dr. Maloy: Oh, we're fine. Yeah. It's not too terrible. It's like a little dusting, but we're supposed to get a ton of snow today, so we'll see how it goes. Boys are home.

Lizzy: Katie has two young sons, who may have a guest appearance. I was just telling everybody that we were freshman year roommates at college. We have been dear friends since! You have gotten every female related question I've ever had in the last 20 years, and also anyone I know has also asked you whether I have given over your phone number or I texted you, you have graciously answered everything.

Liz: The ultimate phone a friend!

Lizzy: She'll walk out of surgery and calmly answer a text of mine with a totally unimportant question. And it doesn't help her that her husband is in emergency medicine and they have two kids. So she also gets most of my pediatric questions. Lots of pictures of children asking if things are okay. Do you want to go ahead? Explain your history, like how you got where you are right now and your path as a doctor?

Dr. Maloy: Sure. So I did my training in Washington, DC, and then after residency, I worked for a couple of years, locally in the DC area, doing some private practice and then one of my current partners and I had done residency together and she is very involved in the residency program that I currently work at.

And she had invited me or recruited me to come and join her in this program in Ohio. And it ended up working out for us because we were struggling so much with childcare. Like I feel like every family can relate to that right now. And so we moved back to Michigan to be closer to our family, which has allowed us to have a little bit more help with our kids, for our crazy work schedule.

So that's how we ended up here!

Lizzy: And talk about your current role. 

Dr. Maloy: So I am an academic laborist or OB hospitalist currently. So I do not have my own practice. I spend the vast majority of my time and effort, teaching residents and then serving that patient population of our hospital that is seen in our resident clinic or patients who come, who don't have an assigned doctor.

I do 24 hour shifts in the hospital and am kind of like an emergency doctor for obstetrics, or any gynecologic emergencies that happen. So I'll take an Ectopic pregnancy to the, or I'll manage all the labor patients who are there for that day, in conjunction with my resident team. And then when I'm not doing shifts, I spend a lot of time doing resident education, and sort of coaching them and helping them learn to be, what I hope will be excellent, OB GYNs!

Lizzy: For sure, under your care! And before you left DC, did you do private practice for a while, where you saw patients from start to finish?

Dr. Maloy: Yeah, and I still do that, with the residents, but they get to take ownership and sort of manage the patients and I'm there as a mentor and an educator, making sure that everything they're doing is correct and helping them learn the process.

Lizzy: Awesome. 24 hour shifts, something I can not imagine.

Dr. Maloy: You get used to it. 

Liz: I'm sure. 

Lizzy: Maybe. okay. Then we'll dive into our questions. We shared some of these questions with Katie before, but we thought we'd walk through kind of pre-pregnancy, post- a little bit, with some specific stuff. So, I guess our first question is before anybody gets pregnant, what's your number one piece of advice for someone that is having trouble conceiving?

Dr. Maloy:So I think the first thing is just to know that you're not alone and that infertility is extremely common. And just be patient and realize these things sometimes take time. I usually recommend starting just with some basic tracking of the period cycles, to try to figure out when you're ovulating by doing some ovulation prediction kits, which can just get over the counter.

And then once we sort of have seen that there's been frequent unprotected intercourse without conception, usually by a year sooner, depending on age, sometimes as early as six months, it's time to ask for help. Bring the data that you've collected during that time to your OB GYN or midwife, and they can help point you in the right direction of what further workup you may need.

Lizzy: And when you say sometimes sooner because of age, is it younger that you recommend sooner or older recommend sooner?

Dr. Maloy: So for women, unfortunately it's not fair, but age related infertility is the number one cause of infertility. So once we start getting into our mid to late thirties into our forties, it can become very difficult to conceive spontaneously without assistance.

So when people are getting into the mid to late thirties, I’d refer them sooner rather than later. Later when they're over 40, really only a short trial of trying spontaneously is probably reasonable. And then just making sure we start the workup in sort of looking at options depending on what that family is interested in.

Liz: Okay. Yeah. That makes sense.

Lizzy: So in pregnancy, if that's kind of where you are, if you're able to get pregnant on your own, then, can you talk a little bit about the length of pregnancy and how we track that. Cause obviously it's a little bit confusing, even when you have babies, while we say nine months, or 10 months? And then also about food during the days when it's really tough to keep stuff down that's agreeable. 

Dr. Maloy: Absolutely. So, the pregnancy is 40 weeks long and so anyone who's managing pregnancies, we don't really talk about “months” at all because it doesn't line up exactly. I know in the popular vernacular, that's how we refer to it, but that’s it, and it is dated since the last menstrual period.

So there's actually two weeks of that 40 weeks that you're not pregnant yet because most of the time ovulation will happen somewhere around that second week of the cycle. So it's 40 weeks in length. And then when we talk about the full term of a pregnancy: early term starts at about 37 weeks of gestation, regular term is at 39 weeks, and then once we get beyond that 40th week, we're looking at post dates and into the post-term period, for that pregnancy. 

So 40 weeks is the answer for that. It’s a long time! And then as far as that first trimester, that's a really common and sometimes challenging experience for patients or for families.

And so I think that the best sort of weird way to think about this is that the pregnancy is a very good parasite, and your body will preferentially give nutrition to that developing pregnancy. So I really tell my patients to focus on hydration and eating what they can keep down. So this is not the time to be stressing about if you're getting enough of a certain vitamin or if you're eating enough kale, it's like, whatever, you can keep down and manage.

As long as you're staying hydrated, your body will preferentially give that nutrition to the pregnancy. And that being said, there are definitely very serious medical conditions where we need to intervene. And so if you start losing weight, if you're getting dehydrated–and the best sort of marker for that, I usually encourage patients to monitor their urine output and the color of their urine.

If it starts to get really dark, then that's a sign of dehydration–And if we're getting dehydrated because of the amount of vomiting that we're having, or the amount of nausea or limited foods that we're able to keep down, it is for sure time to ask for help. And there's lots of medications and things that we can try.

And some people do even need to get IV hydration or hospitalization, depending on how severe their nausea and vomiting of pregnancy is. So, just do the best you can to focus on hydration. And if you're worried, it's time to just ask for help. 

Lizzy: So scary. And there's like such a range of how you can feel that first three months.

Dr. Maloy: Oh yeah. And every pregnancy is different. 

Lizzy: Yeah. Even within your own pregnancies, it can be so wildly different. Along those lines, obviously prenatal vitamins are considered essential. Can you talk about what makes them essential? What pieces of them are essential? I used to always have friends saying, “oh, this one made me constipated.This one made me nauseous.” Like, is that because of the brand or because your body doesn't react the same to things as someone else?

Dr. Maloy: Sure. So this is another very common question that we get all the time and really the data for prenatal vitamins is very robust on folic acid. And that is probably the most important and key thing, and we ideally would want to start that about 12 weeks before you're even considering conception. So, you know, in the United States, 50% of pregnancies are not planned. This is in an ideal world where someone is thinking ahead and planning this pregnancy. So having a prenatal vitamin with folic acid is definitely recommended and that's most important early in the preconception period, and then through the first trimester, because that's when those neural tubes are forming. And that's part of the spinal cord and is also really important in things like cleft palate and things like that. So there's lots of birth defects that are decreased when we have adequate folic acid in our bodies to be able to give to that developing fetus.

So the data, and this has been for many decades, has really been very studied just on folic acid. And so some of these newer prenatal vitamins will use an alternative of folic acid we'll use folate or other derivatives. And the data just hasn't been done yet to say that those are equivalent. OB GYN societies and the Society of Maternal Fetal Medicine have recommended sticking to something that has actual folic acid in it.

As far as the constipation piece, that's usually because iron is also included in that prenatal vitamin and iron is very constipating. So there are some prenatal vitamins that do not have iron in it. And so that's something that if you're not experiencing anemia or low red blood cells, you may be able to omit that from your prenatal vitamin to decrease some of that constipation.

I also will frequently tell people to just get the Costco size bottle of MiraLAX for the pregnancy because many pregnant women experience constipation at baseline. So it's just wise to kind of stay ahead of. Some people do great with Kiwis and prunes as a dietary way to decrease some of that prenatal vitamin constipation, if they're not interested in taking MiraLAX, but it's something that we can easily overcome depending on how you're feeling.

You know, the prenatal vitamins, taking them on an empty stomach in the morning is going to definitely make that early trimester nausea and vomiting worse. And so sometimes I've had families that do better when we take the prenatal vitamin with a meal. Sometimes they'll do better with a gummy prenatal vitamin, or taking it at night. And so there's lots of different things to try. And so my advice is usually take the vitamin that you tolerate, that you remember to take, and that's pretty much it. It doesn't have to be anything fancy as long as it has folic acid. That's the most important thing. 

Lizzy: Wow. That's great. Yeah. I never knew that.

Liz: And then we can't talk about pregnancy without at least touching on the subject of miscarriage because it's super common. Is it 15 to 25%? 

Dr. Maloy: So it’s very common. And you know, when I'm counseling patients on miscarriages, I just try to normalize that. And if they start asking friends or their moms and sisters, you know, most women who've been pregnant have experienced a miscarriage. And it's very age dependent, so depending on how old that person is, that rate of miscarriage is going to increase. But when we look at each 35, it's about 25% of recognized pregnancies will end in a miscarriage. 

Lizzy: So many. 

Liz: Yeah, that is so many. It caught me off guard. It happened on my first pregnancy and I didn't realize that it could happen on your first because it wasn't something I was talking about with my friends at the time. Because that was one of my first friends to get pregnant. And people weren't just talking about it, and so to be totally surprised by it was just awful. So I'm glad that people are talking about it and that it's just more recognized and more known to be so common

Dr. Maloy: Absolutely. And I think one of the things that I find helpful when I'm trying to encourage women, is to just feel that grief, because, you know, as soon as someone finds out they're pregnant, they have feelings about that.

Whether it's positive feelings or negative feelings or neutral feelings, there are feelings about that and giving the space to be able to process those feelings and work through them is really important. 

And the other sort of encouraging thing is that the vast majority of the time after a loss, the next time that there is a pregnancy, the most likely outcome is a term pregnancy.

So that sometimes gives a little bit of hope, but making this, something that we talk about, something that's normalized realizing how common it is, and then trying to provide a space to just work through those emotions, as they're going through them. 

Liz: Yeah. Yeah. It's true. 

Lizzy: It's a real process, yeah. I had one my first as well, and it is a real grading process. Like you don't even realize how much you have invested by that point. 

Dr. Maloy: Oh, absolutely.

Liz: So true. Oh, it's awful. 

Lizzy: Okay. So pregnancy into labor and delivery. How do you prepare your patients for this? We had one reader question that said she was scared about the pain during labor and plans on getting an epidural, but was still very nervous.

And I remember looking around at moms when I was pregnant with India, of all shapes and sizes, and all ages. And I would think like, they're in this club, they know what happens. And I, on the dark side am so scared and like, I'm looking at them and I think “If they can do it, I can do it. But like, I don't feel like I can.”

Liz: Yeah!

Dr. Maloy: So common. And one of the things that I try to do is for patients who have very specific concerns or worries, or if there's something specific about this experience that they're concerned about, I try to talk about that part. 

So if it's pain control, you know, it's talking through IV pain medications, a lot of places will have laughing gas or nitrous as an, as an option.

And then of course there's the epidural, and the epidural tends to be the gold standard of pain control because it's the most effective and also has the least amount of side effects for the baby when we get closer to delivery. And so it's also really common, you know, many women opt to have an epidural during their labor.

And so even for women who choose not to have any pain control, I can't tell you how many times in my day, during those really intense moments of the birthing process it is really common for people to say, “I can't do this.” And that's when having a good support system at your side to sort of flip that switch and say, “You absolutely can. And we're here to be your cheerleaders” to kind of get you through those moments, because no matter what we're doing, that's hard in our life, there's going to be moments when we feel like this is too much, and that is so true. And laboring and also just parenting in general, but I feel like you're doing something that you've never done that is hard physically, if it's your first child or maybe it's a repeat pregnancy, but there's something different about this. Or even just being in that hard moment of laboring and getting ready to do the pushing part, it can be overwhelming. But having a supportive team at your side, you know, a family member that you want to have there, and then of course, hopefully an OB or a midwife that you've built a relationship with, that's when that relationship will really shine when we can help through that, that challenging moment. But I'm always amazed at the resilience and strength of the human body. And it becomes instinctual, like no matter how much someone is nervous or panicking at that moment, the body really just figures it out most of the time. And we are able to ge success. Yeah. 

Liz: And thank goodness there's such a team effort there because I loved my doctor and I would do anything that she said, but it was really the nurses that were just the lifeline!

Lizzy: I like that you're talking about a built relationship, which is so true, but you meet these nurses when you walk in that door and they take over like angels. 

Dr. Maloy: They do. Okay. They are a special type of person and they are able to have that time with you. Usually our labor and delivery nurses have one, maybe two patients that they're taking care of. Whereas for myself, I know I'm managing pretty much every patient who's there, so they just have that ability to be at the bedside and really take the time with the patients to help through those moments. It's really amazing.

Lizzy: They’re incredible. Okay. And then along the same lines, if it's not that, you're walking in, you’re in labor, in pain, or nervous about that piece, talk about induction and what that's like. How many people need to do it? I had to do it for all three of my pregnancies and then also stigma attached to it. 

Liz was surprised to hear me say that, but I had so, so many people in my life say like, “Oh, they might want to induce me, but I really don't want to do that.” Like, there was a lot of questioning around that practice. 

Dr. Maloy: Absolutely. Induction of labor has become much more common. And part of that is we just have more data on the ideal timing of pregnancy. The old thinking before 2018 really, was that induction potentially increased the risk of a C-section. There was a landmark study that was done in 2018 called the ARRIVE Trial. And it really changed obstetric practice because we looked at–and by “we” I mean the researchers who completed the study, and it was very robust and well done study–looked at, first-time moms and then doing an induction at 39 weeks.

And their primary outcome was Cesarean rates. And so what they found was that there actually were some benefits of getting delivered in that 39th week. And so decrease the rate of primary Cesarean section section decrease the rate of the neonate or the baby needing support. So those were some major benefits that we started to see.

And so a lot of practices started to adopt 39 week induction and we actually call them now “Risk Reducing Inductions”, because we know it decreases the risk of hypertension, high blood pressure issues and preeclampsia, and then decreases that C-section rate. So, I think that that stigma still exists, but there's definitely some very robust data to sort of say “We know a little bit more now.” and that we think that part of the benefit of getting delivered by that 39th week, is that that placenta is really not designed to last much longer than that. And so the further we try to push and test that placenta, we tend to see things that are placenta problems come up. So most hypertension or high blood pressure issues and preeclampsia, things like that, that we see in pregnancy or placenta issues. And so if we get that placenta out before it becomes a problem, we can prevent that. And the reason we think the C-section rate decreases is for the same reason that your placenta stops doing its job as efficiently. And so we are able to have a fetus that tolerates labor better because it's getting better perfusion through a better working placenta.

Lizzy: So interesting. Yeah. My OB would always say nothing good happens after 41 weeks because of that. 

Dr. Maloy: I'd even push it to 40. 

Lizzy: Well, she always wanted me to be induced earlier and I kept having the small, tiny hope that one of these babies would choose to come, but, okay, well, we're on the topic. Let's talk about the C-section.

Liz: What can someone expect if it's not planned? And Lizzy has been through that, so you can talk about it as well, I’m sure.

Dr. Maloy: Sure. Depending on the situation, if it's a scenario where we had time to really talk about it and prepare ahead of time, then I usually try to walk through as much detail as the patient is really comfortable with learning about the details of the operating room, the team that'll be there, what they can expect for their surgery.

And I have found that some burning people want to know every detail of what we're doing during the surgery. And I will just walk them through what we're doing each step of the way and others don't want to know at all. And so I really try to, sort of balance that with the risks and benefits and then also their desire of how much they want to know. 

In a true emergency where we're going for life saving surgery, there's not really time to sit down and have a discussion because either the mom is in trouble or the baby's in trouble and we need to act really fast to get that. And so those situations are incredibly scary for everyone involved and for the entire family who's there. So when I'm running the show in that kind of situation, I really just try to look at them and tell her “This entire team of people is here to take care of you.

And we are going to tell you as much as we can, but we're going to go really fast.” And it often will feel kind of like a pit crew swarmed in and everyone is doing stuff to them to try to get us to where we need to be, which is getting that baby delivered really quickly. And so in those true life-threatening emergencies, our goal is to get that baby out really fast. And it feels insanely overwhelming to the families and patients. And so afterwards, when everything is calm and hopefully we have achieved our goal of having a healthy mom and a healthy baby and a safe delivery, I try to really sit down and go over everything that has happened. and talk about how it's normal to have a traumatic response to that, because it is a very traumatic thing and you need to be able to sort of process.

We know that people who have a traumatic delivery have more postpartum depression and anxiety. And so we really try to sort of circle around that and go over everything and make sure that they feel heard and get their questions answered about the experience that they had. And if we have more time to do that, then we try to do it before we need to go to the operating room. And often when we're starting labor, like when someone comes in labor, or they're coming in for an induction, I try to set some groundwork of expectations and there are three main things that make us need to go to the operating room. One is if the baby's not tolerating the labor. So the heart rate that we're seeing on those monitors is giving us signs that the baby's in distress.

The second is if we're working to get that cervix to dilate, and it just is not happening after lots of time and lots of different tricks and all of the medications we have. And then the third is if we get to push and we have several hours of pushing without any movement of that baby down through the pelvis.

And so when it's a cervix or a pushing problem, we often have time to really talk about the buildup to the C-section. And even sometimes if it's a heart rate issue, if it's something that's not super severe, but if we get into a severe heart rate issue, then that's when we end up with emergencies. And of course there's things that can happen to the mom too, that can necessitate that, but it's really just trying to use the time we have to review expectations, answer questions, and make them feel comfortable about why we're doing this, and what the goals are. 

Liz: And in that emergency situation, is there a nurse next to you? 

Lizzy: I had someone next to my head talking to me saying, “This is what we're doing” cause everybody's shouting. So someone is like, “You're okay, this is what they're doing. Oh, I can see the baby he's breathing,” really trying to calm you down. 

Dr. Maloy: Yeah. And so usually the team that will be doing that once you get into the physical operating room is the anesthesia team. And so there's usually one or two anesthesia team members, whether it's a CRN or an anesthesiologist.

And then most of the time when a true emergency happened, it’s the entire unit. So like most of the nurses will be there. and the doctor's like, everyone is all hands on deck to try to expedite providing this care as quickly and as safely as we can. Quick in. Quick out. 

Lizzy: It's like, they all come and they got this, then there's two people there and you're like, um..? 

We had a C-section question from a reader who wanted to know: She said her third C-section uncovered a uterine window–would you say that means no more babies?

Liz: And what is a uterine window?

Dr. Maoly: Perfect, let's start with talking about what that. A uterine window is when we do the dissection on a C-section and we get down to physically looking at the uterus, before we make a cut in it. And so that uterus is usually, it's a very strong muscle, you know, it's strong enough to push the baby out when we're giving birth. And so what can happen when you have a C-section is that every time we make a cut through that muscle, it's a weaker spot. It never gets as strong as it originally was. And so the window is that, when we look in, after making that dissection down to the uterus, that we can literally see into the uterus. And that means there's no strong muscle there. And that can be very concerning because it increases the risk of having something called a uterine rupture where that old scar can break open either during labor, during the birthing process, or even during the pregnancy. And that is catastrophic. It's catastrophic to the mom and potentially to the baby as well. And so, we, you know, that's something that's very specific to her, medical care and I would recommend that she talk at length with a person who did her last surgery, because they're going to be the person who knows intimate extent of that window, meaning how big it is, what kind of repair they did and if they can counsel on whether or not they think it's reasonable to try again, because the biggest risk with that is going to be the rupture of the uterus. And so even when someone has had a rupture previously, it's not a hundred percent that it's going to happen again but it's definitely an increased risk. And so, that's something that really needs personalized counseling on risks for that specific person, that it is something to be mindful of. And it's definitely something that we pay close attention to because it's a defect in the uterus that didn't heal the way that we wished it was.

Lizzy: And is it true or false that usually they say like once you've had three C-sections, it's not like you can have more babies or there are, or are there situations where you can? 

Dr. Maloy: So I don't think that there's necessarily a number that I would say ‘after this many C-sections you shouldn't have any more C-sections’ or, you know, we don't typically recommend a trial of labor, meaning time for a vaginal birth after the second C-section and there's lots of reasons, and that's something that can be discussed with someone's individual OB, but, it really depends more on the healing because you know, I've done someone's sixth or seventh C-section and the uterus has healed beautifully. And sometimes we get in and the second C-section and you're like, wow, this looks like it's the fourth C-section because everyone's body heals so differently.

So saying there's a specific number of C-sections–it's really not possible, but we do know that the more surgery we have, the more like we are to have risks and get into trouble like bleeding, scar tissue, things not being where they're supposed to be. So the bladder sometimes will be where it's not supposed to be, or there can be adhesions or like sticky stuff between the bowel and the uterus.So these are all things that are very specific to someone's care and needs to be discussed individually. 

Liz: Speaking of which, obviously we are so thrilled to have your advice, your medical advice, but anybody listening should know to definitely defer to their primary doctor. 

Lizzy: Yeah, this is not individual medical advice. One other reader question was if you had any information related to marginal cord insertion, which neither Liz or I was familiar with. 

Dr. Maloy: Sure. So, when we do anatomy ultrasounds, we look at that placenta. It's such an important organ that we kind of underappreciate, I think. And so we're looking at where that umbilical cord attaches to the placenta and ideally it should be close to the center because you're then getting access to all of the nutrition.

All the blood flow should be equal and it should function most efficiently. There are some abnormalities that can happen with the location and the umbilical cord. The umbilical cord can insert on the edge of the placenta, and that's what a marginal cord insertion is. It's when, if you think about it like a big circular pancake, that is the placenta, instead of having the umbilical cord smack dab in the middle of the placenta, it'll be over towards the edge, and there are other variations, something where even that umbilical cord inserts off of the placenta into the membranes. And that can be something very dangerous depending on where that is. And so that's why we're looking with that ultrasound; marginal cord insertion by itself usually doesn't really change much, you know, as long as the baby's growing appropriately, it doesn't change our management at all. When we start to see the umbilical cord inserting into the membranes, that's when we start to worry a little bit more about higher risk complications, and something called a vasa previa, which can be where that presenting part, instead of it being a body part of a baby can be that umbilical cord. And that can be very dangerous and something that needs to be managed very closely with a high risk obstetrician. 

Lizzy: So interesting.

Liz: So we talked a little bit about the birth care team when you go to deliver, what can someone expect for their birth care team and then has COVID, or how has COVID impacted that? 

Dr. Maloy: So, I do only hospital-based birth and care, so I can't really speak to any other experiences, but for my patients–I've worked at several different hospitals–there is usually a primary nurse who's going to be the main sort of caretaker and manager of that patient during that laboring experience. There's people at the front desk that will check you in, and there are techs that will come take vital signs and help bring things like water and blankets and whatever human needs people need. There'll be people from the cafeteria that will bring food when you're able to eat. And then there are techs on the floor that will do things like set up the delivery instruments or be in the operating room to hand the surgeon instruments. And then of course you'll have either your midwife or your physician team helping take care of you. And then once the delivery part happens, moving over to a postpartum area in the hospital. Some hospitals do it all in one room. They do labor, delivery, and postpartum in one room. Many placements will have the labor and delivery a room, and then you go for postpartum in a different room. And so over there, you'll again have a nurse that's going to be your primary sort of point person and then the ancillary staff, like the kitchen workers and the housekeepers and the techs who will then also help to give you whatever you need. 

During COVID I think the biggest thing that's changed for us is the visitor policy. We used to not have limitations on how many people you could have come to visit you in the hospital, but because we're trying to, you know, balance the risk of infection with meeting people's needs to be able to have their partners and family members with them, many places have instituted limitations. And I know Lizzy experienced that firsthand, with not being able to have family with her. And so I think that's been the biggest change and it's very fluid. So depending on the case rates and what that hospital's experience, the number of visitors changes. And that's probably been the biggest thing. And then I know because of COVID, everywhere in the United States has really experienced some staffing issues. And so, I know hospitals have been [short staffed], it's been all over the news about how they're struggling with staffing. And I think people are really trying to meet those needs regardless of how staffed they are. But I know that there's waits sometimes for cafeteria food or the nurses may have more patients than they would at baseline. And that's been a big impact or from COVID. Yeah. 

Liz: Actually somebody asked us, the best way, how can we best support doctors and nurses right now?

Dr. Maloy: I know that is such a kind thought, you know. The people who go into these kinds of jobs are really built for service. And so everyone's like motivation is that we are the helpers. We want to be the ones who are helping. And I've, you know, we've noticed in these times like we are doing, people are doing the best they can, and I want people to feel empowered and encouraged to continue to ask for what they need and to speak up if something's not happening, that they think it should be happening.

Being kind. And those interactions are really the best thing. Everyone is stressed. Everyone is functioning at a level that's not easy. And, there's challenges on so many fronts, so everyone wants to meet those needs. And I think just, if you need to ask for something multiple times, then please just do, and this is not talking about like a safety issue, of course, if that's happening, please, do you need to speak up very loudly! But, like an extra glass of water, an extra blanket, you know, just being patient and realizing that everyone's doing the best they can is really all we can ask. Yeah, that's very kind. 

Lizzy: Yeah. It's a very well timed question. Okay. We won't keep you too much longer. Let's talk a little bit about the fourth trimester. Uh, it's really scary to leave those hospital doors and have a baby in your arms and feel like you could do everything wrong at any moment. weird feelings. Yeah. How do we, how should we be preparing for this as parents and yeah, maybe.

Dr. Maloy: You know, I think that one of the things I find myself saying frequently is that this whole laboring, delivering, birthing process is like the first lesson in parenting. And that's that you have no control over our kids. Like they are going to do what they are going to do, and we can make the best plans in the world.

And it is not going to go how we thought it was going to. So. You know, I can say, even as someone who had my kids, when I already was an OB GYN, I remember that first night with my eldest son. And I kept thinking like, “When is someone going to take this baby? Like this can’t be my baby, because why would they give me a baby?” And it just felt so surreal because I had watched my own ultrasounds and just like, felt like they were someone else's ultrasound. So when they handed me this baby, I was like, “okay, now what?” But I think we're all in it together.

You know, we are, people are so resilient and they find a way to figure it out. And there's no perfect parenting. Like, just think about how many books and blogs and influencers there are that are coaching on parenting. And there's just no one way to do it. And I think as long as you're, you know, trying to do something reasonable, and safe then that's all you can do.

You come with love and in an effort to try, and an open mind. And I think that's really all you can do. But, that fourth trimester is hard. And I think it's something that I know the OB GYN societies have really been trying to change and impact because, the care that we're providing in that fourth trimester is really limited. And so much of that is because of the way that healthcare is reimbursed, which makes zero sense. We should be doing what's right for our patients, and a lot of times the insurance coverage and when people lose their insurance again, after having a baby well, dictate that. And so most people get one, maybe two visits in that fourth trimester.

And there's been a big move to really lobby and try to change that so that we're doing more frequent visits and extending that fourth trimester really out to the 12th week postpartum, and trying to do better support there because without having paid leave for people who've just expanded their families, it's really hard to come to these appointments or, you know, let's do some counseling to talk about postpartum depression, talk about early parenting struggles. That's really hard if you have to go back to work and something like 23% of people go back to work within 10 days of giving birth, which to me, is just insane.

Lizzy: That’s not enough at all. 

Dr. Maloy: It’s not! And then by the 40th day, like another 20% of employed people, have gone back to work. So. It's something that I'm very passionate about and will continue to keep advocating for. And I think the willingness on the care team is there. It's just being able to facilitate that both from a reimbursement standpoint, but also in the way that we support families to allow people to be able to have that time to heal and learn to parent.

Liz: It's hard. It's hard and so important. Maybe a quick touch on breastfeeding. We know that there's a lot of information out there. People have very strong feelings about breastfeeding, not breastfeeding. What do women need to know going into it? And what's your best advice?

Dr. Maloy: Sure. So I think, as a mom who has now breastfed two children, it's probably the hardest thing I've ever done. And I think no one can really prepare you for that. You know, everyone says it's just so natural and it should be so easy. And then when you struggle with it, you're just sitting there being like, how is this so hard? But it, it really is. And it's something that even as an OB GYN, I got some basic training and how to coach women, how to latch their babies and stuff, but until you really do that yourself, you're not an expert in it. And there are some fabulous resources available. I really think tapping into your lactation consultants–most hospitals have lactation services–is something you can talk to your team about, and then getting set up with someone who you can sort of follow once you get discharged from the hospital or if you're at a birth center. There's an international board of certified lactation consultants and on their website, you can find a local lactation consultant, which is probably the best sort of help in troubleshooting any issues.

And then there's a lot of peer support. So I love La Leche League for this, for families that don't have the financial resources to pay for a private lactation consultant, because it's peer to peer. There's a lot of peer help that's available. And then of course your OB team, your midwife, they can help you troubleshoot some of those basic things.

But if it becomes more complex than that, then really seeking out some of these breastfeeding experts is going to be your best bet. And there's a website that's called Kelly Mom. And that website is one of my favorites. I tell patients about it all the time, because it has a lot of great peer reviewed sort of breastfeeding data, and resources because, you know, we really want to be able to support families through this challenge and, and using good data and best practices is kind of the, at least my, goal as an OB GYN.

So those are some of my favorite resources, but these breastfeeding issues are so specific that it really needs an individualized approach.

Lizzy: I think you sent me to Kelly Mom a few times and there was great information on there. Okay. We're going to let you go, but do you have any great resources or sites or books that you recommend and pass along?

Liz: And we'll link to all the things that Dr. Maloy has mentioned

Dr. Maloy: Sure. ACOG, which is the OB GYN society, has “a for patients” page, like frequently asked questions segment, so I can definitely send you the access to that. The American Academy of Pediatrics has a book called Caring For Your Baby From Age Zero to Five And I think I have like screenshot and things of that and send them to you before Lizzy.

But it's great, cause it's like, “here is what your pediatrician wants you to know about basic stuff for taking care of the baby” and so that's a really good resource. Most libraries will have that, or it's available from the American academy of pediatrics or from Amazon. And it's, it's just like a great resource for a book.

Um, and then as far as, some social media sort of connections, there, there is an MFM that's Maternal Fetal Medicine doctor named Dr. Shannon Clark. And she does a Instagram and a TikTok that's called “Babies after 30”. She is phenomenal and she really takes things that are in the media and breaks them down in great infographics, and she'll do little TikTok s of, you know, whatever questions people submit to her, and all of her data is very evidence-based because she's a Maternal Fetal Medicine specialist. And so she has great information on that folic acid prenatal question that everyone has, and she talks a lot about, you know, having babies later on in life and she'll talk placental issues. She just posted one about placenta vasa previa the other day, which is a specific placental complication. So, she's one of my favorites because she really breaks down these very tough topics and makes them interesting and very accessible to everyone while we're on the go. 

Liz: Amazing. That's great. Because how many times are you breastfeeding in the middle of the night, trying to look something up? 

Lizzy: All the time!

Liz: So to have that all at the ready is great. Well, we'll make sure to link and list all of these things. 

Dr. Maloy: Well, thank you for having me this morning. This was, fun!

Lizzy: You're a wealth of knowledge yourself. You're the best.

Dr. Maloy: Of course, and happy early birthday.

Lizzy: Oh, thank you. You too. And happy belated, 

Dr. Maloy: I know, it was so sad when we stopped being able to celebrate together because we don't live close to anymore, but 

Liz: Ah! Too far! 

Lizzy: Yeah, thank you so much, Katie. Thank you. 

Dr. Maloy: Anytime. Happy to do it 

Liz: Careful. We'll ask you back!

Dr. Maloy: No problem.