500 hours. That is the cumulative number of hours that I have spent speaking in front of a group. That is three summers I taught courses with 40 lecture hours each; 8 quarters of graduate teaching assistantship; and 10 quarters of undergraduate group tutoring where I led lab lectures for an hour once a week before one-on-one tutoring. That is six conference presentations (and four practice talks), one in-house research presentation, an advancement proposal, and a commencement address. That is two guest lectures in a graduate class, and one in an all-girls' day school. That is at least one trite talk for general-education requirements (I lost count after one, because it matters so little).
I am not so nervous about public speaking anymore. It really does come with practice.
Friday, November 25, 2011
Clinical data management: My response to a new technology
Meanwhile in Austria, at the USAB 2011 conference on eHealth, hundreds of health and technology professionals gather to discuss topics relevant to information flow, patient empowerment, and clinical decision-making.
The first of four (four!) keynote presentations was given by Vimla Patel of Columbia University, whose interests lie in quality of eHealth data. In the talk, Cognitive Approaches to Clinical Data Management for Decision Support: Is It Old Wine In a New Bottle?, Dr. Patel argued that indeed it is new wine in a new bottle. This post chronicles my reactions to the talk. Dr. Patel, if you happen upon this post, please know that I am quite jet-lagged and had had three of the complimentary espressos, in rapid succession, shortly before your talk. I do not intend this as an apology, but as an explanation, and as a hope that you will not hate me for expressing my views so plainly. I don't buy it, and here, I explain why.
Patients are in danger!
The problem was outlined thus: Information technology impacts patient safety. There is simply not enough evidence that current information technology systems are good for patient safety -- in fact, they might be detrimental. One of the reasons is that there is no accountability for these systems. According to Dr. Patel, in many cases, systems are designed and deployed by engineers without consulting with clinicians or patients, and without proper responsibility for upkeep of the systems for new ideas and trends.
Federal regulations
A way to address this? Dr. Patel suggested: Technology should be monitored by an agency or government; there should be federal regulations on software released for eHealth purposes.
Pardon me while I gather my jaw from the floor. Right off the bat, I can think of at least two reasons this will never work.
First: The design-development cycle would be too cumbersome. Can you imagine being the poor programmer that has to succumb to federal regulations, to laws and restrictions, to government-imposed checks and balances? Can you imagine trying to add a new feature, a new decision flow, or a new interaction method? I thought the Apple Developer cycle was bad; this would be murder.
Second: Regulations on software are restricting. No, I don't have a citation for this, you overachiever. I know from my experience and from the experiences of all of my colleagues that regulations are inversely proportional to success of a software product. While it is true that some restrictions spark creativity, what we are talking about here is a severe impediment to the development process.
Here's a bonus: Third: Every hospital, every office, every provider has different requirements. How do you federally-regulate this difference and custom instances of the same product? It is a nightmare.
Why Electronic Health Records (EHRs) suck
Problems with current electronic health record (EHR) system include the following.
In EHRs, information is structured temporally, which is how clinicians come about gathering the data. As a clinician, you see a patient, you take notes; you see the patient again, you take more notes. Over time, this presents a time-oriented view of the patient's health. But the problem is that clinicians do not think about patient health in this way. They think in terms of symptoms and relationships between symptoms, tests, and diagnoses.
So the question is how to store the data in a way that is fundamentally useful to clinicians, and how to retrieve and display it in the same way that they think about the data. There is too much data, too much redundant data, and too many sources of related data. There is a mismatch between cognitive processes of clinicians and the way the data is stored and represented.
The result Dr. Patel drew is that there is poor usability study and requirements gathering for these EHR systems. By involving users (i.e., clinicians) in the process early and often, she argued, we can explicitly retain the relational structure in software that clinicians use in real life: a complex mental model of vital signs linked to symptoms linked to potential diagnoses. A directed graph of thoughts and decisions. Understand what people want, she said. Test iteratively with users, she said.
I thought: Don't be afraid to say participatory design.
User study is not enough
Dr. Patel never outright said it, but it is a question of tagging and metadata and, most certainly, provenance. In effect, the question is the same as in any large-scale file system (think peta-scale): how can you predict which data the user will want to retrieve? I refer the reader to work done by the Storage Systems Research Center which has been tackling the problem in full force.
Sure, representing the data is important. As with any file system (let's face it; that's what we are talking about here), we can know everything about what users want, but it may be fundamentally impossible to deliver this kind of system. Big data have an inherent bottleneck at retrieval; they have an inherent bottleneck at storage and archival.
Nobody likes to be wrong
In real life clinicians draw logical conclusions in a guess-and-check fashion: given a set of symptoms gathered from charts, nurses, attendings, and other sources of information, they make a mental model of the potential problems and solutions which can be confirmed or refuted. In the ideal scenario, the clinicians would chart these decisions and potential diagnoses. They would chart, in this system, anything that they considered potentially important in the future.
Oh god! So many problems!
First, think about the paperwork overhead. Electronic paperwork, whatever. Sure, in the ideal world with infinite time and infinite memory (as they say in computer science), doctors would save all of their thoughts.
Second, think of the liability. I am not even talking about not wanting to be wrong, which, of course, everyone feels. It is well-studied in elderly patients with dementia: they will not admit to forgetting appointments or missing meetings. People won't chart wrong guesses. Being wrong is bad. For a clinician, being wrong leads to liability. Mis-representing a symptom that can lead to a missed diagnosis leads to liability. How can you prove your motives were good, when the patient's health was compromised?
Third, is this another way to minimize patient interaction? Look, in labor and delivery in the US, the average doctor spends something like 2 hours, 41 minutes with her patient, total, throughout her entire average 10-month pregnancy and including the 24-hour birth. With such a system, will it mean that a doctor no longer needs to spend quality time with her patient, but instead spend this time mining data? I do not argue that in aggregate, data gathered over time in a particular facility can be powerful. But what happened to patient-centered care?
It's different on paper
Electronic health records have a different set of abstractions and information flow (and hence, a different set of mistakes one can make) than paper-based ones. For paper-based health records, it goes basic concepts (such as vital signs) : intermediate constructs (what to do with the vitals: e.g., compare to normal, compare to expected, compare over time) : heuristics (visualization and diagnosis). Concrete to abstract. But most experts do not bother writing down some basic concepts because it is inefficient, much in the same way you do math in your head or play chess without writing down the possible moves. For EHRs, the flow goes heuristics : intermediate constructs : basic concepts. Abstract to concrete. The overlap is at intermediate constructs, and the question is how to move them from the head to the computer.
I imagined WebMD, the website that spits out a list of things that could be killing you subtly or not-so-subtly, given an input of real or imagined symptoms. The output from WebMD is potentially useless. You have a stomach cramp and a head ache? It could be a brain tumor and pregnancy.
Disempowered
Of course, the tool Dr. Patel described would need to be understood by a doctor, or someone else medically trained. In fact, she said, in some cases, you do not want the patient to know at all. There are cases that the patient should not have access to these private thoughts of doctors. With the exception of one situation which I do not have training to understand, namely, adolescents seeking psychiatric care (if I were said patient, I would damn well like to know what the doctor thinks!), I thought that it was a huge oversight that the system would be unusable by anyone without proper training. Make it understandable, she said, for the doctor.
What about patient empowerment? What about patient information? In Germany, a doctor will sit alongside the patient to look through a clinical workflow, and they will decide together, collaboratively, on the proper treatment. Why is there not more of this worldwide? And why not just teach the patient?
Dr. Patel said the goal is to move towards patient-centered cognitive support for the clinician. I realize that this is the goal, but with this technology, I worry that we are removing real interactions between the clinician and the patient in favor of data collection. We are in a digital age where we teeter on worshipping data: in some ways, we hold data above all other things. We hold data collection, for example, above the real-life interactions, the real time that doctors and nurses used to spend with patients, that now they spend writing down things about their brief encounters.
Finally, and then I will stop ragging on this keynote, what about evidence-based medicine? Why has it never been mentioned, alone or in conjunction with "patient-centered" care? Why are we increasing the burden on care providers while decreasing the burden on the very people that are meant to do well -- by removing them from the patient and treating their thoughts, education, and logic, which makes them unique and valuable, as interchangeable with any other doctor, clinician, or robot?
Now, take this with a grain of salt because my triple caffeine buzz is wearing off. I was pretty excited about this talk when it began: the initial idea was that medical technology, and electronic health record systems in particular, are possibly doing harm to the patients they intend to serve. But near the end, it was clear that the only take-away, for me, is that more user study is needed for electronic health records, to determine what doctors need to make them disposable. As a patient and as a researcher, I feel disempowered.
But it is an interesting file systems problem.
The first of four (four!) keynote presentations was given by Vimla Patel of Columbia University, whose interests lie in quality of eHealth data. In the talk, Cognitive Approaches to Clinical Data Management for Decision Support: Is It Old Wine In a New Bottle?, Dr. Patel argued that indeed it is new wine in a new bottle. This post chronicles my reactions to the talk. Dr. Patel, if you happen upon this post, please know that I am quite jet-lagged and had had three of the complimentary espressos, in rapid succession, shortly before your talk. I do not intend this as an apology, but as an explanation, and as a hope that you will not hate me for expressing my views so plainly. I don't buy it, and here, I explain why.
Patients are in danger!
The problem was outlined thus: Information technology impacts patient safety. There is simply not enough evidence that current information technology systems are good for patient safety -- in fact, they might be detrimental. One of the reasons is that there is no accountability for these systems. According to Dr. Patel, in many cases, systems are designed and deployed by engineers without consulting with clinicians or patients, and without proper responsibility for upkeep of the systems for new ideas and trends.
Federal regulations
A way to address this? Dr. Patel suggested: Technology should be monitored by an agency or government; there should be federal regulations on software released for eHealth purposes.
Pardon me while I gather my jaw from the floor. Right off the bat, I can think of at least two reasons this will never work.
First: The design-development cycle would be too cumbersome. Can you imagine being the poor programmer that has to succumb to federal regulations, to laws and restrictions, to government-imposed checks and balances? Can you imagine trying to add a new feature, a new decision flow, or a new interaction method? I thought the Apple Developer cycle was bad; this would be murder.
Second: Regulations on software are restricting. No, I don't have a citation for this, you overachiever. I know from my experience and from the experiences of all of my colleagues that regulations are inversely proportional to success of a software product. While it is true that some restrictions spark creativity, what we are talking about here is a severe impediment to the development process.
Here's a bonus: Third: Every hospital, every office, every provider has different requirements. How do you federally-regulate this difference and custom instances of the same product? It is a nightmare.
Why Electronic Health Records (EHRs) suck
Problems with current electronic health record (EHR) system include the following.
In EHRs, information is structured temporally, which is how clinicians come about gathering the data. As a clinician, you see a patient, you take notes; you see the patient again, you take more notes. Over time, this presents a time-oriented view of the patient's health. But the problem is that clinicians do not think about patient health in this way. They think in terms of symptoms and relationships between symptoms, tests, and diagnoses.
So the question is how to store the data in a way that is fundamentally useful to clinicians, and how to retrieve and display it in the same way that they think about the data. There is too much data, too much redundant data, and too many sources of related data. There is a mismatch between cognitive processes of clinicians and the way the data is stored and represented.
The result Dr. Patel drew is that there is poor usability study and requirements gathering for these EHR systems. By involving users (i.e., clinicians) in the process early and often, she argued, we can explicitly retain the relational structure in software that clinicians use in real life: a complex mental model of vital signs linked to symptoms linked to potential diagnoses. A directed graph of thoughts and decisions. Understand what people want, she said. Test iteratively with users, she said.
I thought: Don't be afraid to say participatory design.
User study is not enough
Dr. Patel never outright said it, but it is a question of tagging and metadata and, most certainly, provenance. In effect, the question is the same as in any large-scale file system (think peta-scale): how can you predict which data the user will want to retrieve? I refer the reader to work done by the Storage Systems Research Center which has been tackling the problem in full force.
Sure, representing the data is important. As with any file system (let's face it; that's what we are talking about here), we can know everything about what users want, but it may be fundamentally impossible to deliver this kind of system. Big data have an inherent bottleneck at retrieval; they have an inherent bottleneck at storage and archival.
Nobody likes to be wrong
In real life clinicians draw logical conclusions in a guess-and-check fashion: given a set of symptoms gathered from charts, nurses, attendings, and other sources of information, they make a mental model of the potential problems and solutions which can be confirmed or refuted. In the ideal scenario, the clinicians would chart these decisions and potential diagnoses. They would chart, in this system, anything that they considered potentially important in the future.
Oh god! So many problems!
First, think about the paperwork overhead. Electronic paperwork, whatever. Sure, in the ideal world with infinite time and infinite memory (as they say in computer science), doctors would save all of their thoughts.
Second, think of the liability. I am not even talking about not wanting to be wrong, which, of course, everyone feels. It is well-studied in elderly patients with dementia: they will not admit to forgetting appointments or missing meetings. People won't chart wrong guesses. Being wrong is bad. For a clinician, being wrong leads to liability. Mis-representing a symptom that can lead to a missed diagnosis leads to liability. How can you prove your motives were good, when the patient's health was compromised?
Third, is this another way to minimize patient interaction? Look, in labor and delivery in the US, the average doctor spends something like 2 hours, 41 minutes with her patient, total, throughout her entire average 10-month pregnancy and including the 24-hour birth. With such a system, will it mean that a doctor no longer needs to spend quality time with her patient, but instead spend this time mining data? I do not argue that in aggregate, data gathered over time in a particular facility can be powerful. But what happened to patient-centered care?
It's different on paper
Electronic health records have a different set of abstractions and information flow (and hence, a different set of mistakes one can make) than paper-based ones. For paper-based health records, it goes basic concepts (such as vital signs) : intermediate constructs (what to do with the vitals: e.g., compare to normal, compare to expected, compare over time) : heuristics (visualization and diagnosis). Concrete to abstract. But most experts do not bother writing down some basic concepts because it is inefficient, much in the same way you do math in your head or play chess without writing down the possible moves. For EHRs, the flow goes heuristics : intermediate constructs : basic concepts. Abstract to concrete. The overlap is at intermediate constructs, and the question is how to move them from the head to the computer.
I imagined WebMD, the website that spits out a list of things that could be killing you subtly or not-so-subtly, given an input of real or imagined symptoms. The output from WebMD is potentially useless. You have a stomach cramp and a head ache? It could be a brain tumor and pregnancy.
Disempowered
Of course, the tool Dr. Patel described would need to be understood by a doctor, or someone else medically trained. In fact, she said, in some cases, you do not want the patient to know at all. There are cases that the patient should not have access to these private thoughts of doctors. With the exception of one situation which I do not have training to understand, namely, adolescents seeking psychiatric care (if I were said patient, I would damn well like to know what the doctor thinks!), I thought that it was a huge oversight that the system would be unusable by anyone without proper training. Make it understandable, she said, for the doctor.
What about patient empowerment? What about patient information? In Germany, a doctor will sit alongside the patient to look through a clinical workflow, and they will decide together, collaboratively, on the proper treatment. Why is there not more of this worldwide? And why not just teach the patient?
Dr. Patel said the goal is to move towards patient-centered cognitive support for the clinician. I realize that this is the goal, but with this technology, I worry that we are removing real interactions between the clinician and the patient in favor of data collection. We are in a digital age where we teeter on worshipping data: in some ways, we hold data above all other things. We hold data collection, for example, above the real-life interactions, the real time that doctors and nurses used to spend with patients, that now they spend writing down things about their brief encounters.
Finally, and then I will stop ragging on this keynote, what about evidence-based medicine? Why has it never been mentioned, alone or in conjunction with "patient-centered" care? Why are we increasing the burden on care providers while decreasing the burden on the very people that are meant to do well -- by removing them from the patient and treating their thoughts, education, and logic, which makes them unique and valuable, as interchangeable with any other doctor, clinician, or robot?
Now, take this with a grain of salt because my triple caffeine buzz is wearing off. I was pretty excited about this talk when it began: the initial idea was that medical technology, and electronic health record systems in particular, are possibly doing harm to the patients they intend to serve. But near the end, it was clear that the only take-away, for me, is that more user study is needed for electronic health records, to determine what doctors need to make them disposable. As a patient and as a researcher, I feel disempowered.
But it is an interesting file systems problem.
Tuesday, November 15, 2011
How to get my number at a tech conference
In technology, the male-to-female ratio strikingly favors the males. Of course, it depends on the specific field how rough it is: game design, for example, has more women than semiconductor research; human-computer interaction has more women than systems and security.
Having just had come from Grace Hopper Celebration of Women in Computing I was keenly aware that at Supercomputing 2011 the ratio was not 2:2900 (I think there were a few men at Grace Hopper) but more like 150:11. Yup, I counted, sitting in the back of the room where my workshop was being held. Interestingly, there were five of us students from the same university at this workshop, and four of us were women.
My talk was third in a block of three, and the latter two were similar in that they stemmed from the same set of interviews and touched on similar topics. After my talk, there was discussion in the audience, and when I rejoined my university's group of students, we began being approached by researchers interested in our work -- with comments, suggestions, and questions.
A young man, probably a few years younger than me, in a white and green graph-paper-patterned shirt, wearing dark-rimmed glasses on his long nose, and his hair cropped in the typical defense-industry fashion, approached me and my female colleague.
"I work on the very system you were studying," he said. "I'm the guy. I run everything, set the policy, and have tons of data on it."
"Hang on! Stay right there!" we exclaimed in unison. In a flash, my colleague and I ran off to retrieve our business cards. Tons of data! An expert in the field we are studying! This was very exciting. I ran back to my chair where I had left my laptop and bag, grabbed a stack of cards, and ran back, nearly knocking over chairs in the process. I saw my colleague also rushing and rummaging.
I made it back first. Presenting my card to him (American-style), I said, with a smirk, the first thing that came into my head:
"You just discovered the best way to get two women's numbers at the same time."
He looked at my card, and looked at me, and I could see that he was trying to determine whether what I had said was shocking or funny. I laughed.
Just a disclaimer that it was a joke.
But if you meet me at a tech conference, now you know how to get my card.
Friday, November 11, 2011
The Thin Line: Advising vs. Supervising
This is a post about the session The Thin Line: Advising vs. Supervising at Grace Hopper Celebration of Women in Computing.
The panelists: Laura Dillion has spent decades advising students at three different large universities, and spent time as department chair. Susanne Hambrusch has experience dealing with situations between students and advisors that went from bad to worse. She says that just knowing that a situation can occur is important. Lori Pollock has had experiences being the unbiased mediator between graduate students and their advisors.
Can I be co-advised by two professors? Can I switch advisors?
Sometimes switching advisors is controversial both in terms of your own work and in terms of the political climate of the department or school. Consider your own work, which may or may not move with you to the new advisor or department. It likely won't. Figure out if you will still have a project, and enough to do in order to graduate with a big dent in the new field. If there are concerns (and there should be), find someone that doesn't have a stake in the problem, and ask him or her for help. Someone unbiased can provide valuable advice. It could be a former instructor, a graduate advisor, or even more senior graduate students. Some students don't ask for help. In some places there is no help. That's where you should turn to other sources: e.g., friends' advisors, family, the Systers mailing list.
How and when do you ask about the author order and/or about presenting the paper?
Talk about it early. It can change, but know before you invest a ton into a paper how much credit you'll get for the work. Three possibilities are alphabetical order, percentage of writing done, and switching author orders if you expect more than one publication.
How do you know what your research contribution is on multi-authored work, and what you can present as your own work?
This is a good question in interviews, so make sure you have a well-reasoned answer: your research is your identity. The abstract of your dissertation, and your introduction, should make it very clear the different roles. Co-authored and multi-authored work can become "background" for a dissertation, and some papers never make it into anybody's dissertations. Think ahead: the part that's yours is the part that you will continue when you graduate. Be scrupulously honest.
My advisor keeps giving me more work, and I want to schedule my dissertation and graduate.
Ask. Sit down with your advisor(s), and have the conversation. Don't wait until after you've done the additional work to ask, but ask right then. Show your credentials: the number of papers you have, your advancement proposal which has been fulfilled, the chapters you've written, etc. It may the case that you aren't ready to graduate, but it may be that you are. It may be that you have differences in expectations (e.g., your advisor thinks you want to go to an R1 research institution, but you want to go into industry) which have serious differences in preparation for graduation. You won't know unless you have that conversation with the advisor.
What if my committee doesn't think I'm ready, but my advisor does?
Your advisor is your advocate. He or she needs to convince the committee that you're ready. There are no hard-and-fast rules to follow: you may want to look for a mentor for an outside, unbiased opinion.
What if my advisor is a total jerk? (This question was truncated and summarized.)
Find someone that can advocate for you. Go to the other faculty. But don't go straight to the dean, going over the head of the senior faculty and department chair, because this can cause bad feelings and really burn bridges. Learn about what's possible in your university and what resources you have. Sometimes it takes intervention for your advisor to do change; sometimes you have to switch departments and get your work to count toward your new affiliation. But get support from the senior people in the school that have influence.
What if my advisor lost his or her funding, and has no more money?
Understand that this could very well be true: the faculty member may have thought he had secured money but the money didn't come through; he or she could have overanalyzed the financial possibilities for the quarter or the year. Sometimes the money just disappears, such as with government contracts. It is embarrassing to the advisor, especially when the advisor had already made plans on the money (such as by promising you funding). Consider going to the chair or graduate director. Take up a TAship, teach a summer class, or find other sources of funding around your department or even in a different department.
How do you transition from being a student to being an advisor?
First you have to find a job in a supportive environment. Attend the CRA-W workshop for junior faculty in which they teach you how to be a good mentor and advisor. Have a mentor in the department that you join, that can help you along. Don't do it as trial an error, one student at a time. As a graduate student you can work with undergraduates in the summer on collaborative projects, and practice advising and mentoring.
Connecting the Disconnected: Improving Internet Access for the Other Four Billion
This post is about Connecting the Disconnected: Improving Internet Access for the Other Four Billion with Professor Margaret Martonosi from Department of Computer Science at Princeton University, at Grace Hopper Celebration of Women in Computing.
Information technology is an enabler. It is an enabler in education - for people to learn, through online courses, articles, and things in the public domain; in health care - getting an ultrasound when needed; in agriculture - the ability to find out why your crops aren't thriving; and in open and fair government - the ability to discuss politics openly with other people.
This presentation was about C-LINK, a type of delay-tolerant vehicular network. (Note: This vehicular network is an example of Sneakernet, though I don't think Margaret ever called it this.)
The current state of universal connectivity
Sure, the US is connected. Over 75% of the country has wired or wireless access. But there's the digital divide. The digital divide means that the places that need this technology the most are the places with the most impaired access to it.
The three factors influencing universal information technology access includes relevant and accessible software, using effective and affordable hardware, and have universal connectivity. C-LINK, Margaret's project, was influenced by all three.
The problem with affordable hardware is the "last mile" problem: it is easy to connect the majority of the people, but in the last mile, you have to extend connectivity to rural or hard-to-reach regions. This can be complicated, and costly. In rural Africa (for example), the last mile is of a whole different scale. So then we consider wireless technology, which is expensive, we need to think about how it still needs a wired backbone, requires ongoing maintenance, is subject to corruption or salvaging (because copper sells), and it needs political support. On the other hand, wireless technology is leapfrogging wired connectivity (especially in developing regions). Mobile and cellular is a big growth area and are increasingly penetrating the world. But even though there is so much cellular technology going on, that doesn't mean that it's cheap.
Let's look at effective and affordable hardware. Although there are efforts to build cheap hardware (such as the hundred-dollar laptop made by the One Laptop Per Child organization), it's not taking off. It's just not pervasive -- most of Africa and Asia have less than 10 computers per 100 people. That's even when you consider microcontrollers as "computers." So what is the world's computer? The world's computer is a cell phone. About half of the world's adults own one. There are more cell phones in India than credit cards -- and cell phones, even when they're not smartphones, are chock full of interactivity. (Note: Can you imagine an accessible Qwiki for developing nations that works over SMS? I can.)
Connectivity
Wired connectivity: availability is increasing and costs are dropping. For example, transit prices in Kenya have dropped to $120/Mbps -- which are similar to US prices in 2003.
Delay-tolerant network: Imagine a big city with a broadband connection, and a nearby village. Imagine that the village is on some rural bus or taxi route to the city. Now, imagine that the bus has a laptop inside, with a large hard drive and a wireless access point. People (and goats and chickens) board the bus in the village, send some requests on the laptop. Although the laptop isn't connected to the broadband, it can queue the request and send it when it reaches the city, and bring back the reply when it returns to the village. If the bus visits the village every 5 hours, that's a 5-hour latency -- but at least it is access to information.
The vehicular delay-tolerant network is very low-cost, easy to deploy, and has a very high data carrying capacity. Villagers can collaborate on their queries, and the results can be available to others in the village doing similar web searches (called collaborative caching). The system can also be improved by clever prefetching -- the computer on the bus can be thinking hard over the next several hours about what else can be proactively fetched based on the current queries. Clearly, prefetching all of the links on a page would be smart, but maybe so would translating a page from a local language to a more commonly-used language. This isn't a microcontroller with a tiny cache. This is a big hard drive. If the hard drive is huge, there is no worry about performance loss in prefetching things that will not be used, but the overhead of not having things that may be useful is huge.
"Come back tomorrow. Your data will be on the bus."
The authors designed, built, and tested C-LINK, the vehicular delay-tolerant network, over a week in Nicaragua. The city was Somotillo, Nicaragua -- no skyscrapers, but there was a school with a computer cluster and wired connectivity and a small, expensive Internet cafe with 2 computers. Participants were school children, invited to come in and browse the highly-delayed web. About 80% of the participants in the project had never used the Internet before. One of the cool things that the project looked at is when participants sent at the same query, or searched collaboratively. With each successive trip into the village, the bus brought back more data. As the village's cache filled up, users' miss rates plummeted. Data were on their computers or on the computers of their collaborators -- remember collaborative caching? The authors found that highly correlated access patterns provided strong incentive for collaboration. Oh, and we can evict old data or data that has not been accessed recently. Any cache eviction policy will work here.
Then Margaret and her team considered using laptops and other mobile computing devices and, despite the worry of data loss, found that going mobile wasn't so bad. If anything, it made for more kiosks -- little hubs for collaborative information. Then, they found that the requests for data were fairly small, so it was possible to exploit cellular connectivity, where available. They looked at data brought back by the once-a-day trip into town, by the 5-times-per-day bus ride, and a hybrid data retrieval mode by combining these with exploiting SMS.
Look around you
Other software that the authors found interesting and noteworthy included these.
Information technology is an enabler. It is an enabler in education - for people to learn, through online courses, articles, and things in the public domain; in health care - getting an ultrasound when needed; in agriculture - the ability to find out why your crops aren't thriving; and in open and fair government - the ability to discuss politics openly with other people.
This presentation was about C-LINK, a type of delay-tolerant vehicular network. (Note: This vehicular network is an example of Sneakernet, though I don't think Margaret ever called it this.)
The current state of universal connectivity
Sure, the US is connected. Over 75% of the country has wired or wireless access. But there's the digital divide. The digital divide means that the places that need this technology the most are the places with the most impaired access to it.
The three factors influencing universal information technology access includes relevant and accessible software, using effective and affordable hardware, and have universal connectivity. C-LINK, Margaret's project, was influenced by all three.
The problem with affordable hardware is the "last mile" problem: it is easy to connect the majority of the people, but in the last mile, you have to extend connectivity to rural or hard-to-reach regions. This can be complicated, and costly. In rural Africa (for example), the last mile is of a whole different scale. So then we consider wireless technology, which is expensive, we need to think about how it still needs a wired backbone, requires ongoing maintenance, is subject to corruption or salvaging (because copper sells), and it needs political support. On the other hand, wireless technology is leapfrogging wired connectivity (especially in developing regions). Mobile and cellular is a big growth area and are increasingly penetrating the world. But even though there is so much cellular technology going on, that doesn't mean that it's cheap.
Let's look at effective and affordable hardware. Although there are efforts to build cheap hardware (such as the hundred-dollar laptop made by the One Laptop Per Child organization), it's not taking off. It's just not pervasive -- most of Africa and Asia have less than 10 computers per 100 people. That's even when you consider microcontrollers as "computers." So what is the world's computer? The world's computer is a cell phone. About half of the world's adults own one. There are more cell phones in India than credit cards -- and cell phones, even when they're not smartphones, are chock full of interactivity. (Note: Can you imagine an accessible Qwiki for developing nations that works over SMS? I can.)
Connectivity
Wired connectivity: availability is increasing and costs are dropping. For example, transit prices in Kenya have dropped to $120/Mbps -- which are similar to US prices in 2003.
Delay-tolerant network: Imagine a big city with a broadband connection, and a nearby village. Imagine that the village is on some rural bus or taxi route to the city. Now, imagine that the bus has a laptop inside, with a large hard drive and a wireless access point. People (and goats and chickens) board the bus in the village, send some requests on the laptop. Although the laptop isn't connected to the broadband, it can queue the request and send it when it reaches the city, and bring back the reply when it returns to the village. If the bus visits the village every 5 hours, that's a 5-hour latency -- but at least it is access to information.
Never underestimate the bandwidth of a station wagon carrying tapes hurtling down the highway. -- S. Tanenbaum
The vehicular delay-tolerant network is very low-cost, easy to deploy, and has a very high data carrying capacity. Villagers can collaborate on their queries, and the results can be available to others in the village doing similar web searches (called collaborative caching). The system can also be improved by clever prefetching -- the computer on the bus can be thinking hard over the next several hours about what else can be proactively fetched based on the current queries. Clearly, prefetching all of the links on a page would be smart, but maybe so would translating a page from a local language to a more commonly-used language. This isn't a microcontroller with a tiny cache. This is a big hard drive. If the hard drive is huge, there is no worry about performance loss in prefetching things that will not be used, but the overhead of not having things that may be useful is huge.
"Come back tomorrow. Your data will be on the bus."
The authors designed, built, and tested C-LINK, the vehicular delay-tolerant network, over a week in Nicaragua. The city was Somotillo, Nicaragua -- no skyscrapers, but there was a school with a computer cluster and wired connectivity and a small, expensive Internet cafe with 2 computers. Participants were school children, invited to come in and browse the highly-delayed web. About 80% of the participants in the project had never used the Internet before. One of the cool things that the project looked at is when participants sent at the same query, or searched collaboratively. With each successive trip into the village, the bus brought back more data. As the village's cache filled up, users' miss rates plummeted. Data were on their computers or on the computers of their collaborators -- remember collaborative caching? The authors found that highly correlated access patterns provided strong incentive for collaboration. Oh, and we can evict old data or data that has not been accessed recently. Any cache eviction policy will work here.
Then Margaret and her team considered using laptops and other mobile computing devices and, despite the worry of data loss, found that going mobile wasn't so bad. If anything, it made for more kiosks -- little hubs for collaborative information. Then, they found that the requests for data were fairly small, so it was possible to exploit cellular connectivity, where available. They looked at data brought back by the once-a-day trip into town, by the 5-times-per-day bus ride, and a hybrid data retrieval mode by combining these with exploiting SMS.
Look around you
Other software that the authors found interesting and noteworthy included these.
- TEK is an e-mail-based web browser.
- M-Profesa helps Kenyan children prepare for the secondary school test through SMS.
- Ushahidi, also originally Kenyan, helps with crowd-sourcing of information.
Getting more involved
Imagine what you could do if you could alleviate teacher shortages by having better distance learning technologies. Imagine what you could do if you could have better information flow and expose corruption in the government. Get involved in Engineers Without Borders and attend Development conferences, such as ACM DEV 2012. Make a company. Build stuff!
Thursday, November 10, 2011
Community College Women in Computer Science: A Study's Preliminary Results
This is a post about Community College Women in Computer Science: A Study's Preliminary Results at Grace Hopper Celebration of Women in Computing.
The authors present their preliminary results from studies from community college students around California, aiming to answer the question what makes community college students transfer to 4-year university? That is: What factors determine whether community college students enrolled in a CS1-like course intend to study computer science at a 4-year university?
True or false? There are different motivations for males and females in pursuing computer science as a major, and women just don't value computing. The answer is false. Men were found to have great expectations for success with computing, but there were no gender differences in how much students value computing.
True or false? Family support is critical in choice of major and parental pressure is based on gender stereotypes. Also false. Family support was not critical, but peer encouragement was very important for both women and men in pursuing science.
True or false? Women's under-representation in computer science majors is due to lack of computer use an lack of computer game play. This one is true. Intention to pursue computer science was very important, and exposure to computing and computers (including gaming) was associated with intention.
The authors presented work collected over a true longitudinal study over two years, looking at demographics as well as social factors that may influence students' staying in computing after community college. They sampled the students three times: at time of enrollment, half-way through the program, and at the end of the two-year program.
Women were more likely to be older, have had a degree already, have a mother working in computing, and have had a programming mentor when enrolling in the introductory programming course, compared to male students. Whether or not a woman was comfortable talking to her professor did not affect her intention to pursue computing (and the other way around). Women thought computer programming was like thinking.
Men had a greater intention to pursue computer science at a four-year university, were more likely to play video games longer, and have mothers with no BS/BA, compared to female students. Men thought computer programming was creative.
How do we increase the number of women in computer science?
1) Men see computer science as creative, but women don't -- they see it as thinking. How can we bring creativity to women?
2) Men are influenced by computing experiences, including video games, in their intention to pursue compter science. How do we use games to help intention to pursue a bachelors (or higher) degree in computing? How do we get gals into games? How do we provide early programming opportunities to gals?
3) Men report that they get more support from their peers. How do we encourage peer support for women?
And this leads to the awesomest idea of the conference:
How do we use video games (especially competitive ones) to bring early interventions to women?
I'm envisioning a League of Legends clan for high school girls!
The authors present their preliminary results from studies from community college students around California, aiming to answer the question what makes community college students transfer to 4-year university? That is: What factors determine whether community college students enrolled in a CS1-like course intend to study computer science at a 4-year university?
True or false? There are different motivations for males and females in pursuing computer science as a major, and women just don't value computing. The answer is false. Men were found to have great expectations for success with computing, but there were no gender differences in how much students value computing.
True or false? Family support is critical in choice of major and parental pressure is based on gender stereotypes. Also false. Family support was not critical, but peer encouragement was very important for both women and men in pursuing science.
True or false? Women's under-representation in computer science majors is due to lack of computer use an lack of computer game play. This one is true. Intention to pursue computer science was very important, and exposure to computing and computers (including gaming) was associated with intention.
The authors presented work collected over a true longitudinal study over two years, looking at demographics as well as social factors that may influence students' staying in computing after community college. They sampled the students three times: at time of enrollment, half-way through the program, and at the end of the two-year program.
Women were more likely to be older, have had a degree already, have a mother working in computing, and have had a programming mentor when enrolling in the introductory programming course, compared to male students. Whether or not a woman was comfortable talking to her professor did not affect her intention to pursue computing (and the other way around). Women thought computer programming was like thinking.
Men had a greater intention to pursue computer science at a four-year university, were more likely to play video games longer, and have mothers with no BS/BA, compared to female students. Men thought computer programming was creative.
How do we increase the number of women in computer science?
1) Men see computer science as creative, but women don't -- they see it as thinking. How can we bring creativity to women?
2) Men are influenced by computing experiences, including video games, in their intention to pursue compter science. How do we use games to help intention to pursue a bachelors (or higher) degree in computing? How do we get gals into games? How do we provide early programming opportunities to gals?
3) Men report that they get more support from their peers. How do we encourage peer support for women?
And this leads to the awesomest idea of the conference:
How do we use video games (especially competitive ones) to bring early interventions to women?
I'm envisioning a League of Legends clan for high school girls!
What if... You Thrived on the Tenure Track?
This is a post about What if... You Thrived on the Tenure Track? at Grace Hopper Celebration of Women in Computing.
Ceclia Aragon took a 14-year leave from graduate school. In the time, she had two kids, was a stunt pilot (yup, in air shows), and worked for NASA. When she was a little tired with the life of a badass rockstar, she finished her PhD and got a tenure-track position (she is now tenured). She gives some advice about organic networking: It's easy to say that you should hang out with important people. But what do you do when you're shy? "I hang out with my friends, and now, guess what -- my friends are now important people." She says that the life of an academic suits her perfectly because it lets her pursue the things that are interesting and to truly find balance in her home. Jobs are more flexible, interesting, and fun at the top of the food chain, she says, and you work just as hard as in lower-level, less interesting jobs. "Life balance works well when you have that kind of autonomy."
Magdelena Balazinska has a lot of accomplishments, but also a lot of failures: grant rejections, paper rejections, proposal rejections. "Just don't list those," she says. Focus on the positive. She shows pictures of the house she and her husband designed and built, and her two children in various stages of infancy and toddlerhood. How does she manage? "I get help from anyone who's willing to help! I do what I have to do, and I ask for what I need." She flashes photographs of her husband with a baby during one business trip, and her mother with a baby during a conference in Greece where she had to present. NSF panel in Washington, DC? No problem -- a photograph of her and a baby outdoors with an explanation: "You can just call in, and then nobody sees how you nurse your baby!" Magdelena says, "I don't try to be perfect. I just do what I can."
Following a different path, Anne Condon was an assistant professor when she was barely 25 years old -- and now her daughter, whom she had when in her first faculty job, is attending Grace Hopper Celebration. "For me personally, the combination of the academic life and the family life is fantastic." Anne gives some advice:
Q: We all know that tenure-track positions are hard to get. Should we accept non-tenure-track positions (postdoc, industry), or hold out?
Ceclia Aragon took a 14-year leave from graduate school. In the time, she had two kids, was a stunt pilot (yup, in air shows), and worked for NASA. When she was a little tired with the life of a badass rockstar, she finished her PhD and got a tenure-track position (she is now tenured). She gives some advice about organic networking: It's easy to say that you should hang out with important people. But what do you do when you're shy? "I hang out with my friends, and now, guess what -- my friends are now important people." She says that the life of an academic suits her perfectly because it lets her pursue the things that are interesting and to truly find balance in her home. Jobs are more flexible, interesting, and fun at the top of the food chain, she says, and you work just as hard as in lower-level, less interesting jobs. "Life balance works well when you have that kind of autonomy."
Magdelena Balazinska has a lot of accomplishments, but also a lot of failures: grant rejections, paper rejections, proposal rejections. "Just don't list those," she says. Focus on the positive. She shows pictures of the house she and her husband designed and built, and her two children in various stages of infancy and toddlerhood. How does she manage? "I get help from anyone who's willing to help! I do what I have to do, and I ask for what I need." She flashes photographs of her husband with a baby during one business trip, and her mother with a baby during a conference in Greece where she had to present. NSF panel in Washington, DC? No problem -- a photograph of her and a baby outdoors with an explanation: "You can just call in, and then nobody sees how you nurse your baby!" Magdelena says, "I don't try to be perfect. I just do what I can."
Following a different path, Anne Condon was an assistant professor when she was barely 25 years old -- and now her daughter, whom she had when in her first faculty job, is attending Grace Hopper Celebration. "For me personally, the combination of the academic life and the family life is fantastic." Anne gives some advice:
- Work on important problems, because the unimportant ones aren't interesting and just aren't worth your time.
- Communicate effectively -- and if you need to bulk up your public speaking skills, it's never too late.
- Enjoy teaching others.
- Build strong research support networks. The research community is just not that supportive, she says. "You might give a talk at a conference and there might be 20 people in the room, and 19 of them are on their laptops." I think she looked at me, here, as I typed out that phrase. Oops.
- Persist in the face of challenges; and, of course, go for it!
Natalie Jerger just finished her 3rd year review on her way to tenure. She suggests that one of the most important things is to find a supportive partner. Next, set your priorities. For her, she and her husband always eat dinner together -- this is an important thing for her. Last priority? Cleaning the house. "Both me and my husband are professionals. We don't have time to clean the house. We don't have time to argue about whose turn it is to clean the house. Hire a cleaning lady." Professionally, seek out and work on problems that you find interesting -- problems that you are passionate about. Develop a support netwrok and find good mentors, those whose interests and priorities align with yours. Finally, practice saying "no" so that you aren't stuck in a situation that you don't enjoy.
Jodi Tims, when she was 4, taught her friends about arithmetic -- that's how early she knew that she would be a professor. Like Magdalena, Jodi took a decade to finish her PhD. Violating all her advisors' rules about what one should do while in grad school, she worked full time as an instructor, did her academic research, and had two children. "You just find a way to balance that together," she said. Her advice for aspiring academics:
- Accept advice of good mentors. This is as much about receiving good mentoring as it is about learning how to give good advice: "One day you wake up and realize, 'I'm the mentor!'"
- Don't underestimate your potential
- Focus on your students. Mentoring your students is a form of teaching, and this is a service that you need to provide to your students.
- Know your institution. You don't have to make it work if your expectations are not met.
- Get involved beyond your institution. This is where opportunities come from, to grow as a person and as a researcher.
- Appreciate life beyond work. Family and friends make life worthwhile.
- Enjoy the ride!
Questions were presented on index cards from the audience.
Q: How did you make the choice to go into academia?
Cecilia: In academia, you get to determine what is important. You choose to perform research that has impact.
Magdalena: Apply everywhere, and make the decision with an offer in hand from both industry and academia. The interviewing process is a lot of fun. The reason I went into academia because the interview in academia was more fun than in industry. One of the huge advantages in academia is not only that you get to pick what you work on, but also who you work with.
Q: We all know that tenure-track positions are hard to get. Should we accept non-tenure-track positions (postdoc, industry), or hold out?
Cecilia: In 2004 I wanted to be a faculty member, but I wasn't ready (by publication count and preparation). I took a job in an industry lab not really knowing if I would make the transition. But I worked on making my CV look like I was an academic while keeping up in my industry job. I wrote papers and attended academic conferences that came out of novel research in my job. Choose the industry position or the post-doc that will be most suited to your goals. Have a deliberate plan.
Jodi: There are lots of schools out there that are not the R1 institutions. If you really want to get into academia, consider going to lower-tier institutions. Maybe the pay isn't as good, maybe you start on a non-tenure-track position, but keep your mind open to other options.
Q: Do you really need a post-doc nowadays to get a tenure-track position?
Anne: As someone that went straight into such a position without a post-doc, I think it's a good thing to do. There is a maturity process that happens over that time; you meet different people and you investigate other institutions. I encourage you not to rush through things if there is no reason not to.
Cecilia: That's a great answer. I have seen people that have gone straight through. If you do it right from the very beginning of your PhD program -- you are publishing 2 papers in top conferences, you're networking with the top people in your field for 5 years -- then yes, you can get such a position. But if you're like everyone else, you don't have the pedigree in your publication record, then yes, take a post-doc. But make sure you choose your postdoctoral mentor carefully: they can make or break your career. A post-doc is an apprenticeship. You're getting paid less than you're worth. But on the flip-side, you're getting priceless mentoring from someone that's going to show you the ropes and make you very marketable.
Q: How do you make the choice between academic offers, or between a research lab versus a university?
Magda: If you have no other constraints (e.g., personal ones), go to the best university, because you will work with better students. The better the students, the easier it is for the faculty to do well.
Ioana: Go where the smarter people are and where there are more opportunities.
Cecilia: I put together a matrix of things that were important to me. Vacation locations, startup package, what my family liked.
Natalie: The people. Colleagues. Also, my husband was leaving his job so I wanted to go somewhere that he had a choice
You have to go home every night and still be happy.
Q: Cecilia, you are shy. How do you overcome this and how does it impact your career?
Cecilia: Yeah, I am shy. I miss important connections, and I just accept that. I know that when I started interviewing, I did not mention certain rare accomplishments that few academics achieve, and I didn't mention my highly technical background in mathematics and algorithms. The unsurprising feedback was that I wasn't technical enough, and I didn't get an offer from this institution. I told myself that for future interviews, I'm going to brag, even if I don't like doing that. I felt like I was acting kind of like a jerk, but I got offers. It works.
Q: How do you publish, write grants, mentor students, etc., in your first years?
Natalie: At first, it was terrifying. Teaching can suck up a lot of your time because it's the most urgent thing. The hardest thing is to make time for the thinking, to think about problems, solutions, and what you're going to do next. I think I messed up my first student. And have someone in your life that can give you practical advice when you're stuck.
Q: How do you deal with stress?
Jodi: It's actually a very important question. If you don't deal with it, it will impact everything that you do. I have to get out and do something: ride my bike, go to the gym, jump on the treadmill. And then I go do something else, make myself some space to think about something else. Then things fall into place and things don't look so bad as when you left them.
Magda: I talk -- to my husband, my family, my friends. But not colleagues. That's why it is so important to have family and friends.
Q: Family is my first priority. I want to be a professor, but the 7-year tenure time is prime baby time. I'm afraid that my male department won't like my priority of family dinners and baby-having.
Cecilia: Men, when they have to take care of a family obligation, they say, "I'm busy." Women say, "I'm busy, I have to go take care of my kid." So when you have to go take care of a family obligation, be more like a man, and say: "I'm busy."
Magda: I work and work and work, and at 5, I say, "I have to go." And I leave. And guess what, a lot of my male colleagues have to go too. And after the kids are in bed I work and work and work. Maybe I don't sleep always as much as I used to, but it works for me. And when I need to, I do sleep.
Ioana: Having family as a priority is not a problem. Being confident and admitting that is the way to go. I wouldn't want to be hired by a family-unfriendly institution. I was very open about my 2-body problem in my job search. The places that were not very accommodating, I did not consider.
Q: What advice do you have for someone applying for a tenure-track position with a partner? It's a 2-body problem with a similar area of computing.
Anne: I think it's good to bring it up reasonably early with the institution. If one of you has got an interview, that is a good time to bring it up. You may want to wait until you have an offer, but it is better to let them know sooner so that the university can work on this issue. Institutions need time for this. There are other options: a short-term position that can turn into something more permanent; maybe there is industry nearby. Be flexible but know what you really want. For the university, if you can attract two great people to your institution, it's amazing.
Q: What are you proud of that you have done outside your academic career that you wouldn't have been able to accomplish without an academic career?
Jodi: My academic career allows me to be flexible to do things like pursue mentoring with ACM-W and Grace Hopper Celebration
Anne: I got to take on many projects of national scope, such as the distributed mentor project and work through the Computing Research Association (CRA).
Tuesday, November 8, 2011
Grace Hopper '11 checklist: Five things to do at GHC11
Grace Hopper Celebration of Women in Computing is basically a giant lady-party in which all of the conference attendees are gorgeous, brilliant, and interesting. But you already know this, because I have blogged about Grace Hopper in my post about do-overs next time I go, and in my post from my attendance in 2009. That is not totally right -- it is not just a party. It is an opportunity to showcase your work, learn about other women's research, find out ways to bring more women into our field and make it more woman-friendly, meet new people, and build lasting relationships.
Here are the top five things that I wish to get out of attending Grace Hopper Celebration this year, in 2011.
5. Reconnect with old friends
It has been a year -- in some cases, more -- since I have seen old acquaintances, friends, and mentors. From my first room mate, to the professor that has changed how I see myself as a researcher, to the group of 200 women that have given me the gift of working with my rockstar undergraduate student, I look forward to seeing these ladies again.
4. Find a collaborator
Researching alone can be dismal. Would it not be fun to meet someone with similar interests, in which we can complement each others' strengths? I have this rosy dream about collaborating on a paper with someone I had met once (maybe twice) at Grace Hopper.
3. Meet a new mentor
My career will soon be in flux: next year, I will be dissertating while on the academic job market. (Note: Even though Blogger doesn't think "dissertating" is a word, it totally is.) I imagine I will be in need of new guidance -- of help finding appropriate job openings, navigating the complicated job-seeking and application system, and finding the best way to present myself to particular universities. What better place to meet someone that can potentially help me than at Grace Hopper?
2. Make a new mentee
(Note: Blogger doesn't think "mentee" is a word, but if it isn't, it should be. It's who mentors advise!) As a senior graduate student in her final throes, maybe -- maybe -- my experience can be valuable to someone. I have an undergraduate degree with two majors, I worked in industry for 3 years, I had a baby pre-advancement in graduate school, and I work in a highly interdisciplinary field doing research of my own invention. I write grants, I write blog posts, I invent eHealth learning methods, and I play video games. Surely I could be a resource to somebody!
1. Say thanks
I am pretty lucky that in four years of attending Grace Hopper, I have never paid for the visit myself. In three years, I have never paid for child care. In two years, I have contributed to the program at Grace Hopper, hosting sessions and panels. I feel privileged that I have helped shape the community of women that I am about to see again, meet, or just observe. So, at Grace Hopper this year, I plan to say thanks for accepting me as a part of the package of women in computing, of technical women.
If you will be at Grace Hopper Celebration of Women in Computing in Portland, please find me and say hello! I will be tweeting as @lexyholloway.
Here are the top five things that I wish to get out of attending Grace Hopper Celebration this year, in 2011.
5. Reconnect with old friends
It has been a year -- in some cases, more -- since I have seen old acquaintances, friends, and mentors. From my first room mate, to the professor that has changed how I see myself as a researcher, to the group of 200 women that have given me the gift of working with my rockstar undergraduate student, I look forward to seeing these ladies again.
4. Find a collaborator
Researching alone can be dismal. Would it not be fun to meet someone with similar interests, in which we can complement each others' strengths? I have this rosy dream about collaborating on a paper with someone I had met once (maybe twice) at Grace Hopper.
3. Meet a new mentor
My career will soon be in flux: next year, I will be dissertating while on the academic job market. (Note: Even though Blogger doesn't think "dissertating" is a word, it totally is.) I imagine I will be in need of new guidance -- of help finding appropriate job openings, navigating the complicated job-seeking and application system, and finding the best way to present myself to particular universities. What better place to meet someone that can potentially help me than at Grace Hopper?
2. Make a new mentee
(Note: Blogger doesn't think "mentee" is a word, but if it isn't, it should be. It's who mentors advise!) As a senior graduate student in her final throes, maybe -- maybe -- my experience can be valuable to someone. I have an undergraduate degree with two majors, I worked in industry for 3 years, I had a baby pre-advancement in graduate school, and I work in a highly interdisciplinary field doing research of my own invention. I write grants, I write blog posts, I invent eHealth learning methods, and I play video games. Surely I could be a resource to somebody!
1. Say thanks
I am pretty lucky that in four years of attending Grace Hopper, I have never paid for the visit myself. In three years, I have never paid for child care. In two years, I have contributed to the program at Grace Hopper, hosting sessions and panels. I feel privileged that I have helped shape the community of women that I am about to see again, meet, or just observe. So, at Grace Hopper this year, I plan to say thanks for accepting me as a part of the package of women in computing, of technical women.
If you will be at Grace Hopper Celebration of Women in Computing in Portland, please find me and say hello! I will be tweeting as @lexyholloway.
Sunday, October 30, 2011
Women, video games, and stereotype threat
How does being a woman affect my perceived ability to, as they say, pwn it up in video games? Secretly, I feel a huge pressure to do well, and feel that I constantly fail to achieve not only mine, but everyone else's expectations for me as a member of a multiplayer team. No one is more surprised than I am when I capture a point, destroy an enemy, or execute a plan. I tell myself that it must be an accidental and temporary victory. What is it that renders me unable to believe my own accomplishments in game, and how do I deal with these feelings?
In a recent meeting of women scientists and engineers on our college campus, we discussed stereotype threat and how it can affect women. Stereotype threat is defined on Wikipedia as "the experience of anxiety or concern in a situation where a person has the potential to confirm a negative stereotype about their social group." How susceptible one is to stereotype threat depends on a few things:
It is not destiny.
I will just out and say it: I am a gamer. Whew. Just writing that makes me feel all sorts of awkward. Because in my head there is a doubting monologue: Am I a gamer? But I'm not good. I'm not that good. I'm actually pretty bad. In fact, I'm worst on the team. We lose because of me. I spend most of my time dead or making bad choices, or both. It's probably pretty dull to have me on the team. My playing frustrates my teammates. People play with me out of pity. It goes on and on and manifests itself in other ways: for example, if a teammate types something mean in chat (such as "wtf, noob" -- code for "you idiot"), I start looking around furiously for what I have done wrong.
And here is the weird thing. Nine times out of ten, I have done nothing wrong, and the comment is not intended for me. A quarter or even half the time, I am among the top three players on my team. People still play with me.
Why is this surprising to me? I come from a long line of anti-gamers. With the exception of my grandfather, who played chess, a socially-acceptable game, none of my family looked kindly on games and the people that play them. Moreover, there is the rest of society: Women should not be gamers. And if they are gamers, they should be really good, like they always are in the webcomics about gamers. They should be pro-level. They should be so good that nobody dares to challenge them. I am not making this up -- do a quick search for "woman gamer." I am not like any of these women.
In the women in sciences group meeting, it occurred to me that I expect the worst so that I can be pleasantly surprised in the end. I do this in classes, on exams, in grants; to some extent, in my conference publication submissions... and in video games. I expect to be worst on the team, and when, at the end of the game, I discover that I was not worst (or better) -- well, it is cause for celebration! Right?
But it is more complicated than pure joy at the surprise: The feeling sours quickly. I feel that it is a fluke. Somehow, the statistics engine generating the score had a malfunction. It missed a few of those times that I fired the missile in the wrong direction. Or teleported on top of an enemy and died instantly. Or forgot to use my very powerful weapon ability. Video games are a strange place to find impostor syndrome, but there it is.
Of course, none of those thing happened. There was no fluke in measurement. I really did perform as well as the statistics say I did: nine kills, four deaths, ten assists. Number two on the team. Really. Why is it so hard to acknowledge my own success? Because there is no way I am as good as my male peers, and I am nowhere near as good as I feel I ought to be, as a woman-gamer.
What is interesting is that the level of anxiety that surrounds me playing multiplayer online battle arena (MOBA) games greatly exceeds anything else I have done: public speaking, presenting research, taking a math final... even wooing hot-shot investors. Although -- no surprise -- playing games is more fun, it is also the thing about which I have such serious performance anxiety and self-criticism.
Getting over it, baby steps
I have attended several "impostor panels," panels and talks about impostor syndrome -- including at Grace Hopper Celebration for Women in Computing and locally at my university through the women in science, engineering, and technology group. Here are some of the steps in dealing with stereotype threat and impostor syndrome.
One final note for women: In online multiplayer video games, it helps to remember that more than half the time, everyone else thinks you are a 14-year-old boy anyway. Me? I like to act the part.
About you
Have you studied stereotype threat in women in video games? If so, I would love to hear about it. I have found only one proposed study on stereotype threat for women in gaming, and the rest seems to be anecdotal. How has your experience been?
In a recent meeting of women scientists and engineers on our college campus, we discussed stereotype threat and how it can affect women. Stereotype threat is defined on Wikipedia as "the experience of anxiety or concern in a situation where a person has the potential to confirm a negative stereotype about their social group." How susceptible one is to stereotype threat depends on a few things:
- How much one identifies with a particular group;
- The negative stereotypes society places on that group;
- Knowing about (2), and not knowing how to counteract stereotype threat (e.g., by just knowing thine enemy).
It is not destiny.
I will just out and say it: I am a gamer. Whew. Just writing that makes me feel all sorts of awkward. Because in my head there is a doubting monologue: Am I a gamer? But I'm not good. I'm not that good. I'm actually pretty bad. In fact, I'm worst on the team. We lose because of me. I spend most of my time dead or making bad choices, or both. It's probably pretty dull to have me on the team. My playing frustrates my teammates. People play with me out of pity. It goes on and on and manifests itself in other ways: for example, if a teammate types something mean in chat (such as "wtf, noob" -- code for "you idiot"), I start looking around furiously for what I have done wrong.
 |
| This is the game at which I allegedly suck. |
And here is the weird thing. Nine times out of ten, I have done nothing wrong, and the comment is not intended for me. A quarter or even half the time, I am among the top three players on my team. People still play with me.
Why is this surprising to me? I come from a long line of anti-gamers. With the exception of my grandfather, who played chess, a socially-acceptable game, none of my family looked kindly on games and the people that play them. Moreover, there is the rest of society: Women should not be gamers. And if they are gamers, they should be really good, like they always are in the webcomics about gamers. They should be pro-level. They should be so good that nobody dares to challenge them. I am not making this up -- do a quick search for "woman gamer." I am not like any of these women.
In the women in sciences group meeting, it occurred to me that I expect the worst so that I can be pleasantly surprised in the end. I do this in classes, on exams, in grants; to some extent, in my conference publication submissions... and in video games. I expect to be worst on the team, and when, at the end of the game, I discover that I was not worst (or better) -- well, it is cause for celebration! Right?
But it is more complicated than pure joy at the surprise: The feeling sours quickly. I feel that it is a fluke. Somehow, the statistics engine generating the score had a malfunction. It missed a few of those times that I fired the missile in the wrong direction. Or teleported on top of an enemy and died instantly. Or forgot to use my very powerful weapon ability. Video games are a strange place to find impostor syndrome, but there it is.
Of course, none of those thing happened. There was no fluke in measurement. I really did perform as well as the statistics say I did: nine kills, four deaths, ten assists. Number two on the team. Really. Why is it so hard to acknowledge my own success? Because there is no way I am as good as my male peers, and I am nowhere near as good as I feel I ought to be, as a woman-gamer.
What is interesting is that the level of anxiety that surrounds me playing multiplayer online battle arena (MOBA) games greatly exceeds anything else I have done: public speaking, presenting research, taking a math final... even wooing hot-shot investors. Although -- no surprise -- playing games is more fun, it is also the thing about which I have such serious performance anxiety and self-criticism.
Getting over it, baby steps
 |
| Really? This is what I look like? |
- Recognize it. Just knowing that stereotype threat and impostor syndrome is there, looming, empowers you to reframe your experiences, both during the experience and after the fact. Recognize that your feelings, although genuine, are affected by societal pressures, and that these are things you can change.
- Talk about it. Lots of other people have these feelings. How many other women feel like I feel about video games? I have no idea. But I know that lots of other women feel this way about being in computing, hard science, and math fields because I have talked to them about it. I have heard their stories and shared mine. And part of moving on is to get validation.
- Help others. One of the ways found to counteract stereotype threat was to just say at the start of class that the threatened group is expected to (or is known to) perform as well as the other group. "Men and women score the same on this test." If you are a professor, teaching assistant, teacher, or just a friend, you can do this. One (male) player told me, "You play just as well as my other friends." And that was priceless.
- Take criticism, and take praise. Criticism is meant to make you perform better. You could have solved that problem differently, better, or faster? Think about it, and move on. If someone offers praise -- you really blew everyone out of the water with that proof (or damage-dealing stun), take it at face value. This part is difficult, but you can start by saying "Thank you" rather than the self-insulting "Oh, it was nothing" while feeling that you did not deserve that victory. There is even a WikiHow on how to stop putting yourself down.
One final note for women: In online multiplayer video games, it helps to remember that more than half the time, everyone else thinks you are a 14-year-old boy anyway. Me? I like to act the part.
About you
Have you studied stereotype threat in women in video games? If so, I would love to hear about it. I have found only one proposed study on stereotype threat for women in gaming, and the rest seems to be anecdotal. How has your experience been?
Wednesday, October 26, 2011
I write like Jonathan Swift?!
I Write Like, the website which analyses your writing and tells you which author your writing resembles most, analyzed my blog with the following result:
Next, I input a couple paragraphs from my most recent publication on file systems usability:
What's interesting is not necessarily the authors, but what this may mean. Is my academic writing hard to read and antiquated? Do I use unnecessary English anachronisms? I don't know.
But I do know that I Write Like analysed a professor-mentor's academic writing as David Foster Wallace. Her grant proposals read like my blog.
That's harrowing. By which I mean, that's distressing.
I write like
David Foster Wallace
David Foster Wallace
I Write Like by Mémoires, journal software. Analyze your writing!
Next, I input a couple paragraphs from my most recent publication on file systems usability:
What's interesting is not necessarily the authors, but what this may mean. Is my academic writing hard to read and antiquated? Do I use unnecessary English anachronisms? I don't know.
But I do know that I Write Like analysed a professor-mentor's academic writing as David Foster Wallace. Her grant proposals read like my blog.
That's harrowing. By which I mean, that's distressing.
Friday, September 23, 2011
Why I'll never be a nurse
I'll be honest. My research direction has been making me curious. Could I be a nurse, or a midwife, or even an obstetrician? I am already a doula, and I have more book-knowledge of labor, birth, and the early postpartum period, including surgery, than many of the nursing students I have met. Each time I have attended a birth so far, my curiosity was tickled: is this for me?
When I was invited to attend a labor support workshop, part of a nursing student course in midwifery taught by one of my research collaborators, I was excited. Walking up to the building and passing dozens of men and women dressed in scrubs, walking quickly along both sides of the sunny street, engaged in conversation or talking on cell phones, I thought: with a small difference, a slight twist of fate, that could have been me.
To the workshop I arrived on time, took a seat, and looked about the room. It was filled with students just like me: young (I would like to think I am young, despite being older than most of the students in the room), energetic, eager to learn. I asked around and learned that everyone had already chosen a specialty. The woman sitting beside me would become a nurse practitioner, the man beside her will be an "acute" nurse (that is, working with very ill patients), and the woman across the table will go on to an administrative position.
I was interested in this, and was especially interested in the students' experiences in different classes. One student talked about her last class, which was about oncology. I liked the idea of the "grand tour" of specializations that every student submits to, no matter his or her interest, and thought that something similar for computer science (or, more broadly, computing and electronics) would be excellent. I knew I would be a computer engineer even before I took my first computer engineering course -- but the course sealed my love and I declared my major. But other students were not so lucky to have found their niche as smoothly as I did. Would they have benefitted from a grand tour, exposing them to electrical engineering, programming languages, assembly language, high-level database design, and robotics?
Later, I asked my colleague, who was teaching the class, how it is that everyone already knows what they will be at the end of the three-year program. She explained that students choose their specialties before they even apply. Once applied and accepted, they cannot switch, and if switching to another program (such as midwifery, as often happens as a result of this birthing class), they must withdraw from the program and re-apply.
"Yikes," I said. "That's heartless!"
"Yes, it is difficult," she replied. "There is no way to know for certain before you apply what you will be good at, or what you will even enjoy as a profession."
I spent all day in the hospital classroom among the students learning about birth support, and what it means to support a woman in birth. Having undergone doula training and having read everything possible on the subject, I could answer the rhetorical questions about the mother and how to support her. But I was pleased to learn about the relationships between the clinicians and to hear, from a midwife who practices in a hospital, how the medical pieces of birth fit together and work.
I did not know, for example, about the rigid hierarchy that exists between nursing students, nurses, clinician instructors, and providers. But on learning of it, I thought it was lovely. Every student that belongs in the program occupies a very specific place in it. As a student, you always know where your place is and to whom to turn with questions. And whom you mentor. You know where your responsibility lies, and (more importantly) where your responsibility ends, and where you escalate your issue or question to someone else, someone farther up the hierarchy.
In computer science, we do not have this. You wade through your program, sometimes overtaking your peers, and other times falling back. You graduate, sometimes ahead of your peers, sometimes behind them. You get a job, and depending on the work and the company and the culture, you are left to fend for yourself. You are given a stack of tasks, sometimes poorly-defined, and are left to figure them out on your own, because you are, after all, a college graduate. You are a computer scientist. When you have questions, you ask anybody and everybody and hope for the best, or you ask no one at all. Mentoring relationships are forged, usually accidentally, sometimes forcedly -- and frequently, not at all. The stereotype of the computer scientist working alone, always alone, is sadly true, but never desired. Nobody likes to work in a vacuum.
So, I thought these relationships which were so rigid and unquestioning were also beautiful, like lace that ties all these students who will be graduates together and to their peers and superiors.
As I looked around the room in the second half of the workshop, I saw some faces still eagerly listening, taking it all in. Other faces were contorted in horror -- the horror of the memory of what a woman's vagina actually does. The explanation came moments before. And then it hit me: Nurses learn not to fear their jobs. They do not come in to the practice unfearing. First they learn to conceal their fear, and then they learn not to fear.
At the end of the workshop, I left for another hospital, where I attended a volunteer doula meeting. I am in the process of becoming a volunteer with this teaching hospital (in which many of the students from the workshop will be training). In the meeting, issues came up which highlighted some doulas' misunderstanding of the nursing relationship to the patient and to the provider. For example, doulas do not always understand why certain procedures are necessary and argue on behalf of their clients in inopportune ways. Continuous fetal monitoring is always required with an epidural because the baby is at risk when drugs are crossing the placental barrier, yet sometimes, through their own ignorance and not through any malicious means, doulas may argue with the nurses. I was surprised to learn this because I thought as a doula, my job is not to argue with anybody, and especially on behalf of the mother -- to create a calm atmosphere regardless of the situation at hand.
But really, what the doula meeting taught me was that doulas are seriously unprepared. A workshop covering the basics of nursing and the clinician relationships is absolutely essential. I am glad I profited from such a workshop, and wish more doulas had a similar opportunity.
I came home that night exhausted. I had spent the majority of the day in hospitals. The monotony of artificial lighting, artificial air, and artificial manner (for example, nurses hiding their boredom) was too much for me. All this talk about birth and babies, a topic that I absolutely adore and consider a fundamental cornerstone to my own work, had, for the first time ever, completely drained me. At home, I was conscious of the desire to reunite with my computer, to pull out my notebook, and to design, code, engineer, and think.
And for the first time since embarking on my research, I realized: Nursing, midwifery, and obstetrics -- maybe these are not for me.
I am a technical woman.
When I was invited to attend a labor support workshop, part of a nursing student course in midwifery taught by one of my research collaborators, I was excited. Walking up to the building and passing dozens of men and women dressed in scrubs, walking quickly along both sides of the sunny street, engaged in conversation or talking on cell phones, I thought: with a small difference, a slight twist of fate, that could have been me.
To the workshop I arrived on time, took a seat, and looked about the room. It was filled with students just like me: young (I would like to think I am young, despite being older than most of the students in the room), energetic, eager to learn. I asked around and learned that everyone had already chosen a specialty. The woman sitting beside me would become a nurse practitioner, the man beside her will be an "acute" nurse (that is, working with very ill patients), and the woman across the table will go on to an administrative position.
I was interested in this, and was especially interested in the students' experiences in different classes. One student talked about her last class, which was about oncology. I liked the idea of the "grand tour" of specializations that every student submits to, no matter his or her interest, and thought that something similar for computer science (or, more broadly, computing and electronics) would be excellent. I knew I would be a computer engineer even before I took my first computer engineering course -- but the course sealed my love and I declared my major. But other students were not so lucky to have found their niche as smoothly as I did. Would they have benefitted from a grand tour, exposing them to electrical engineering, programming languages, assembly language, high-level database design, and robotics?
Later, I asked my colleague, who was teaching the class, how it is that everyone already knows what they will be at the end of the three-year program. She explained that students choose their specialties before they even apply. Once applied and accepted, they cannot switch, and if switching to another program (such as midwifery, as often happens as a result of this birthing class), they must withdraw from the program and re-apply.
"Yikes," I said. "That's heartless!"
"Yes, it is difficult," she replied. "There is no way to know for certain before you apply what you will be good at, or what you will even enjoy as a profession."
I spent all day in the hospital classroom among the students learning about birth support, and what it means to support a woman in birth. Having undergone doula training and having read everything possible on the subject, I could answer the rhetorical questions about the mother and how to support her. But I was pleased to learn about the relationships between the clinicians and to hear, from a midwife who practices in a hospital, how the medical pieces of birth fit together and work.
I did not know, for example, about the rigid hierarchy that exists between nursing students, nurses, clinician instructors, and providers. But on learning of it, I thought it was lovely. Every student that belongs in the program occupies a very specific place in it. As a student, you always know where your place is and to whom to turn with questions. And whom you mentor. You know where your responsibility lies, and (more importantly) where your responsibility ends, and where you escalate your issue or question to someone else, someone farther up the hierarchy.
In computer science, we do not have this. You wade through your program, sometimes overtaking your peers, and other times falling back. You graduate, sometimes ahead of your peers, sometimes behind them. You get a job, and depending on the work and the company and the culture, you are left to fend for yourself. You are given a stack of tasks, sometimes poorly-defined, and are left to figure them out on your own, because you are, after all, a college graduate. You are a computer scientist. When you have questions, you ask anybody and everybody and hope for the best, or you ask no one at all. Mentoring relationships are forged, usually accidentally, sometimes forcedly -- and frequently, not at all. The stereotype of the computer scientist working alone, always alone, is sadly true, but never desired. Nobody likes to work in a vacuum.
So, I thought these relationships which were so rigid and unquestioning were also beautiful, like lace that ties all these students who will be graduates together and to their peers and superiors.
As I looked around the room in the second half of the workshop, I saw some faces still eagerly listening, taking it all in. Other faces were contorted in horror -- the horror of the memory of what a woman's vagina actually does. The explanation came moments before. And then it hit me: Nurses learn not to fear their jobs. They do not come in to the practice unfearing. First they learn to conceal their fear, and then they learn not to fear.
At the end of the workshop, I left for another hospital, where I attended a volunteer doula meeting. I am in the process of becoming a volunteer with this teaching hospital (in which many of the students from the workshop will be training). In the meeting, issues came up which highlighted some doulas' misunderstanding of the nursing relationship to the patient and to the provider. For example, doulas do not always understand why certain procedures are necessary and argue on behalf of their clients in inopportune ways. Continuous fetal monitoring is always required with an epidural because the baby is at risk when drugs are crossing the placental barrier, yet sometimes, through their own ignorance and not through any malicious means, doulas may argue with the nurses. I was surprised to learn this because I thought as a doula, my job is not to argue with anybody, and especially on behalf of the mother -- to create a calm atmosphere regardless of the situation at hand.
But really, what the doula meeting taught me was that doulas are seriously unprepared. A workshop covering the basics of nursing and the clinician relationships is absolutely essential. I am glad I profited from such a workshop, and wish more doulas had a similar opportunity.
I came home that night exhausted. I had spent the majority of the day in hospitals. The monotony of artificial lighting, artificial air, and artificial manner (for example, nurses hiding their boredom) was too much for me. All this talk about birth and babies, a topic that I absolutely adore and consider a fundamental cornerstone to my own work, had, for the first time ever, completely drained me. At home, I was conscious of the desire to reunite with my computer, to pull out my notebook, and to design, code, engineer, and think.
And for the first time since embarking on my research, I realized: Nursing, midwifery, and obstetrics -- maybe these are not for me.
I am a technical woman.
Five do-overs since my first Grace Hopper Celebration for Women in Computing
Grace Hopper Celebration for Women in Computing is an annual event bringing together thousands of women from different technical computing specialties and at different stages of their career. Attendees include undergraduates considering computer science as a major, graduate students choosing their research direction, recent graduates looking for a job, women in industry, professors, researchers, and recruiters. It is a diverse, funky, exciting, inspiring, and nurturing environment of two thousand women, all of whom are smart, brilliant, beautiful, and different in their own right.
This year will be my fourth time attending, which makes me a Grace Hopper veteran. I first heard about Grace Hopper Celebration from my room mate from CRA-W Grad Cohort -- a similar but much smaller mentoring program for graduate student women -- when I asked my room mate how on earth she knew all these people. She was saying "Hi," calling people by name, and giving hugs to everybody!
"How do you know everyone already?" I asked her.
"Some women I know from last year's Grad Cohort," she replied. "But some women I see basically twice a year: at the Grad Cohort and then again at Grace Hopper Celebration."
"What's that?" I asked. Casually hiding her surprise that I had neer heard of Grace Hopper Celebration, she explained it to me, and that night in our hotel room I looked it up and bookmarked it.
When Grace Hopper Celebration came around that year, my advisor asked if there are any women that would like to go, because our university was a sponsor and received a few spaces for student attendees. Of course, I replied immediately in the affirmative, and off I went!
Now that I have been three times to Grace Hopper Celebration (this year will mark my third time as a contributor) and twice to the CRA-W Grad Cohort, I can look back on my first Grace Hopper Celebration visit a bit critically.
My first year, Grace Hopper Celebration was held in Keystone, Colorado, a small resort town situated in the mountains among an aspen forest. The trees were just starting to turn in ones and twos: blots of color among a sea of green leaves. I was driven from the airport in a shuttle and looked out onto the picturesque landscape with wide eyes. I was young, impressionable, and pregnant.
Yup, I was about 24 weeks along in my pregnancy. I knew I was carrying a boy, and I had just returned from a trip abroad -- a delayed honeymoon -- before having time to buy clothes that fit me. My belly had just started getting too big for my pants. It happened so suddenly that I was ill-prepared, wardrobe-wise, for the change in my figure. I was a hot mess, unbuttoning my jeans and praying that my fitted t-shirts did not bust into holes stretched over my growing belly. When my mother saw me at the airport on my return from Grace Hopper, she was shocked at my fashion sense, but at the time, I figured that is just an extension of the typical graduate student lifestyle. Right? Please tell me I am right.
Anyway, back to the point -- I could have done a better job. As an early(ish) graduate student, my main role was to be receptive to mentoring and to meet people that would help me in my career path. I see that now, in hindsight, but at the time I did not recognize these goals. Here were my top five mistakes from the first year. Every year I go back, I get a do-over and do my best to avoid these.
Do-Over #5. Eat lunch and dinner.
At CRA-W Grad Cohort, one of the rules was that no two women from the same university could sit together at lunch. You had to learn to network, and to meet other women. But here, at Grace Hopper Celebration, there was no such rule, and even if there was, there is no way to enforce it with 2000 attendees. So attendees would sit with the people they knew more often than not, and I, seeing this social norm, followed suit. Not a good idea. Now I know that it is best to sit at a table where you know no one. Even better: sit at a table where you know no one, and everyone is different from you. Is everyone older? They have more experience. Is everyone younger? Maybe they have questions. But if everyone is exactly like you, there is no way you can broaden your experience. Challenge yourself.
Do-Over #4. Use the room mate.
I was at Grace Hopper Celebration on an underwriter scholarship, and, like all scholarship recipients, I had a room mate. Actually, in this year, we were in a three-room cabin in the mountains of Keystone, Colorado, and I had two house mates. My house mates were amazing. They asked me about pregnancy and married life, about the proverbial work-life balance (as if there is one), about what I will do once I have the baby (hint: stay in school). On our last night in Colorado, we all went shopping to the outlets nearby and my lovely room mates bought me a shirt that actually covered my entire front. Maybe it is silly, but I was moved.
But most of the day, my house mates (who knew each other) would be off on their own, and, in pregnancy-related discomfort (more on this later), I left them to themselves. I did not go to see their posters at the poster session; I did not ask for introductions to other women; I did not sit with them and their colleagues at lunch. But this was wrong. Use your room mate (or room mates, if you are lucky enough to have two) -- use them as mentors if they are more experienced at Grace Hopper Celebration than you are; use them as friends if they are new like you; use them as a sounding-board for your elevator pitch for your research.
My room mates approached me on the second day and said, with a sly grin, "We are thinking of taking a drive up to the summit, instead of one of the sessions. Are you in?" I considered for a moment, wondering if it is OK to skip sessions, and if we could leave the conference grounds without arousing suspicion among the organizers. Hesitating a little, I said that it sounds like great fun, and that I would certainly come.
As we arrived to the summit, the weather shifted dramatically, from cool and clear autumn to cold and foggy winter. Not another person and not another vehicle was within sight: it was just us. It began to snow in large, fluffy flakes. The electricity in the air made our hair stand straight up, and lightning bolts noiselessly crashed all around us. We giggled and photographed and huddled in our insufficient jackets -- and bonded. We formed relationships which would survive the test of time and geography -- relationships we could later fall back on in our professional and personal lives, because we had this shared experience.
Do-Over #3. Couch potato networking.
During the course of Grace Hopper Celebration, my baby, whom I called Galahad ever since knowing I was pregnant, grew as well. I would like to think it is because of my rock hard abs that, one day into the Celebration, I started getting rib pain. My ribs were expanding to fit my high-carried fetus and I was in pain from the pressure in my ribcage from about noon until I went to bed every night. I did not tell anybody (except my amazing room mates) because I had never enjoyed complaining, especially to strangers. Even strangers that are there for the express purpose of caring for and mentoring me.
Half the day, my ribs would hurt so much that I could not sit up. Sometimes I would go back to my room and lie down; other times, I would sprawl out sideways on one of the low arm chairs in the conference area and try not to moan. Both of these were missed networking opportunities. Now I see that it is OK to sprawl in pain rather than attend a session, as long as I am doing something to further my career.
See, I had no idea where my academic career was going. Here I was, not even half-way through my first pregnancy, not even two years through grad school, and with no idea where my research interests were. Every class I took was fascinating for the first three weeks; every project I undertook was interesting only for the first half. I knew I was a fantastic teacher but had never undertaken any serious research project. I knew I wanted to be a professor eventually -- but a professor of what? How do you find the one thing that really turns you on?
These are all questions that, though they cannot be answered by someone else, they can point you and your mind and heart into a direction. Other women's experiences can influence how you experience yourself. Maybe I am getting a little hippy-dippy. But my point is that I was not using this time to the best of my abilities. I could have been meeting women in a higher position than myself and asking for advice; I could have been meeting my future mentor; I could have been learning with others, rather than suffering alone!
Do-Over #2. Tell your secret.
Maybe it was the pregnancy hormones talking, but I posted an anonymous advertisement on the bulletin board:
I had only told my room mates, and mentioned it once at lunch. One of the women, another student, lit up: "Do you have maternity leave at your university?" I answered honestly that I did not know. She persisted: "You know, it should be covered by the union. They bargained for it just last year. It is brand new this year. You should look it up." After lunch, she and I both went to the computers and found the relevant sections. She was glad to help me, and I was glad for the help, because until then, I had never considered my rights and my future as an employee of the university.
It was not until the last hour of the last day, when several of us were loading the bus, that I told one more person about my pregnancy. She was a young woman with a large baby, and introduced herself as a professor. We chatted briefly about pregnancy, and exchanged information. It seemed so natural and inconsequential at the time -- especially as I had such a reverence for professors because of what I now see was mild impostor syndrome -- but I was calmed by her easy nature and friendly manner. This small event which I had put out of my mind as an impossibility because of the difference in rank, this easy exchange of words and information, this event was probably the best thing that happened to me at Grace Hopper Celebration that year. Today, the professor who befriended me continues to mentor and support me through my final years of graduate school. I told my secret to the best person I could possibly meet.
Do-Over #1. Meet the speakers.
I had attended a great many talks, but one in particular still speaks to me today. It was a talk I had heard before, at CRA-W, given by a graduate student that had changed direction several times in the course of her studies. She was explaining the same feelings I was having: She would take an introductory class and enjoy it immensely, but not enjoy the follow-up class. It took her a long time to find a dissertation topic. She explained several ways that dissertation topics come into existence: the extended course project, the advisor's list of unfinished work, the stroke of genius, and others. She struck me as someone I would love to be friends with -- but she was so smart! so accomplished! What would I have to offer by speaking with her?
Wrong, wrong, wrong!
Now that I am also a speaker at Grace Hopper Celebration, I know that speakers are people too. I love it when people attend my talks, and I love it even more when they stay afterwards to tell me that the talk was useful to them, my nervousness did not show, or even that my animation skills in the slides were top-notch. Which, I assure you, they are not. I love it when people tweet about my talk. I love it when people come to ask me for advice, or ask for my contact information in the case they have questions about something I said. I love just knowing that someone, somewhere, was affected by my talk.
I did approach this particular speaker, and I told her that I had heard her talk before and I really admired her. She was surprised: "What, me?" Laughing heartily, she chatted with me about grad school, clearly expressing that she considered us equals. She and I are still friends today.
Since then, I make it a point to meet every speaker that inspires me. Even if she is the president of some fancy corporation, or the first author of an influential paper, or simply the woman that said something that really resonated with me. I introduce myself and say, "What you said just now, I really took to heart. Thank you for a great talk." If we happen to meet again, I can say, "We met at Grace Hopper last year. I loved your talk." This usually leads to an invitation to join her lunch table, which -- by the way -- I always gladly accept.
This year will be my fourth time attending, which makes me a Grace Hopper veteran. I first heard about Grace Hopper Celebration from my room mate from CRA-W Grad Cohort -- a similar but much smaller mentoring program for graduate student women -- when I asked my room mate how on earth she knew all these people. She was saying "Hi," calling people by name, and giving hugs to everybody!
"How do you know everyone already?" I asked her.
"Some women I know from last year's Grad Cohort," she replied. "But some women I see basically twice a year: at the Grad Cohort and then again at Grace Hopper Celebration."
"What's that?" I asked. Casually hiding her surprise that I had neer heard of Grace Hopper Celebration, she explained it to me, and that night in our hotel room I looked it up and bookmarked it.
When Grace Hopper Celebration came around that year, my advisor asked if there are any women that would like to go, because our university was a sponsor and received a few spaces for student attendees. Of course, I replied immediately in the affirmative, and off I went!
Now that I have been three times to Grace Hopper Celebration (this year will mark my third time as a contributor) and twice to the CRA-W Grad Cohort, I can look back on my first Grace Hopper Celebration visit a bit critically.
My first year, Grace Hopper Celebration was held in Keystone, Colorado, a small resort town situated in the mountains among an aspen forest. The trees were just starting to turn in ones and twos: blots of color among a sea of green leaves. I was driven from the airport in a shuttle and looked out onto the picturesque landscape with wide eyes. I was young, impressionable, and pregnant.
Yup, I was about 24 weeks along in my pregnancy. I knew I was carrying a boy, and I had just returned from a trip abroad -- a delayed honeymoon -- before having time to buy clothes that fit me. My belly had just started getting too big for my pants. It happened so suddenly that I was ill-prepared, wardrobe-wise, for the change in my figure. I was a hot mess, unbuttoning my jeans and praying that my fitted t-shirts did not bust into holes stretched over my growing belly. When my mother saw me at the airport on my return from Grace Hopper, she was shocked at my fashion sense, but at the time, I figured that is just an extension of the typical graduate student lifestyle. Right? Please tell me I am right.
Anyway, back to the point -- I could have done a better job. As an early(ish) graduate student, my main role was to be receptive to mentoring and to meet people that would help me in my career path. I see that now, in hindsight, but at the time I did not recognize these goals. Here were my top five mistakes from the first year. Every year I go back, I get a do-over and do my best to avoid these.
Do-Over #5. Eat lunch and dinner.
At CRA-W Grad Cohort, one of the rules was that no two women from the same university could sit together at lunch. You had to learn to network, and to meet other women. But here, at Grace Hopper Celebration, there was no such rule, and even if there was, there is no way to enforce it with 2000 attendees. So attendees would sit with the people they knew more often than not, and I, seeing this social norm, followed suit. Not a good idea. Now I know that it is best to sit at a table where you know no one. Even better: sit at a table where you know no one, and everyone is different from you. Is everyone older? They have more experience. Is everyone younger? Maybe they have questions. But if everyone is exactly like you, there is no way you can broaden your experience. Challenge yourself.
Do-Over #4. Use the room mate.
I was at Grace Hopper Celebration on an underwriter scholarship, and, like all scholarship recipients, I had a room mate. Actually, in this year, we were in a three-room cabin in the mountains of Keystone, Colorado, and I had two house mates. My house mates were amazing. They asked me about pregnancy and married life, about the proverbial work-life balance (as if there is one), about what I will do once I have the baby (hint: stay in school). On our last night in Colorado, we all went shopping to the outlets nearby and my lovely room mates bought me a shirt that actually covered my entire front. Maybe it is silly, but I was moved.
But most of the day, my house mates (who knew each other) would be off on their own, and, in pregnancy-related discomfort (more on this later), I left them to themselves. I did not go to see their posters at the poster session; I did not ask for introductions to other women; I did not sit with them and their colleagues at lunch. But this was wrong. Use your room mate (or room mates, if you are lucky enough to have two) -- use them as mentors if they are more experienced at Grace Hopper Celebration than you are; use them as friends if they are new like you; use them as a sounding-board for your elevator pitch for your research.
My room mates approached me on the second day and said, with a sly grin, "We are thinking of taking a drive up to the summit, instead of one of the sessions. Are you in?" I considered for a moment, wondering if it is OK to skip sessions, and if we could leave the conference grounds without arousing suspicion among the organizers. Hesitating a little, I said that it sounds like great fun, and that I would certainly come.
As we arrived to the summit, the weather shifted dramatically, from cool and clear autumn to cold and foggy winter. Not another person and not another vehicle was within sight: it was just us. It began to snow in large, fluffy flakes. The electricity in the air made our hair stand straight up, and lightning bolts noiselessly crashed all around us. We giggled and photographed and huddled in our insufficient jackets -- and bonded. We formed relationships which would survive the test of time and geography -- relationships we could later fall back on in our professional and personal lives, because we had this shared experience.
Do-Over #3. Couch potato networking.
During the course of Grace Hopper Celebration, my baby, whom I called Galahad ever since knowing I was pregnant, grew as well. I would like to think it is because of my rock hard abs that, one day into the Celebration, I started getting rib pain. My ribs were expanding to fit my high-carried fetus and I was in pain from the pressure in my ribcage from about noon until I went to bed every night. I did not tell anybody (except my amazing room mates) because I had never enjoyed complaining, especially to strangers. Even strangers that are there for the express purpose of caring for and mentoring me.
Half the day, my ribs would hurt so much that I could not sit up. Sometimes I would go back to my room and lie down; other times, I would sprawl out sideways on one of the low arm chairs in the conference area and try not to moan. Both of these were missed networking opportunities. Now I see that it is OK to sprawl in pain rather than attend a session, as long as I am doing something to further my career.
See, I had no idea where my academic career was going. Here I was, not even half-way through my first pregnancy, not even two years through grad school, and with no idea where my research interests were. Every class I took was fascinating for the first three weeks; every project I undertook was interesting only for the first half. I knew I was a fantastic teacher but had never undertaken any serious research project. I knew I wanted to be a professor eventually -- but a professor of what? How do you find the one thing that really turns you on?
These are all questions that, though they cannot be answered by someone else, they can point you and your mind and heart into a direction. Other women's experiences can influence how you experience yourself. Maybe I am getting a little hippy-dippy. But my point is that I was not using this time to the best of my abilities. I could have been meeting women in a higher position than myself and asking for advice; I could have been meeting my future mentor; I could have been learning with others, rather than suffering alone!
Do-Over #2. Tell your secret.
Maybe it was the pregnancy hormones talking, but I posted an anonymous advertisement on the bulletin board:
Looking to connect with other pregnant graduate students and those with kids.I added my e-mail address and hoped for the best. The truth is that I did not know what I was looking for. Support? Advice? Encouragement? I did not have any concrete questions but I wanted to know that I was not alone, that my experience was not unique. In some ways, I suppose, I wanted validation. I wanted someone to say, "I know things will get rough, but you can do it, because I did it." Though I did receive a few notes, mainly by other participants pinning replies to the same bulletin board, I never replied to them, in part because I did not know what I wanted to say, and in part because I did not want to give away my secret.
I had only told my room mates, and mentioned it once at lunch. One of the women, another student, lit up: "Do you have maternity leave at your university?" I answered honestly that I did not know. She persisted: "You know, it should be covered by the union. They bargained for it just last year. It is brand new this year. You should look it up." After lunch, she and I both went to the computers and found the relevant sections. She was glad to help me, and I was glad for the help, because until then, I had never considered my rights and my future as an employee of the university.
It was not until the last hour of the last day, when several of us were loading the bus, that I told one more person about my pregnancy. She was a young woman with a large baby, and introduced herself as a professor. We chatted briefly about pregnancy, and exchanged information. It seemed so natural and inconsequential at the time -- especially as I had such a reverence for professors because of what I now see was mild impostor syndrome -- but I was calmed by her easy nature and friendly manner. This small event which I had put out of my mind as an impossibility because of the difference in rank, this easy exchange of words and information, this event was probably the best thing that happened to me at Grace Hopper Celebration that year. Today, the professor who befriended me continues to mentor and support me through my final years of graduate school. I told my secret to the best person I could possibly meet.
Do-Over #1. Meet the speakers.
I had attended a great many talks, but one in particular still speaks to me today. It was a talk I had heard before, at CRA-W, given by a graduate student that had changed direction several times in the course of her studies. She was explaining the same feelings I was having: She would take an introductory class and enjoy it immensely, but not enjoy the follow-up class. It took her a long time to find a dissertation topic. She explained several ways that dissertation topics come into existence: the extended course project, the advisor's list of unfinished work, the stroke of genius, and others. She struck me as someone I would love to be friends with -- but she was so smart! so accomplished! What would I have to offer by speaking with her?
Wrong, wrong, wrong!
Now that I am also a speaker at Grace Hopper Celebration, I know that speakers are people too. I love it when people attend my talks, and I love it even more when they stay afterwards to tell me that the talk was useful to them, my nervousness did not show, or even that my animation skills in the slides were top-notch. Which, I assure you, they are not. I love it when people tweet about my talk. I love it when people come to ask me for advice, or ask for my contact information in the case they have questions about something I said. I love just knowing that someone, somewhere, was affected by my talk.
I did approach this particular speaker, and I told her that I had heard her talk before and I really admired her. She was surprised: "What, me?" Laughing heartily, she chatted with me about grad school, clearly expressing that she considered us equals. She and I are still friends today.
Since then, I make it a point to meet every speaker that inspires me. Even if she is the president of some fancy corporation, or the first author of an influential paper, or simply the woman that said something that really resonated with me. I introduce myself and say, "What you said just now, I really took to heart. Thank you for a great talk." If we happen to meet again, I can say, "We met at Grace Hopper last year. I loved your talk." This usually leads to an invitation to join her lunch table, which -- by the way -- I always gladly accept.
Friday, September 9, 2011
Violet's birth. Part 2: Fay gives birth.
Read Part 1 of Violet's birth, in which Fay negotiates with Dr. Kim in the weeks before her due date.
That night, the day of the NST and start of the 42nd week, Fay's belief in her body was reinstated as she lost her mucus plug and had some mild contractions for about an hour, but then they stopped. I did a little dance of joy on her behalf, because I knew that her body was getting ready for it.
And that night, Fay and Simon went in to the hospital to have their NST. With the nurse's help, Fay climbed up on the hospital bed, turned on her back, and --
Gush!
"Did I pee?" She wondered. "Is it blood?"
She looked down.
Nope, not blood. It was clear and odorless. The nurse turned to her and smiled. Fay's water had broken. Simon looked on.
"I guess you're staying now," the nurse said. "I'd better admit you."
"Deliver, not rest."
Admitted to the hospital, Fay lay on the hospital bed and looked at Simon. "This is it!" she thought. The non-stress-test (NST) was beeping merrily on the cart beside her. The nurse entered, and Fay said:
"I think I'm having a contraction. I can feel it in my back and my belly."
The nurse looked at the monitor.
"Doesn't look like it," she said. "But we'll have to get them started four hours from now. I'll bring the Pitocin."
Fay and Simon looked at the clock on the wall. It was 11pm and they were exhausted. Fay remembered my advice to her: sleep when you can in early labor.
"Can we wait?" asked Fay. "Until morning. So we can sleep and be well-rested for the Pitocin in the morning."
The nurse rolled her eyes. "You came here to deliver, not to rest."
Simon spoke next. "No, actually." He cleared his throat. "We came here for a non-stress test. We did not come to deliver."
Fay asked, "Can we go home?"
"No," replied the nurse, her voice raising in annoyance. Collecting herself, she added: "Well, yes, but you would have to sign this form in which it says you are leaving against doctor's orders. What happens to you outside this hospital," she closed her eyes and spread her hands, palms up, for dramatic effect, "is out of my hands."
Fay and Simon looked at each other.
"We'd like to wait eight hours before Pitocin."
"What difference does it make?" huffed the nurse. "If labor doesn't start in four hours, what makes you think it will start in eight?"
Fay and Simon blinked at her.
"Fine. Fine!" she scolded. "You can have six hours. I will be back to check you in four hours, at 4am. Then at 6am I will start Pitocin."
"Deal," Fay and Simon said, and breathed a sigh of relief as she waddled from the room.
Sleeping labor, and active labor
Simon slept on the roll-out partner bed. And in her sleep, Fay had contractions. She woke up for each and every one of them. The pain radiated from her back, and with each contraction she would wake up and press her back into the bed with all her might. The counter-pressure was a relief but the pain was exhausting and all-consuming.
At 4am, the nurse returned and checked Fay's cervix. It was 4cm dilated. The nurse was defeated. Packing up her Pitocin bags, she left the room and left Fay to labor, quietly, on her own.
At 6am, Fay called me, her doula, to come. In the meantime, I told her, get on all fours and have Simon squat over you, putting pressure on your back with his hands. On your back in bed is the worst place to be. And drink some water. And try the shower. Water on the back may feel nice.
The doula comes
When I arrived, Fay and Simon were in the bathroom, with Fay in the shower. The room was hot. I knocked and pushed open the bathroom door as steam poured out. I closed the door behind me. There was a floral scent of shampoo, and with each contraction, Simon would lean into the shower and press on Fay's lower back.
"The pain was easily ten times worse in the bed," said Fay. "It was unbearable. It is so much better here in the shower, but my back still hurts during contractions."
"Sometimes back labor is caused by the baby presenting in an odd way," I said. "She's probably pressing with her head on your spine. Being upright and leaning forward like you're doing will help the baby turn a bit." When we get out, I thought, we will try hands and knees, kneeling, and lunging.
"Ohhhh," said Fay as a contraction hit, turning her back toward the hot stream.
"The bonus is that in this shower, you won't run out of hot water." I smiled and Fay copied my smile.
I heard some noise outside the bathroom door. "I'll be right back," I said and excused myself.
How much does it hurt?
In the room, a nurse, Katie, was standing with another woman whom she introduced as one of the nursing teachers. I told Katie I am Fay and Simon's doula, and Katie exclaimed that she was so cool with doulas, unlike some other nurses, and that we would work well together. The shower turned off, and in a few minutes, Simon and Fay emerged.
Katie did her work, taking blood pressure and temperature readings and setting up the monitors to listen to the baby.
"I don't usually ask this," she said, blowing her bangs out of her eyes, "but, on a scale of one to 10, ten being the worst you could possibly imagine, how would you describe your pain right now?"
I rolled my eyes. Here we are, Simon, Fay, and I, trying to keep Fay from seriously thinking about her pain, trying to keep her distracted and taking things one at a time, and now she is expected to put a number on her sensation.
"In the bed," answered Fay, "it was bad. Like nine. I can't imagine it being worse. But in the shower the pain decreased tenfold; probably a four."
I stammered: "Can we, uh, not do that again?"
"Yeah, sure, it's just one of the vital signs," explained the nurse, who probably saw me rolling my eyes anyway. "Temperature, blood pressure, pain level. We have to take it every hour. If you want, I can just fill in numbers from now on. Six, seven, six, seven."
Simon and Fay nodded, watching me. I nodded vigorously.
Katie pulled on a sterile glove and checked Fay's cervix. Fay held Simon's and my hands.
"Five centimeters," Katie announced. "I think it is great you are laboring normally," she said, not looking at anyone in particular, and added that natural labors usually are assigned to her because she is so awesome at "dealing" with them. Then she started talking about what a "good" labor pattern looks like and how we can tell that we are "progressing well." She pulled up a chart showing 1cm per hour dilation. Simon looked on, and I, knowing that talking about expected progress is not encouraging, sat by Fay's head and talked to her about her night in the hospital.
"I'll be back in about an hour to take your vitals again," Katie said. We thanked her as she left.
Fired from birth support
We labored normally for several hours, changing positions frequently. We tried every position that I could think of to try to alleviate back labor. I coached Simon how to spread his legs, lock his elbows, and use his back to push on Fay's lower back during contractions as Fay leaned forward on a stack of pillows on the raised bed. If his hands slipped, or he changed his grip, or he got the wrong spot, Fay would scold him for a good half of each contraction -- and then we would all laugh as the contraction eased. Laughter brought on contractions. Walking brought on contractions. Touching Fay brought on contractions. We joked that we could not do any of these things, and if we did, Simon would be fired.
Simon was fired from labor support eleven times.
At 10:30, just two hours after the previous cervical check, we had progressed to a heartening "6cm, almost 7." Things were great.
But at noon, something happened.
Crying
We were sitting in the middle of the room, with Fay on the birth ball between contractions, Simon in the glider, and me squatting at Fay's knee. We heard a noise next door. It was a woman. And she was screaming. She screamed for what felt like an hour, though it must have been just a minute. She would stop screaming only to take a sharp breath and then the blood-curdling scream would come again. Under the woman, we could hear other people's loud, mumbled voices.
Fay looked at me.
"She is not doing as well as you are," I said, smiling. "Those are bad noises to make. You are making good noises."
The screaming continued. Fay stared at me.
"She is probably delivering," offered Simon.
The screaming continued.
"Oh my God," said Fay, the color draining from her face.
"It isn't necessarily pain," I said. "The sensation is overwhelming. This is why she is screaming." We all looked at the floor, waiting for it to stop.
The screaming increased in pitch for a split second. We held our breath. Then, the screaming stopped, and was replaced by tearful shouts: "Oh, my baby, my baby!"
I looked at Fay and smiled. She was crying. Tears were rolling down her face. I looked at Simon. He was pale.
We talked about it. We talked about fear, and how we need to get past it. About how the baby is coming today, and we are helping her come. About how most women do not sound like that. Fay did not talk about delivery. She was trying not to think about delivering the baby, about pushing the baby out, about the woman screaming next door.
Fay was exhausted. Climbing into the bed and rolling onto her side, she fell asleep in no time. Though I tried to convince Simon to sleep, he and I sat near each other and talked. We would chat, and then Fay would wake up with a contraction. We would rush to her: Simon to her back, me to hold her hand. Then it would ease and she would drift off. This happened infrequently: contractions slowed to a crawl. Every seven minutes. Every ten minutes.
The drill sergeant
At 1pm, I went to fetch the nurse. Because contractions seemed stronger, though infrequent, and there was that electric feeling in the air, that particular odor that I have come to associate with transition. Katie came back in and, checking, we were pleased to hear we were 7-8cm. Which is almost transition. It is close.
"I've had some women complete on the toilet," Katie suggested, meaning that women dilate the rest of the way, to 10cm, or "complete" the dilation.
"Try the toilet," Katie continued. "Try the shower. Try nipple stim. We gotta get things moving."
Determined to do everything I can that we should get through this part, that is, transition, quickly, I got Fay out of bed (bribing her with getting back in it later) and we went to the toilet. Then the shower. Then the birth ball, with her legs spread wide. I kept waiting for that contraction with the pressure on top which indicates real transition, but I did not hear it. It did not come.
Acting as a drill sergeant, I sent Fay back and forth from the door to the baby warmer. She did laps around the room, and I suggested she try some nipple stimulation. She ate a little bit. She drank water. We tried effleurage, in which Simon gently rubbed Fay's belly to bring on contractions. But contractions were still slow, and there was still no pressure at the top.
An hour later, at 2:30pm, we learned that we had made no progress.
At 4, Katie returned with a vengeance. She showed us the graphs again (and again, I distracted Fay from seeing them). She talked about progress and how we were not making any. And she gave Fay two options: an epidural, which would help her relax, and the relaxation which may bring on contractions again, or Pitocin, which would bring on contractions.
"But if I choose the epidural," said Fay, leaning on the bed, "wouldn't contractions slow down, and then I will need Pitocin anyway?"
"Maybe," said Katie. "Maybe you just need to relax, that's all. But it's possible that we will need Pitocin too." She looked her up and down. "See, we've been talking about this for about five minutes. You should have had two contractions by now."
Fay stood up and started walking, rubbing her belly in small circles. No contraction came.
"Look," Katie proceeded once she was sufficiently convinced that she would not sell the epidural. "We can start you on the lowest dose of Pit. We can turn it off once contractions have started again." Again she brought up a graph. "See, this is a woman that's already delivered. This is her contraction pattern at 7cm, which is where you are."
"Are these Pitocin contractions?" I asked, recognizing the shape -- which looks markedly different than that of a natural contraction.
Katie checked. "Yes, it is." But she was not discouraged. "But it doesn't matter," she pleaded. "See, you should be having another contraction, right now. I want you to have this baby vaginally. I want to help you. You have to let me help you. What have you been trying?"
"We've been walking around," I said. "Nipple stimulation. Effleurage."
"Why did you stop the nipple stim?" Katie asked Fay. Fay looked away.
"Walking around seemed to work too," said Simon.
"But it isn't working!" cried Katie. "It is not working. Fine. What about Fentanyl. It's a narcotic and it may help you relax a little. We just have to get you past this hump." Katie felt Fay's belly during a contraction. "See, it's not very strong, either." She sighed. "Sometimes a mom needs some help to get over the hump. Sometimes she just needs to relax, or a break from the pain. Sometimes she needs Pitocin to make contractions stronger. Sometimes the baby won't come at all, and she needs a c-section."
I winced. Katie had made offhand c-section comments before, but I was too busy distracting Fay from the conversation to wince properly. This time I winced. Alluding to surgical birth to a laboring woman is akin to alluding to filet mignon to a calf. For some women, it is a blow to her faith in herself.
Passenger, passage, and power
Contractions were coming in pairs: a big one, and a little one riding on its back. Then seven minutes of silence. This is called coupling, and is fine unless no progress is being made. But if the labor is dysfunctional, which is, medically speaking, where we were heading, then it can be treated with rest (which we had done in the hour Fay slept), hydration (which we were doing), and everything Katie suggested: Pitocin, epidural, Fentanyl.
Coupling contractions can be a symptom of an occupit posterior (OP) position of the baby, or sunny-side up. Other symptoms of an OP baby are back labor. Which is why we had been trying so hard to get Fay's baby to turn. Most babies, something like 70-90%, that start out OP will eventually turn in labor. We had hope.
Katie suggested, "We have one more thing we could try before Pit." She left and came back with a package, a long tube inside. "This is an intra-uterine pressure catheter. It goes in next to baby's head in the amniotic fluid, and when you have a contraction, we measure the strength of the contraction in milligrams of mercury."
She paused to make sure we followed. We did.
"Normal labor has three components. The passenger, the passage, and the power. We don't know much about the passenger. We don't know how big she is. Do we?"
"No, we don't," said Fay.
Katie continued: "Maybe she's malpresented. Maybe she's facing funny down the birth canal." She pressed her glasses up her nose, letting her blonde bangs fall into her face. "We don't know much about the passage yet. About the birth canal. Maybe you aren't big enough to let the baby pass. I don't know. So we can try to find the power."
She held up the IUPC. "We use this to measure the strength of the contractions. We can use this measurement over time, over the space of several minutes and several contractions, to get an objective number called a Montevideo unit, an MVU. If we have enough MVUs, we know that contractions are strong enough and that labor should be progressing -- and if it isn't, then one of the other things, the passenger or the passage, is stopping it. But if we do not have enough MVUs, we can try putting you on Pit, to make the power stronger." She paused. "This is real, empirical evidence."
Now, hang on a second. I am a newer doula, so I had not heard about the "three Ps of labor." But I did know about the fourth P: Patience. Sometimes it just takes time. We had been patient, resting and walking and eating, at 7cm for three hours. The clock was ticking since Fay's water had been broken for 16 hours.
Fay and Simon talked about it. "Basically, our options are Pitocin, or IUPC and Pitocin," Simon concluded. "Let's just do the Pitocin."
"Finally," Katie said. "You are letting me help you. I feel like I am doing something."
Fay, Simon, and Katie agreed on a dose of Fentanyl and the lowest dose of Pitocin, just to get past the hump. Fay would still be allowed to labor upright, but intermittent monitoring was no longer an option. Antibiotics were started because of the ruptured membranes.
Pitocin contractions were different. They hurt more, and lasted longer, but they were not closer together. An hour later, the dose of Pitocin was increased, and, the contractions still not any closer (though more painful), Fay asked for an epidural.
Katie started an IV, and we waited for the doctor, all the while taking one contraction at a time.
The doctor, an older man with white hair who seemed to be old enough to retire by now, came with his epidural cart and asked Fay to bend forward, achieving "the worst posture you could imagine." He cleaned Fay's back, numbed it, and inserted the needle.
"Hmm," he said. "Can you lean forward more? I seem to have missed the epidural space."
I gave her a pillow to hug in her lap.
He stuck her again. "Hmm," he said, withdrawing the needle. "I hit the bone again," he said. Simon's eyebrows raised, but he was quiet.
The needle went in again. "Missed," he mumbled, perplexed.
"Look," he grumbled, having missed again, "just curl your back into a C."
Eventually, it made it in, and the pain from the contractions dispersed. They were still coupling, so Katie increased the Pitocin. They were still coupling.
Before she left, knowing her shift was soon over and we would not be delivering on her watch (as was secretly our plan), I asked her to transfer us to another nurse that would be patient and kind with us and try to get us back on the path of natural birth. She said she would, but no promises. Then, she added:
"The IUPC is your last resort, so keep it in mind." She glanced at the door. It was closed. Katie lowered her voice. "If your doctor comes in and tells you she wants to do a c-section, you ask her to try the IUPC. Try to see if the power is sufficient, if the MVUs are enough to get the cervix opened. Do you understand?" We nodded. "Good," she said, taking her leave.
A new hope
At 8pm, the sun was starting to descend outside the closed mini-blinds. Fay drifted back to sleep, covered by a sheet and a blanket. Simon, who still refused to sleep, and I were sitting under the window, talking about how good it was that Fay was getting rest.
A new nurse came in, introducing herself as Megan. She was stouter than Katie, brown-haired, and was full of fresh energy.
"Hi, Megan," I said, and, meaning how Fay has been coping with labor, "we've been doing great!"
"Not really," she said, turning away from the computer with just her shoulders. "You haven't made progress since 1pm. Your labor has stalled." She turned back to the computer and read the notes.
I looked at Simon and gestured that I clearly said the wrong thing.
Megan woke Fay to check her. "Eight or 9cm," she said.
"There, that's progress," I suggested.
At this point, Simon went to take a break, and brought back food for me. When he returned an hour later, Dr. Kim came, and Megan checked Fay's cervix in Dr. Kim's presence.
"She's a nine," said Megan. Dr. Kim looked concerned, turning up the Pit again, and promised to check back in an hour.
The 11th hour
It was 10pm, 23 hours after Fay's water broke, when Megan and Dr. Kim returned.
"The contractions have spaced out, and they are moderate," Megan explained. "Maybe the uterus is tired. That can happen. The uterus is a muscle, and muscles get tired."
Fay, Simon, and I looked at each other. I nodded: it's true. They do.
Dr. Kim pulled on a glove. "Still nine," she said, withdrawing from under Fay's sheet.
"Do you know what this is?" Dr. Kim asked, holding up the IUPC that Katie described earlier. We nodded. "I'm going to use this to measure the strength of your contractions. We will see what is happening."
Meanwhile, Megan took Fay's temperature and found it to be elevated. Megan pulled the blanket away from Fay. "You can't use this anymore," she said, and set the temperature in the room to a cool 68F.
Alone in the room with Fay and Simon, they turned to me.
"We need to talk about the possibility of a c-section," Fay said, and Simon leaned in close to me. It was like a team meeting at a football game. "What if they come in and offer me a c-section? I think I should take it."
I did not reply, but listened.
"It has been a long time and I don't know if this will happen naturally. We have been trying everything."
"We can try a few more things. Let's see what happens," I said. Fay and Simon nodded, and we all relaxed into the possibility.
Complete
At midnight, Fay was complete. Megan checked with Fay's pushes: "Pushing doesn't seem to move the baby," she said. "We'll let you labor down, meaning the baby will come down on her own." We pushed in many different positions, despite being connected to so many machines: squatting, side-lying, legs up, legs down, back, all fours. As Megan's hand disappeared under the sheet, she looked at me and shook her head sadly.
I was drinking a lot of soda by this point. It was past midnight and I was tired, walking down the long hallway to the staff kitchen for more caffeine. I ran into Megan in the hall. She whispered to me:
"I don't know," she said, "if this baby will be coming vaginally. Her pelvis is so small. I can barely get my fingers inside. I can feel the head and it's just sitting there," she made a motion with her fingers, "just sitting there on the pelvic bone." She looked at me with sad eyes. "Talk to them," she said, "get them ready for a conversation about a c-section." I nodded.
Going back to the room, I did not talk to them about the possibility of a c-section, because we were already on the same page.
She looked at Fay, then at Simon. "The baby is not moving down," she said. "I slide my finger up by the baby's cheek," she said, showing with her fingers, "and I expect the baby to slide against my finger with each contraction. And the baby just isn't moving down."
We sighed.
"I don't know if this baby wants to come vaginally. I think this may have to be a surgical birth. You have tried everything you could: I have never seen a mom spend so much time upright and out of bed. You really have tried everything, and I have tried everything that I could think of as well."
When she left the room, I talked Fay and Simon through the procedure. I tried to explain what Fay would feel, when she could see the baby, and where Simon would be. Where I would be. This hospital had a strict one-person-per-patient policy, so I could not come into the OR as I had previously done in other births.
"Will you visit us tomorrow?" Fay asked.
"I will visit you in the recovery room," I said, smiling. "I will see you as soon as I can. I will help you breastfeed your baby." Simon was quiet, pulling on his hospital robe and paper shower cap. We were all so exhausted. Simon was worried both about his baby, who was showing signs of stress in utero, and about his wife, who had been in labor for 29 hours.
I knew Fay and I had done everything we could think of to turn and move the baby. Simon was an amazing birth partner, pressing on Fay's back with almost every contraction for over a day. Bags under our eyes and our feet heavy with the weight of relief, we collected our items, for we would not be returning to the delivery room.
As we rolled away, Megan exclaimed, "It's a party! A birthday party!"
Postpartum
That's the end of the story, at least, the story as I know it. Baby Violet was born beautifully just after 2am, and though her head came out screaming before the rest of her body was even born, and though she had spent quite some time in a meconium-rich environment (for she had pooped quite some time ago), she had not breathed any of it in. She had a ridge crosswise on her head, rather than lengthwise where the plates of her head typically fold over each other. She was trying to get out, but really was stuck.
Latching on to the breast in record time, Violet was perhaps the most relieved of all to be born.
Foreshadowing?
Was it premonition, or did she just know, when Dr. Kim had pressed her point, with a sly smile: "Just keep your mind open for a c-section?" Had she known that a surgical birth was necessary, she still had the kindness (to Violet and Fay) to let labor go on naturally for as long as she did.
Megan, the second nurse, on whose shift Violet was born, approached the topic of a c-section with such kindness and sensitivity to the laboring mom that I was swept off my feet. I appreciated her acknowledgement of our hard work, of the hours we poured into the labor, and the multitude of things we tried. I liked how she looked Fay in the eyes when she said these things with a soft voice and maternal touch on her thigh.
And, for the doulas and birth partners that read this blog: What would you have done?
That night, the day of the NST and start of the 42nd week, Fay's belief in her body was reinstated as she lost her mucus plug and had some mild contractions for about an hour, but then they stopped. I did a little dance of joy on her behalf, because I knew that her body was getting ready for it.
And that night, Fay and Simon went in to the hospital to have their NST. With the nurse's help, Fay climbed up on the hospital bed, turned on her back, and --
Gush!
"Did I pee?" She wondered. "Is it blood?"
She looked down.
Nope, not blood. It was clear and odorless. The nurse turned to her and smiled. Fay's water had broken. Simon looked on.
"I guess you're staying now," the nurse said. "I'd better admit you."
 |
| Non-stress test (NST) |
Admitted to the hospital, Fay lay on the hospital bed and looked at Simon. "This is it!" she thought. The non-stress-test (NST) was beeping merrily on the cart beside her. The nurse entered, and Fay said:
"I think I'm having a contraction. I can feel it in my back and my belly."
The nurse looked at the monitor.
"Doesn't look like it," she said. "But we'll have to get them started four hours from now. I'll bring the Pitocin."
Fay and Simon looked at the clock on the wall. It was 11pm and they were exhausted. Fay remembered my advice to her: sleep when you can in early labor.
"Can we wait?" asked Fay. "Until morning. So we can sleep and be well-rested for the Pitocin in the morning."
The nurse rolled her eyes. "You came here to deliver, not to rest."
Simon spoke next. "No, actually." He cleared his throat. "We came here for a non-stress test. We did not come to deliver."
Fay asked, "Can we go home?"
"No," replied the nurse, her voice raising in annoyance. Collecting herself, she added: "Well, yes, but you would have to sign this form in which it says you are leaving against doctor's orders. What happens to you outside this hospital," she closed her eyes and spread her hands, palms up, for dramatic effect, "is out of my hands."
Fay and Simon looked at each other.
"We'd like to wait eight hours before Pitocin."
"What difference does it make?" huffed the nurse. "If labor doesn't start in four hours, what makes you think it will start in eight?"
Fay and Simon blinked at her.
"Fine. Fine!" she scolded. "You can have six hours. I will be back to check you in four hours, at 4am. Then at 6am I will start Pitocin."
"Deal," Fay and Simon said, and breathed a sigh of relief as she waddled from the room.
Sleeping labor, and active labor
Simon slept on the roll-out partner bed. And in her sleep, Fay had contractions. She woke up for each and every one of them. The pain radiated from her back, and with each contraction she would wake up and press her back into the bed with all her might. The counter-pressure was a relief but the pain was exhausting and all-consuming.
At 4am, the nurse returned and checked Fay's cervix. It was 4cm dilated. The nurse was defeated. Packing up her Pitocin bags, she left the room and left Fay to labor, quietly, on her own.
At 6am, Fay called me, her doula, to come. In the meantime, I told her, get on all fours and have Simon squat over you, putting pressure on your back with his hands. On your back in bed is the worst place to be. And drink some water. And try the shower. Water on the back may feel nice.
The doula comes
When I arrived, Fay and Simon were in the bathroom, with Fay in the shower. The room was hot. I knocked and pushed open the bathroom door as steam poured out. I closed the door behind me. There was a floral scent of shampoo, and with each contraction, Simon would lean into the shower and press on Fay's lower back.
"The pain was easily ten times worse in the bed," said Fay. "It was unbearable. It is so much better here in the shower, but my back still hurts during contractions."
"Sometimes back labor is caused by the baby presenting in an odd way," I said. "She's probably pressing with her head on your spine. Being upright and leaning forward like you're doing will help the baby turn a bit." When we get out, I thought, we will try hands and knees, kneeling, and lunging.
"Ohhhh," said Fay as a contraction hit, turning her back toward the hot stream.
"The bonus is that in this shower, you won't run out of hot water." I smiled and Fay copied my smile.
I heard some noise outside the bathroom door. "I'll be right back," I said and excused myself.
 |
| Pain scale. I just want to punch someone when I see one of these in labor. |
In the room, a nurse, Katie, was standing with another woman whom she introduced as one of the nursing teachers. I told Katie I am Fay and Simon's doula, and Katie exclaimed that she was so cool with doulas, unlike some other nurses, and that we would work well together. The shower turned off, and in a few minutes, Simon and Fay emerged.
Katie did her work, taking blood pressure and temperature readings and setting up the monitors to listen to the baby.
"I don't usually ask this," she said, blowing her bangs out of her eyes, "but, on a scale of one to 10, ten being the worst you could possibly imagine, how would you describe your pain right now?"
I rolled my eyes. Here we are, Simon, Fay, and I, trying to keep Fay from seriously thinking about her pain, trying to keep her distracted and taking things one at a time, and now she is expected to put a number on her sensation.
"In the bed," answered Fay, "it was bad. Like nine. I can't imagine it being worse. But in the shower the pain decreased tenfold; probably a four."
I stammered: "Can we, uh, not do that again?"
"Yeah, sure, it's just one of the vital signs," explained the nurse, who probably saw me rolling my eyes anyway. "Temperature, blood pressure, pain level. We have to take it every hour. If you want, I can just fill in numbers from now on. Six, seven, six, seven."
Simon and Fay nodded, watching me. I nodded vigorously.
Katie pulled on a sterile glove and checked Fay's cervix. Fay held Simon's and my hands.
"Five centimeters," Katie announced. "I think it is great you are laboring normally," she said, not looking at anyone in particular, and added that natural labors usually are assigned to her because she is so awesome at "dealing" with them. Then she started talking about what a "good" labor pattern looks like and how we can tell that we are "progressing well." She pulled up a chart showing 1cm per hour dilation. Simon looked on, and I, knowing that talking about expected progress is not encouraging, sat by Fay's head and talked to her about her night in the hospital.
"I'll be back in about an hour to take your vitals again," Katie said. We thanked her as she left.
 |
| Counterpressure to lower back |
We labored normally for several hours, changing positions frequently. We tried every position that I could think of to try to alleviate back labor. I coached Simon how to spread his legs, lock his elbows, and use his back to push on Fay's lower back during contractions as Fay leaned forward on a stack of pillows on the raised bed. If his hands slipped, or he changed his grip, or he got the wrong spot, Fay would scold him for a good half of each contraction -- and then we would all laugh as the contraction eased. Laughter brought on contractions. Walking brought on contractions. Touching Fay brought on contractions. We joked that we could not do any of these things, and if we did, Simon would be fired.
Simon was fired from labor support eleven times.
At 10:30, just two hours after the previous cervical check, we had progressed to a heartening "6cm, almost 7." Things were great.
But at noon, something happened.
Crying
We were sitting in the middle of the room, with Fay on the birth ball between contractions, Simon in the glider, and me squatting at Fay's knee. We heard a noise next door. It was a woman. And she was screaming. She screamed for what felt like an hour, though it must have been just a minute. She would stop screaming only to take a sharp breath and then the blood-curdling scream would come again. Under the woman, we could hear other people's loud, mumbled voices.
Fay looked at me.
"She is not doing as well as you are," I said, smiling. "Those are bad noises to make. You are making good noises."
The screaming continued. Fay stared at me.
"She is probably delivering," offered Simon.
The screaming continued.
"Oh my God," said Fay, the color draining from her face.
"It isn't necessarily pain," I said. "The sensation is overwhelming. This is why she is screaming." We all looked at the floor, waiting for it to stop.
The screaming increased in pitch for a split second. We held our breath. Then, the screaming stopped, and was replaced by tearful shouts: "Oh, my baby, my baby!"
I looked at Fay and smiled. She was crying. Tears were rolling down her face. I looked at Simon. He was pale.
We talked about it. We talked about fear, and how we need to get past it. About how the baby is coming today, and we are helping her come. About how most women do not sound like that. Fay did not talk about delivery. She was trying not to think about delivering the baby, about pushing the baby out, about the woman screaming next door.
Fay was exhausted. Climbing into the bed and rolling onto her side, she fell asleep in no time. Though I tried to convince Simon to sleep, he and I sat near each other and talked. We would chat, and then Fay would wake up with a contraction. We would rush to her: Simon to her back, me to hold her hand. Then it would ease and she would drift off. This happened infrequently: contractions slowed to a crawl. Every seven minutes. Every ten minutes.
The drill sergeant
At 1pm, I went to fetch the nurse. Because contractions seemed stronger, though infrequent, and there was that electric feeling in the air, that particular odor that I have come to associate with transition. Katie came back in and, checking, we were pleased to hear we were 7-8cm. Which is almost transition. It is close.
"I've had some women complete on the toilet," Katie suggested, meaning that women dilate the rest of the way, to 10cm, or "complete" the dilation.
"Try the toilet," Katie continued. "Try the shower. Try nipple stim. We gotta get things moving."
Determined to do everything I can that we should get through this part, that is, transition, quickly, I got Fay out of bed (bribing her with getting back in it later) and we went to the toilet. Then the shower. Then the birth ball, with her legs spread wide. I kept waiting for that contraction with the pressure on top which indicates real transition, but I did not hear it. It did not come.
Acting as a drill sergeant, I sent Fay back and forth from the door to the baby warmer. She did laps around the room, and I suggested she try some nipple stimulation. She ate a little bit. She drank water. We tried effleurage, in which Simon gently rubbed Fay's belly to bring on contractions. But contractions were still slow, and there was still no pressure at the top.
 |
| How to do effleurage in labor |
An hour later, at 2:30pm, we learned that we had made no progress.
At 4, Katie returned with a vengeance. She showed us the graphs again (and again, I distracted Fay from seeing them). She talked about progress and how we were not making any. And she gave Fay two options: an epidural, which would help her relax, and the relaxation which may bring on contractions again, or Pitocin, which would bring on contractions.
"But if I choose the epidural," said Fay, leaning on the bed, "wouldn't contractions slow down, and then I will need Pitocin anyway?"
"Maybe," said Katie. "Maybe you just need to relax, that's all. But it's possible that we will need Pitocin too." She looked her up and down. "See, we've been talking about this for about five minutes. You should have had two contractions by now."
Fay stood up and started walking, rubbing her belly in small circles. No contraction came.
"Look," Katie proceeded once she was sufficiently convinced that she would not sell the epidural. "We can start you on the lowest dose of Pit. We can turn it off once contractions have started again." Again she brought up a graph. "See, this is a woman that's already delivered. This is her contraction pattern at 7cm, which is where you are."
"Are these Pitocin contractions?" I asked, recognizing the shape -- which looks markedly different than that of a natural contraction.
Katie checked. "Yes, it is." But she was not discouraged. "But it doesn't matter," she pleaded. "See, you should be having another contraction, right now. I want you to have this baby vaginally. I want to help you. You have to let me help you. What have you been trying?"
"We've been walking around," I said. "Nipple stimulation. Effleurage."
"Why did you stop the nipple stim?" Katie asked Fay. Fay looked away.
"Walking around seemed to work too," said Simon.
"But it isn't working!" cried Katie. "It is not working. Fine. What about Fentanyl. It's a narcotic and it may help you relax a little. We just have to get you past this hump." Katie felt Fay's belly during a contraction. "See, it's not very strong, either." She sighed. "Sometimes a mom needs some help to get over the hump. Sometimes she just needs to relax, or a break from the pain. Sometimes she needs Pitocin to make contractions stronger. Sometimes the baby won't come at all, and she needs a c-section."
I winced. Katie had made offhand c-section comments before, but I was too busy distracting Fay from the conversation to wince properly. This time I winced. Alluding to surgical birth to a laboring woman is akin to alluding to filet mignon to a calf. For some women, it is a blow to her faith in herself.
Passenger, passage, and power
Coupling contractions can be a symptom of an occupit posterior (OP) position of the baby, or sunny-side up. Other symptoms of an OP baby are back labor. Which is why we had been trying so hard to get Fay's baby to turn. Most babies, something like 70-90%, that start out OP will eventually turn in labor. We had hope.
Katie suggested, "We have one more thing we could try before Pit." She left and came back with a package, a long tube inside. "This is an intra-uterine pressure catheter. It goes in next to baby's head in the amniotic fluid, and when you have a contraction, we measure the strength of the contraction in milligrams of mercury."
 |
| Intra-uterine pressure catheter (IUPC) |
She paused to make sure we followed. We did.
"Normal labor has three components. The passenger, the passage, and the power. We don't know much about the passenger. We don't know how big she is. Do we?"
"No, we don't," said Fay.
Katie continued: "Maybe she's malpresented. Maybe she's facing funny down the birth canal." She pressed her glasses up her nose, letting her blonde bangs fall into her face. "We don't know much about the passage yet. About the birth canal. Maybe you aren't big enough to let the baby pass. I don't know. So we can try to find the power."
She held up the IUPC. "We use this to measure the strength of the contractions. We can use this measurement over time, over the space of several minutes and several contractions, to get an objective number called a Montevideo unit, an MVU. If we have enough MVUs, we know that contractions are strong enough and that labor should be progressing -- and if it isn't, then one of the other things, the passenger or the passage, is stopping it. But if we do not have enough MVUs, we can try putting you on Pit, to make the power stronger." She paused. "This is real, empirical evidence."
 |
| Position of intra-uterine pressure catheter (IUPC). |
Now, hang on a second. I am a newer doula, so I had not heard about the "three Ps of labor." But I did know about the fourth P: Patience. Sometimes it just takes time. We had been patient, resting and walking and eating, at 7cm for three hours. The clock was ticking since Fay's water had been broken for 16 hours.
Fay and Simon talked about it. "Basically, our options are Pitocin, or IUPC and Pitocin," Simon concluded. "Let's just do the Pitocin."
"Finally," Katie said. "You are letting me help you. I feel like I am doing something."
Fay, Simon, and Katie agreed on a dose of Fentanyl and the lowest dose of Pitocin, just to get past the hump. Fay would still be allowed to labor upright, but intermittent monitoring was no longer an option. Antibiotics were started because of the ruptured membranes.
Pitocin contractions were different. They hurt more, and lasted longer, but they were not closer together. An hour later, the dose of Pitocin was increased, and, the contractions still not any closer (though more painful), Fay asked for an epidural.
Katie started an IV, and we waited for the doctor, all the while taking one contraction at a time.
The doctor, an older man with white hair who seemed to be old enough to retire by now, came with his epidural cart and asked Fay to bend forward, achieving "the worst posture you could imagine." He cleaned Fay's back, numbed it, and inserted the needle.
"Hmm," he said. "Can you lean forward more? I seem to have missed the epidural space."
I gave her a pillow to hug in her lap.
He stuck her again. "Hmm," he said, withdrawing the needle. "I hit the bone again," he said. Simon's eyebrows raised, but he was quiet.
The needle went in again. "Missed," he mumbled, perplexed.
"Look," he grumbled, having missed again, "just curl your back into a C."
Eventually, it made it in, and the pain from the contractions dispersed. They were still coupling, so Katie increased the Pitocin. They were still coupling.
Before she left, knowing her shift was soon over and we would not be delivering on her watch (as was secretly our plan), I asked her to transfer us to another nurse that would be patient and kind with us and try to get us back on the path of natural birth. She said she would, but no promises. Then, she added:
"The IUPC is your last resort, so keep it in mind." She glanced at the door. It was closed. Katie lowered her voice. "If your doctor comes in and tells you she wants to do a c-section, you ask her to try the IUPC. Try to see if the power is sufficient, if the MVUs are enough to get the cervix opened. Do you understand?" We nodded. "Good," she said, taking her leave.
A new hope
At 8pm, the sun was starting to descend outside the closed mini-blinds. Fay drifted back to sleep, covered by a sheet and a blanket. Simon, who still refused to sleep, and I were sitting under the window, talking about how good it was that Fay was getting rest.
A new nurse came in, introducing herself as Megan. She was stouter than Katie, brown-haired, and was full of fresh energy.
"Hi, Megan," I said, and, meaning how Fay has been coping with labor, "we've been doing great!"
"Not really," she said, turning away from the computer with just her shoulders. "You haven't made progress since 1pm. Your labor has stalled." She turned back to the computer and read the notes.
I looked at Simon and gestured that I clearly said the wrong thing.
Megan woke Fay to check her. "Eight or 9cm," she said.
"There, that's progress," I suggested.
At this point, Simon went to take a break, and brought back food for me. When he returned an hour later, Dr. Kim came, and Megan checked Fay's cervix in Dr. Kim's presence.
"She's a nine," said Megan. Dr. Kim looked concerned, turning up the Pit again, and promised to check back in an hour.
The 11th hour
It was 10pm, 23 hours after Fay's water broke, when Megan and Dr. Kim returned.
"The contractions have spaced out, and they are moderate," Megan explained. "Maybe the uterus is tired. That can happen. The uterus is a muscle, and muscles get tired."
Fay, Simon, and I looked at each other. I nodded: it's true. They do.
Dr. Kim pulled on a glove. "Still nine," she said, withdrawing from under Fay's sheet.
"Do you know what this is?" Dr. Kim asked, holding up the IUPC that Katie described earlier. We nodded. "I'm going to use this to measure the strength of your contractions. We will see what is happening."
Meanwhile, Megan took Fay's temperature and found it to be elevated. Megan pulled the blanket away from Fay. "You can't use this anymore," she said, and set the temperature in the room to a cool 68F.
Alone in the room with Fay and Simon, they turned to me.
"We need to talk about the possibility of a c-section," Fay said, and Simon leaned in close to me. It was like a team meeting at a football game. "What if they come in and offer me a c-section? I think I should take it."
I did not reply, but listened.
"It has been a long time and I don't know if this will happen naturally. We have been trying everything."
"We can try a few more things. Let's see what happens," I said. Fay and Simon nodded, and we all relaxed into the possibility.
Complete
At midnight, Fay was complete. Megan checked with Fay's pushes: "Pushing doesn't seem to move the baby," she said. "We'll let you labor down, meaning the baby will come down on her own." We pushed in many different positions, despite being connected to so many machines: squatting, side-lying, legs up, legs down, back, all fours. As Megan's hand disappeared under the sheet, she looked at me and shook her head sadly.
I was drinking a lot of soda by this point. It was past midnight and I was tired, walking down the long hallway to the staff kitchen for more caffeine. I ran into Megan in the hall. She whispered to me:
"I don't know," she said, "if this baby will be coming vaginally. Her pelvis is so small. I can barely get my fingers inside. I can feel the head and it's just sitting there," she made a motion with her fingers, "just sitting there on the pelvic bone." She looked at me with sad eyes. "Talk to them," she said, "get them ready for a conversation about a c-section." I nodded.
Going back to the room, I did not talk to them about the possibility of a c-section, because we were already on the same page.
Five minutes later, I saw Megan rushing in from down the hall. The machine was beeping with the baby's decelerating heart rate. She urged Fay not to push, and we went back to the breathing we had been doing earlier. Megan turned off the Pitocin.
"Talk to us," I said to Megan after the contraction had passed.
"Talk to us," I said to Megan after the contraction had passed.
She looked at Fay, then at Simon. "The baby is not moving down," she said. "I slide my finger up by the baby's cheek," she said, showing with her fingers, "and I expect the baby to slide against my finger with each contraction. And the baby just isn't moving down."
We sighed.
"I don't know if this baby wants to come vaginally. I think this may have to be a surgical birth. You have tried everything you could: I have never seen a mom spend so much time upright and out of bed. You really have tried everything, and I have tried everything that I could think of as well."
When she left the room, I talked Fay and Simon through the procedure. I tried to explain what Fay would feel, when she could see the baby, and where Simon would be. Where I would be. This hospital had a strict one-person-per-patient policy, so I could not come into the OR as I had previously done in other births.
"Will you visit us tomorrow?" Fay asked.
"I will visit you in the recovery room," I said, smiling. "I will see you as soon as I can. I will help you breastfeed your baby." Simon was quiet, pulling on his hospital robe and paper shower cap. We were all so exhausted. Simon was worried both about his baby, who was showing signs of stress in utero, and about his wife, who had been in labor for 29 hours.
I knew Fay and I had done everything we could think of to turn and move the baby. Simon was an amazing birth partner, pressing on Fay's back with almost every contraction for over a day. Bags under our eyes and our feet heavy with the weight of relief, we collected our items, for we would not be returning to the delivery room.
As we rolled away, Megan exclaimed, "It's a party! A birthday party!"
Postpartum
That's the end of the story, at least, the story as I know it. Baby Violet was born beautifully just after 2am, and though her head came out screaming before the rest of her body was even born, and though she had spent quite some time in a meconium-rich environment (for she had pooped quite some time ago), she had not breathed any of it in. She had a ridge crosswise on her head, rather than lengthwise where the plates of her head typically fold over each other. She was trying to get out, but really was stuck.
Latching on to the breast in record time, Violet was perhaps the most relieved of all to be born.
Foreshadowing?
Was it premonition, or did she just know, when Dr. Kim had pressed her point, with a sly smile: "Just keep your mind open for a c-section?" Had she known that a surgical birth was necessary, she still had the kindness (to Violet and Fay) to let labor go on naturally for as long as she did.
Megan, the second nurse, on whose shift Violet was born, approached the topic of a c-section with such kindness and sensitivity to the laboring mom that I was swept off my feet. I appreciated her acknowledgement of our hard work, of the hours we poured into the labor, and the multitude of things we tried. I liked how she looked Fay in the eyes when she said these things with a soft voice and maternal touch on her thigh.
And, for the doulas and birth partners that read this blog: What would you have done?
Subscribe to:
Posts (Atom)
