Depending on who’s reading this, I know this will land in different ways, and that is 1000% the reason I’m writing it; so, there’s your disclaimer, no offense intended… let’s dive down this rabbit hole 🙃… Again, these are thoughts NOT affiliated with any particular institution and of my own free mind.

For anyone that’s not intricately involved in the delicate dynamic of the mother-baby dyad (a term that google AI will tell you is defined as: “a term used to describe the close biological, social, and psychological relationship between a mother and her infant“), it might seem obvious that the care and relationship between a mother and her baby are very closely intertwined. For months, there exists a literal symbiotic relationship that extends beyond the delivery of a baby to the newborn/neonatal time period and, as most people know too well, realistically for years, and usually, decades. However, one thing I’ve come to notice over the years is the focus Medicine inevitably places on trying to care for one part of this intimate connection as if there is the ability to have mutual exclusion. For maternal or newborn providers alike, due to multifactorial reasons that are not always within one’s control or mental workload capacity, the concept of a “dyad” is increasingly absent the more specialized we get, the more focused we become, and the less we truly interact with the relationship on a personal level day to day. It’s really no one’s fault, and it’s frankly inevitable to avoid becoming siloed if you stay in the nest or in the tower for too long, but maintaining a vision of the “forest beyond the trees” may be paramount for both parties in providing next-level care. Ultimately, it is of my own opinion that understanding the concept of The Dyad doesn’t only elevate the potential of the care I can provide, but is crucial for my basic understanding of The Why of my job, in the first place.

I will never forget as a Pediatric Resident trainee getting a phone call from the OBGYN Resident trainee to notify us of a mother in labor with a concerning fetal heart tracing: “Just an FYI, the strip is now a Category II.” I had absolutely no idea what they meant, “What kind of EKG is that?!” I would think to myself… I had of course rotated through my OBGYN rotation as a medical student a few years prior, but couldn’t remember implications of what this meant and would brush it off as a shoulder shrug and response of, “Well, just let us know if you think you need me at the delivery.” Then, in 2020, I graduated Residency, popped out into the world as a theoretically full-fledged Pediatrician and entered the world of Locum Tenens. Suddenly, I left the hierarchy of urban practice and academia finding myself in small hospitals where the Pediatrician spent more time in the Labor and Delivery Unit then any other part of the hospital. Suddenly, I found myself becoming close friends with OBGYNs and nurses that predominantly took care of mothers in the antepartum/prenatal period. Suddenly, I found myself, a Pediatrician, beginning to understand what Pregnancy was about, what Labor was about, and how much the babies I took care of didn’t exist in a vacuum without their mothers. In 2021, I even delivered a baby myself, by accident, but I did it, and it was damn awesome. I began to appreciate and understand the world from a completely different lens, but began to see how much that lens was necessary to fully see inside my own sphere.

Babies.

The concept to me of a Children’s Hospital having a section of it dedicated to delivering complicated babies is fascinating. For many people, not working in the medical system, it might seem sensible. If a baby is known in the “preborn” state, as I like to call it, to have some significant anomalies (or as we say, “differences”), wouldn’t you want them to be as close as possible to the highest level of care they would need to deal with for whatever they may face after birth? Thus creates the concept of a Fetal Health Delivery Center – a place centered around the baby. After the baby is born, all of the state-of-the-art technology and expertise you could ask for is at your fingertips immediately to intervene in whatever life-saving treatments you could attempt to offer. I have been present for such deliveries multiple times in my life… One such delivery was an ‘attempted’ ex utero intrapartum treatment (a.k.a. EXIT) procedure whereby a baby with a prenatally known large mass squishing the airway is delivered still attached to the mother via a cesarean section, and an Ear Nose and Throat specialist inserts a specialized breathing tube into the airway prior to the baby being fully delivered hoping to ensure the best possible establishment of breathing for when the umbilical cord is disconnected. Now, our case was as complicated as possible and that baby required an escalation to the most significant technology known to man called ECMO, or heart-lung bypass, which is for another day, but all-in-all, there was a grand total of ~45 people needed to attempt this delivery. Fourty-Five. The part that I draw your attention to? Of all of those people, only maybe 5 or 6 people in the entire room, knew the mother’s medical history. Only that group of people knew how worried the mother was about her OWN health, that she was of an advanced maternal age and that she had had prior issues with emergent bleeding from her last delivery… The rest of the room was fixated on the baby.

Mothers.

I wanted to be an OBGYN for a bit, surprise! As a medical student, I will never forget the first c-section I went to. It was quiet in the OR, the surgeon was in a zen moment, and then… BAM! The best magic trick in the world, a brand new baby popped out of nowhere and screeched at the top of it’s lungs, breaking the silence immediately – something, I’ve since learned, unfortunately doesn’t happen all of the time. Interestingly, for a field ultimately dedicated to the focus of ensuring the healthy delivery of a baby and of course the care of a healthy mother throughout and after said delivery, there is little emphasis and thought on the baby after the baby is born. I often liken the experience to a football game to my non-medical friends. Many people over the years have asked me how many babies I have delivered, and for the longest time, until i accidentally DID deliver one as i said above, I would have to laboriously explain that that was NOT what I did: The OBGYN was the quarterback, and I was simply the receiver. But, unlike most football games, once the OBGYN throws me the baby, they turn back to the mother, as they should, and the baby disappears into my care as if they weren’t part of the game in the first place. An exaggeration possibly, there have been so many times that I have realized after a baby has been born, that an OBGYN is completely unaware of the care the baby goes through after they are born, unless they themselves of course have undergone those experiences with their own child. I will never forget, as a Neonatology Fellow actually, my time spent as a shadow with the high risk maternal fetal medicine OBGYN service, after being a Locum Tenens pediatrician out in the world in the dual experience of a labor and delivery unit with OBGYNs that DID work closely with me and ask for follow-up every day on the babies they birthed. I will never forget showing up to morning rounds at 7AM and hearing the team run through the list for the day trying to plan discharges of postpartum mothers when the OBYGN attending asked the rotating medical students, “Wait, why is the baby in the NICU?” And the medical student responded, “Oh, i don’t know.” They all shrugged, and moved on, “Eh, ok I guess find out later if they’re staying for a while or something and whether or not we can send mom home today.” Striking, that it didn’t matter or, the nonchalance of disinterest pervaded…

I don’t believe ignorance on either end of the spectrum is on purpose nor that it is to blame, and i’m 1000% not saying that every provider isn’t interested in the other side of the table. I have worked with phenomenal people and come across at least 100 physicians at this point in my life. But, I don’t believe that the time of our jobs allows for more mental capacity as I stated earlier and frankly, for anyone that has been as involved that we can do much on a day-to-day basis to change things when we are constantly drowning with minutia that we can barely keep up with within our own specialties and within our own needs. However, I find it constantly understated the importance of understanding the dyad and will fight until the end of the day and until the end of my career to emphasize that this is a worthwhile focus. It is critically important that I understand my counterparts, that I understand the jobs of the OBGYNs, and that I understand the intricacies of what they do to ensure adequate care of the mothers that will someday birth the children I will take care of. When the babies I care for grow up, they will go home with these mothers, and understanding their health, their social determinants and the multifactorial positions that lead to the places that their babies are in, is a fundamental part involved in holistic care of the family unit. For an OBGYN, understanding the care a baby will need after a baby is born, will help to guide a mother through pregnancy and prepare them mentally and emotionally for what will come, will help for guidance towards postpartum care, towards recurrence, towards compliance, trust and longevity of the provider-patient relationship.

In a world where things are becoming infinitely more specialized and we have slowly and inevitably moved away from true ‘family medicine’ in many parts of the world and parts of society, due to economic/infrastructural reasons, although it does still strongly exist and it’s great, often due to medical complexity and sometimes unpreventable comorbidities with technological advancement, the feeling of the dyad is fading. This relationship and understanding of it’s importance is more important than most realize. I will continue to watch the fetal heart strips late into the night, I will continue to discuss maternal care with my OBGYNs as much as I can and learn to understand things that are none of my damn business. I will continue to give updates on how babies are doing and I will do all that I can to re-inforce that the dyad is greater than the individual mother or baby alone. I will continue to work on strengthening the relationships I have between specialties because the lives of my patient and the patient of my colleagues’ are intertwined. Nothing exists in a vacuum. Nothing exists without the other. It is only a fool that believes we exist individually without connection.

An OBGYN cares for a mother, a Pediatrician cares for a baby; but, together we care for the future.

Image: A funny elephant dyad I met in Thailand almost 10 years ago.