Journal of I've Never Heard of It

One of the exciting things that begins to happen during the postdoc, if you're lucky, is that you yourself will be asked to serve as a reviewer for some journals. This is great news because it means your name is, however tentatively, respected. Furthermore, you have the opportunity to demonstrate yourself a thoughtful scientist and referee to some editors. And finally, you learn a lot about the review process by being on the other side.

So it was with excitement that I opened up an email today asking me to review a manuscript. Here's the tricky thing, though: I've never read a single article in the journal that sent me this request. This is a not uncommon scenario for a junior person doing reviews--you're low on the food chain, and the journal that asks your opinion may be correspondingly low. On the other hand, it may be that this journal is respected but that it publishes very few papers from my subfield, which is why I've never read anything in it.

I asked a mentor how I should approach the review, given that I don't have any idea how to grade the "novelty and significance" of a manuscript if I don't know the reputation of the journal. His advice was interesting: "You should always apply the same standard of accuracy to all manuscripts you review, regardless of whether they are for Nature or Journal of I've Never Heard of It. Let the editor worry about whether the paper is novel or exciting enough. Your job is to make sure that the authors have done the proper controls to come to the conclusion they state in the abstract." So, after I have a chance to look over the table of contents for the past few issues of this journal, this is what I will do.

Well, that and looking up some however-irrelevant-and-useless impact factors.

To our dearest beloved SfN

Abstracts for the unmissable* Society for Neuroscience annual meeting are due today.

So we're getting excited for the upcoming meeting, right? Should we get our plane tickets? Reserve a room? Oh wait, the meeting starts November 13th.

Today is May 13th. I did a quick count, using toes for the extra two months, and this means that the meeting is six months away.

Because the number of attendees at SfN is in the tens of thousands, I thought that the delay between abstract submission and meeting actually occurring was somewhat forgivable back in the days of 5-and-a-quarter-inch floppy drives. Back when 64 MB was the size of a fancy new hard drive. Someone's got to program all those abstracts into thematically organized sessions, and make sure that the Big Shots in my subfield are scheduled to give their symposium talks at the exact same time as my poster so that I can never ever go to a symposium talk I actually care about. That doesn't just happen by itself, people.

But now? When Google can predict, before I finish typing, the rest of the last name of the ex-boyfriend I'm thinking about? When we can crowd-source an encyclopedia with useful entries on "Factors affecting the crack spread"? [I clicked on the "random" button, I swear.] Does it honest to God still take six months to sort 20,000 abstracts with preselected keywords into one of 8 themes and some number of subthemes/sessions?

Do they have a small staff of medieval scribes rewriting everything in calligraphy, or what?

---
* Because it's the only place you can see every single neuroscientist, living or dead, you have ever known. As a meeting, it makes you want to drink hemlock by Day Two.

Dear Science*

You write a nice magazine. Sure, it's no Nature, but we still read it.

However, each time I download a pdf of your work, it comes with a totally useless front page. This cover page says something stupid about the citation and copyrights of the work (I don't know, I never read it) and then lists other articles I might be interested in**.

News flash, I'M NOT. I'm interested in reading THE ARTICLE I DOWNLOADED, thanks anyhow. And now when I go to print, I have to type in the "pages" field "2-5" or whatever, so that I don't have this useless piece of junk in front of everything else.

Maybe no one ever explained this to you, but pdfs are designed for printing. Yes, they're also nice to collate in your Papers or whatever, but the entire reason Acrobat was invented was so that one could transmit complex pieces without messing up the layout....for ease of printing at the other end. Yet here you have taken this beautiful, simple idea and inexplicably screwed it up by taping on a cover page, like you're a goddamn seventh-grader turning in a class report. Why, why?

---
* You too, J Neurophys
** J Neurophys, hilariously/irritatingly, lists Medline search terms on the front page. I recently noticed a pdf where the front page listed "HIV--AIDS" as a relevant topic. The authors were talking about lobule HIV (H-IV) in the cerebellum.

The good news is, we're not alone

A recent article in Newsweek tackles the issue of gender discrimination in journalism--even at Newsweek itself (though perhaps a bit soft-pedaled, that part). The authors tell an all-too-familiar storyline:

1) Sexism was really, really awful when women first started making major inroads in the workplace (the women at Newsweek were called "dollies;" they were told outright that women didn't write).
2) Now things are much much better!
3) Except.

Except men wrote 88% of the cover stories for Newsweek last year ("and two of those used the headline 'The Thinking Man.'"). Except women still earn less than men. Except women are still underrepresented on the masthead. Except, except, except...the equality isn't so very equal.

What I find interesting is that the type of metrics and stories that women tell about discrimination at today's magazines are so similar to what I hear in the sciences. Replace "cover stories" with "speaking invitations at conferences." Replace "underrepresented on the masthead" with "underrepresented on the faculty." Replace "earn less" with, uhh, "earn less."

In the biological sciences, women who join with confidence in graduate school are still disappearing, particularly at the postdoc-to-professor transition. Men still represent ~80% of the faculty.

(My department recently held a faculty job search. When I complained that an overwhelming percentage of the invited candidates were male, one faculty member told me that the department had recently hired several women, so I shouldn't worry. Well phew--thank goodness we've filled that quota! Now we don't have to concern ourselves with inviting the ladies for a while.)

The article made me think that efforts to address women's stymied progress in the sciences cannot be confined to financial solutions, like providing better campus childcare, but need to confront the systemic cultural attack on women.

Though, campus childcare would be a nice start.

Power: a wee quiz

Jonah Lehrer blogged about a finding also reported in The Economist: that powerful people tend to exhibit less empathy for others than the powerless do.

The UC Berkeley psychologist Dacher Keltner has found that, in many social situations, people with power act just like patients with severe brain damage. "The experience of power might be thought of as having someone open up your skull and take out that part of your brain so critical to empathy and socially-appropriate behavior," he writes. "You become very impulsive and insensitive, which is a bad combination."

Let us consider how these traits of the powerful may translate to the scientific community. Check all that apply to your PI:

Lack of empathy for others/Impulsivity indicators
___ Lets manuscripts languish untouched for months
___ ...or years
___ Brings Famous Visiting PI around the lab, showing her the equipment but failing to introduce any of the trainees
___ Or introduces her to other trainees, but not to you
___ Doesn't send in recommendation letters on time
___ Doesn't respond to emails asking whether recommendation letters have been submitted
___ Doesn't answer emails regarding conference abstracts, despite urgent deadline
___ Shows up 10 minutes late for lab meeting
___ Shows up 30+ minutes late for lab meeting
___ Cancels lab meeting by virtue of being out of town, without telling anyone about plans
___ Suggests you help write a review....two days before it's due
___ Then turns it in late anyhow, after letting it sit on his desk for two weeks
___ Expects you to interpret cryptic cuneiform handwritten comments on drafts
___ "Oh, yeah, everyone, this is our new postdoc. I forgot he was coming."

Of course, I'm sure that PIs can make their own impulsivity/lack of empathy checklist for deans.

And let's not get started on the Glamour editors...

Social parenting 101

Small and I were at the playground recently when a woman who was there with her daughter and granddaughter struck up conversation, as playground adults are wont to do.

She assumed Small was a girl, which many people do (on account of his ridiculous cuteness, I think). Normally I just respond, "Oh, actually he's a boy" or similar, but I wasn't in that chatty a mood and just let it go. Besides, who cares?

When Small and I were leaving the playground, the woman smiled and waved. "Bye," she called. "What's your daughter's name?"

I panicked. Correcting her this late in the game would be an admission that I had let her prattle on about how cute my "little girl" was without having the decency to let her know it was a little boy. But the other option was....

"Smallette," I called back.

"Bye, Smallette!" she called out. "Bye!"

I now live in dread of seeing her at the playground again.

Dear Mrs. Google

You know how I can google the whole everlivin' web, or just, say, one domain name?

I want to be able to google with the search restricted to all sites in my search history.

A week or two ago I read a post, or something like that, on PI handwriting. But where? If I could just aim my google-box to "Sites I've frequented lately" we would be all set. Hop to it.

Yours,
Dr. Jekyll

ps) Found it at doubledoc's! But jeez, I had to work. What's the fun in that?

The least unique

My department is in the middle of a faculty search right now, with the result that we’ve had several job candidates deliver talks in the last couple of months. The talks have been uniformly clear, well-delivered, and polished. Based on the research and future directions, most of the candidates seem to be well-positioned to start up research programs and land a couple of grants. This is all very impressive.

But in one respect I have found the talks slightly disappointing. By and large, the candidates have not described future directions that were surprising. By that I mean that no one has carved out a scientific niche for him or herself that seems distinct from the territory occupied by other people in the field.

For example, one speaker alluded to papers that had come out from competing groups around the same time as his most recent paper. These competing groups had been studying marginally different types of cells, so nobody was technically scooped, but it struck me that if this candidate were to have a piano land on his head tomorrow, there would still be plenty of people pursuing the types of questions that he plans to pursue.

I voiced this concern to some lab colleagues who told me that I was being too critical, and that nobody occupies unique scientific space and therefore this was an impossible standard. And of course a PI can compete with others in the field and still excel--and it’s even a mark of the importance of the field, in some respects, that there's so much interest in it.

Yet when I think about faculty whose work I consider singularly exciting, many of them have either developed techniques that let them answer questions no one else in their field has been able to attack, or they have devised a research program that addresses questions--frequently at the intersection of two separate fields--that nobody else is pursuing.

There’s still time for these junior candidates to grow into those shoes, but I’m left wondering if their feet are going to get any larger.

Bespoke labs

A graduate student complained to me about his advisor. "He treats me and another graduate student totally differently! With her he's hands off, but with me he micromanages!"

A faculty member commented to me, "One of the hardest things I had to learn as a PI was how to recognize that everyone in my lab needs different things from me because of their own strengths and weaknesses, so I need to tailor my style to their needs."

Who's right?

I'm sympathetic to the faculty member, because it's quite true that different trainees have differing strengths. Some are good at experiments but bad at writing; others are good at thinking about science but bad at benchwork; others can't give a presentation worth a damn, regardless how good their data are. So the various lab members really do need different kinds of guidance from their mentor.

However, what I think I hear in the graduate student's complaint is not, in fact, that he is angry about differential treatment. He is angry that he perceives the differential treatment to reveal something about his advisor's opinion: namely, that the advisor respects the other graduate student more (leading to hands-off mentorship), and doesn't trust the male graduate student enough to let him conduct his own experiments without significant input from the PI.

(Of course, it's possible that the female grad student in this example is peeved that the male grad student gets so much attention, while she is neglected. Grass is always greener etc.)

The point is, not only should the PI ideally tailor his or her mentoring strategies to meet the different needs of the trainees, it must be clear that this tailoring is not favoritism, which is the tailoring to the benefit of one trainee over the others.

This is one of the many reasons that management looks hard to me.

They are carbon-based

Our mouse colony has expanded so rapidly that we've hit a space crunch despite getting one increase from the space committee already. Each person in lab "owns" a certain set of cages, and so we sat down to come up with a system to keep cage usage under certain limits.

The result? We each have a fixed maximum number of cages for our mice, but we can loan those spaces to others if we're not using them.

What do we call this system? Cap and trade.

Best practices

Dr Hyde's PI attended grad school ~40 years ago. He was taught a list of ten or so "fundamental concepts" in neuroscience. It ran something like:

1. Dale's Law--each neuron releases only one type of neurotransmitter.
2. No new neurons are born in the adult brain.
3. Inputs to the neuron occur only on the dendrites and soma.
4. Outputs from the neuron occur only from axonal boutons.
5. Action potentials are always initiated in the soma or axon.
6. Synapses are unidirectional; there is no retrograde signaling.
7. The brain is immune privileged.

Those of you who are neuroscientists are laughing, because none of these things are true. They were all reasonable approximations to the truth, based on the best available evidence at the time--but they've all been convincingly overturned.

With this context, how to think about the move towards more evidence-based medicine? The Obama administration is making an effort to decide upon "best practices" in medicine as evidenced by research, and then to nudge doctors towards using those "best practices" by a series of governmental carrots or sticks.

Dr. Jerome Groopman discusses the potential pitfalls to this idea in this month's New York Review of Books. Not only is the literature often (usually?) wrong, it is also inadequate. Clinical studies are frequently restricted to patients with only one condition, or to selected subsets of patients (most glaringly, men); whereas in reality, many people have multiple ailments at a given time, and women, or poor people, or underrepresented minorities, have an irritating propensity to respond differently to treatments than do the more homogeneous clinical populations.

I'm not a doctor, but as a researcher I know how much literature is going to be disproven a few years down the road. Furthermore, basic science research is usually far superior in quality to clinical trials, in large part due to the laboratory setting where one can actually hold all variables constant except for the one under study--far from true in a clinical setting.

But at the same time, why do we even bother trying to figure out the best way to treat a disease if we're not going to use that information? I support Groopman's plea that doctors should have significant leniency to pursue the course of treatment that seems best to them, even if it deviates from "best practices" as currently evaluated.

But I'll go one step further (and this is a naive suggestion from someone who knows next to nothing about medicine, really): the number and type of clinical trials should be vastly expanded, by virtue of keeping tabs on the success of procedures at clinics and hospitals all over the country. We already do this with some types of procedures (close to my heart is sart.org, which tracks IVF success at different locations), but we aren't going far enough. We should be tagging all these outcomes with detailed patient information, ideally using a unique identifier for each patient that allows us to track patients wherever they go.

Then, put the army of supernumerary biomedical Ph.D.s to work. They can easily learn how to sift through these massive datasets to identify what treatments work for 35-year-old white men with elevated blood pressure but not for 60-year-old Asian women with fallen arches.

Effectively, clinical trials designed by one or a few doctors, occurring in a small number of patients, would be a thing of the past. The dreadful meta-analysis of twelve crappy published studies, which is what we currently rely on to devise most "best practices," would vanish.

There are probably a lot of reasons, including patient privacy, why this can't ever happen. But it would completely transform biomedical research. Basic scientists mostly look down their noses, and rightfully so, at the quality of clinical trials--but this approach would give clinical trials a sample size far beyond even the most ambitious basic science research. Rigorous researchers might actually want to be involved with medical science.

Especially now that we've come up with a whole new set of fundamental principles in neuroscience, and this time they're definitely right.

Open secret?

Several journals have Previews, or News and Views, or whatever they may choose to call an introductory short piece about an article in that journal. This introductory piece is typically written by another scientist in the field.

From my very limited dataset, the scientist writing the Preview was also a reviewer on the paper (presumably, one of the positive ones...) Is this generally true? If I see a Preview, can I usually assume that the author was a reviewer? Or do journals regularly contact still another scientist to read the pre-print and write about it?

Ring, ring

Except it's never "Ring, ring" these days, it's the theme from Super Mario Bros coupled with vibrate...

What do you as a speaker do when someone's cell phone goes off during a seminar? (The question also applies to other noisy distractions, like hallway noise or a jet overhead, but the cell phone is ever the standard-bearer of unwonted noise.)

For very loud interruptions, I favor the sip of water approach, which makes the speaker look unfazed and vaguely productive. But most of these noises are loud enough to distract but not loud enough to drown out the speaker.

In the early days of cell phones, it was a novelty and the speaker would often make a joke about it. But that diverts attention and gets old fast.

Some speakers will simply pause so as not to compete with the noise. Advantage: the audience's attention is undivided when you resume. Disadvantage: long pause in your talk, and it feels obscurely like the cell phone owner won.

Others will continue talking right over the sound, perhaps at higher volume to compensate. Advantage: no break in your stride, and the speaker sounds unflappable. Disadvantage: audience may not catch what the speaker says or are too distracted to parse it.

I think the best solution, unless the sound is very loud, is to continue talking over the interruption, but then to reiterate the point once the noise has ceased, ideally with a smooth, "In other words..." or "To recap..." or "That is,..."

Less good transitions include, "To repeat without the Lone Ranger soundtrack" or "As you would have heard had it not been for the jerk in the third row..."

Open Lab 2009

I am famous, for having blogged about my bodily fluids. Who would have thought the internet was the sort of place where people would like that? I am just shocked.

Go check out the other Open Lab winners for a sort of year-end carnival.

Sleeping on it

I like to think about science in the evening, after dinner. It's a good time for me to think structurally about upcoming experiments: what order to carry them out; reagents to order; protocol details; analytical aspects. If I'm on a roll, I'll write down a list of everything in my head and tuck it in my bag for the next day.

For me, this clears my mind--all the ideas buzzing around get written down so I don't need to carry them in my brain, and I can go to bed clear-headed. For Dr Hyde, though, evening is the worst possible time to think about experiments. He starts ruminating and brain-storming and fretting, and insomnia is the inevitable result. Writing things down just makes him think more about them.

So we live in a strange evening split, where I am often thinking about my upcoming week but I cannot mention any of it to Dr Hyde, who will grab his head and cry "No, no science now!"

Instead he thinks on the bus in the morning, which I can't do at all--too groggy and easily distracted. So if we ride the bus together, he wants to tell me his latest, and I only nod and smile because I really can't follow logic in the early morning.

It's good we eat dinner together or we might never find out what the other is up to.

Managers ?= cleaners

Our lab is looking to hire a new lab manager, and it turns out that there are differing opinions on what a lab manager's job includes. Some lab members say that it is a lab manager's job to keep the lab clean, including (but not limited to) washing glassware that has been neglected in the sink, wiping down the lunch/conference table daily, tidying the tool bench, and cleaning shared lab benches. Others say that lab members should be responsible for these cleaning duties, and the highest priority in hiring should be administrative excellence.

There's a third way to look at it, which is that if your lab manager is young and inexperienced, cleaning comes with the turf; but if you have an experienced manager, best not to waste his/her valuable time on menial tasks. (Also perhaps an older, wiser lab manager knows how to get trainees to clean up after themselves?)

What say you? There's a poll on the right...

Defending the gates of Journal X

I recently served as a reviewer for a journal. This was the first time I myself had been asked to review, so I was both excited and a bit nervous. Would I have useful things to say? Would it be difficult to assess the paper's suitability for Journal X? After all, it's one thing to aid your advisor with a review, but it's another to be the only person evaluating the work.

The manuscript seemed to me to be a clear reject. And here was the funny thing: I had thought that in the event of a reject, I would feel righteous. Like I was defending the Journal from shoddiness. Like I was a bulwark against the frustrated feeling you have when you read a bad paper in a journal you respect.

Instead, I mostly felt sad for the authors, even though I don't know them. I kept twisting their data around in my head, trying to find a way they could revise the manuscript with just one or two experiments so that it would be publication-worthy. "What if....? Hm, no, that's still not going to cut it. Or perhaps...? No, that would turn it into a totally different manuscript." In place of righteousness, I felt regret that I could not rescue this effort from the reject pile.

I doubt any of this regret came through in my review, though.

-----

ps. Ten bucks says CPP tells me to sack up and quit having emotional responses to fuckwad manuscripts, amirite?

Birth part 2: the bit with the hollering

Into the birth center, where the midwife checks me out. Bad news. Small has a fetal arrhythmia--a hiccup in his heartbeat.

We'd known this was a possibility. He'd had the same hiccup at his last prenatal checkup, and though the midwives were pretty sure it was trivial--the sort of thing that often resolves at birth--we were scheduled for a fetal echocardiogram to make sure. But the echo doctor was out of town and couldn't see us until two days before the due date--and here we were, in labor five days earlier. The midwives had warned us that if the arrhythmia was present during labor, we would have to be in the labor and delivery ward, not the birth center, so I'd willed the hiccup to vanish before then. To no avail.

Ok, we'd known this was a possibility, so down to the L&D. Except, no. L&D had no rooms open. One room was being cleaned up, would be ready in twenty minutes. So, now tethered to the damn external fetal monitor and IV I'd hoped to avoid by being in the birth center, we waited.

Ever waited through a hospital's "twenty minutes"? Two hours passed. The contractions were strong; I was encumbered by the monitor, which slipped if I moved too much, and I felt unable to get up and move around. Sitting across the room, taunting me, was the lovely large hot tub I had been fantasizing about. Full of water, even. Our bathtub at home hadn't been deep enough to submerge my giant belly, and all I wanted in the world was to get into a deep hot tub.

But instead, there I sat with Dr Hyde, the doula, and intermittently the nurse and midwife on duty, waiting. It was like sitting on an airport tarmac. You can't open your laptop because you're not in the air yet. You can't fall asleep because you're anticipating take-off. You are penned into your little seat and aren't supposed to get up. And you wait.

I couldn't settle into labor--my body knew that we would be moving, any time now, and so it sort of went into withdrawal. Not that the contractions stopped! Ha ha, no. But they stopped accomplishing anything. The midwife said my cervix was only 4-5 cm, a crushing bit of news, since it'd been hours since my doula had said the same thing. I dozed a bit more, as did everyone else--I remember waking up for a contraction and being a little affronted that both Dr Hyde's and the doula's heads were lolling back in their chairs. If I am in pain you should be, I don't know, witnessing.

Finally, finally--now about 4 pm--we were moved down to L&D. It was 20 hours into labor, and I was exhausted and cranky. Still only 5 cm. Well if there's one good thing about being in L&D, it's DRUGS. And I wanted some, pronto. If I had to put up with hours of waiting and NO GODDMAN HOT TUB, I was sure as hell taking the one recourse available to me.

Doula D asked, "Do you want an epidural, or do you want a short-acting narcotic?" she asked. "Because if you have the narcotic and you want more, we can always go to the epidural, but once you have the epidural, you can't go back."

So I had a dose of the narcotic Nubain, and then another when the first wore off. It took the edge off the pain and made me quite sleepy--we were back to dozing between contractions. The sleep was good because I was so exhausted (the night before I went into labor I had slept uncharacteristically poorly, and obviously the night of labor hadn't been real restful either). All told, I spent four hours under the influence of Nubain, but alas, the labor made little progress--I was only at 5-6 cm. So that was the end of the Nubain (and you're not really supposed to take it late in labor anyhow due to its effects on the baby).

8:30 pm, 24 hours into this. How to get labor moving again? My midwife had an idea. "We're going to break your water, ok? And everything's going to get more intense--are you ready?"

I peered at her through the haze of pain and fatigue. She couldn't possibly be expecting a hearty assent, could she? I was already miserable, and she wanted me to say, "Yes, please make this worse"?? (Also, was there a choice?) I gave some sort of sullen acknowledgment that she had spoken, the way that as a teenager angry at my parents I knew better than to say "ARE YOU FUCKING KIDDING THAT'S A BAD IDEA" but still had to make clear that I was Not On Board with their plan of going to the farmers' market at 8 am or whatever.

So they broke my water. It felt as though my body was a bathtub and the drain had just been opened. "AAAAAAUUUUURRRRGGGGHHH," I said. In fact, from this point forward you should assume that I was saying something like that nearly nonstop unless otherwise specified.

I couldn't believe the volume of fluid I was disgorging. It felt like I was creating my own personal Slip 'n' Slide, and hurtling down it at Mach 2. Also, pain. The stage of labor from 7 to 10 cm is called "transition," which I now understand as meaning that you will "transition" from a comparatively normal adult in significant amounts of pain to a crazed animal unable to see straight.

The next couple of hours are pretty hazy. I was panting so shallowly that my blood oxygen kept dropping, necessitating yet another damn sensor, this one a finger clamp that monitored blood ox. Periodically someone would tell me that I needed to breathe more deeply to keep my oxygenation up, which never failed to puzzle me because I was breathing LIKE TWENTY TIMES A SECOND LIKE A GODDAMNED MOUSE so how could I be out of oxygen, but I cooperated nonetheless, or at least I think I did.

Time passed. Dr Hyde says that the nurses and midwives changed out the sopping wet bed pads underneath me, but all I remember is the sensation of my toes going squish underneath me whenever I moved. At some point I asked whether it was the pushing phase yet, and someone asked me if I felt like pushing. Instead I felt like dying, which made it difficult to assess much else.

"You're doing great!" the doulas kept telling me. This was so patently false that I was irritated. Pretty CLEARLY, I was hollering at full strength, ergo NOT SO GREAT. But this seemed so obvious that I hesitated to point it out.

10 cm! Only 2-ish hours after they'd broken my water. But a new problem: every time I pushed, the baby's heartrate dropped low. After a few rounds of this, my midwife announced that unless we could get the baby out within 45 minutes, she would have to call in the obstetrician for possible vacuum / forceps / Caesarean.

The doulas helped turn me around so I could hold onto the raised head of the bed for support as I knelt on the (still squishy) lower half, both to accelerate the process and in the hopes that a position shift would fix whatever was causing the rate drop. Still his heartrate decelerated when I pushed. My right leg was pulled up so I was half kneeling, half squatting. Still the heartrate dropped. They decided I should switch to left leg squatting, right leg kneeling. I had had about enough of this, and, in a brief moment of clarity and coherence, much as you might experience during severe drunkenness, said politely, "Actually, I'm ok like this."

They all laughed at me (in my memory, probably not in reality) and said, "It's not for you, it's for the baby!" FUCK THE BABY, I did not say, instead shifting my weight. Still Small's heartrate dropped during contractions.

So now the pressure was on to deliver the baby asap. My hollering had shifted to more of an "OWWWWW" sound. Doula S stood by my head, next to Dr Hyde. "Ouuut," she urged me. "Ouuut."

I could do that. I wasn't hollering OW, I was chanting a fucking mantra! "OWWWWWWWWWWTT," I said, enunciating the final T like I was in goddamn singing class. See? Not a cry of pain. A mantra. A mantra that could be heard two miles away.

I did some pushing. It wasn't apparently doing very much. Doula D uttered the following words of wisdom: "Are you feeling rectal pressure?" (YES OH YES) "Do whatever makes that pressure the strongest and most intense."

This was the clue I needed. What's more, it helped me focus on the sensation of pressure, as distinct from the pain. Delivering a baby I didn't know how to do, but pooping seemed (barely) within my competency. And that was exactly what it felt like--taking a 7 lb poop, with 8 or 10 people cheering me on (Small's arrhythmia and heartrate had brought an entire NICU team into the room on standby).

Within half an hour, Small had emerged, his hollering picking up where mine left off. The cord was wound around his neck and stomach, but not in such a way as to cause harm. And as soon as the doctors could listen to his heart--not a single arrhythmia to be found. He was as healthy as they come.

Oh but there's one last step! The delivery of the placenta. Pushing something else through my vag seemed like the worst idea anyone had ever had, and the midwife's cheery "Don't worry, the placenta has no bones!" was not in fact reassuring. If someone had offered me an epidural right then, with Small over on the warming table, I would have taken it. In fact I was contemplating requesting a Caesarean. But out it somehow went.

And then they brought over Small and he headed right for my breast as though he'd been doing it for years.

Query

Manuscripts sent out for review may state explicitly that the referee should destroy the manuscript after review. Presumably in this day and age, that would mean "delete the PDF." Does anybody actually do this?

Labor lasted 27 hours so you're damn right it's a two-part post

One tends to hear a lot about pregnancy--the morning sickness, the swollen feet, the constant bathroom trips--but much less about labor and birth. In part this is because birth is a private act, while pregnancy is performed publicly, but in part it is because falling birth rates and delayed childbearing reduce the exposure we have to women giving birth.

In academia, with its further fertility delays, these effects are exacerbated. I was in my late twenties before any of my close friends or relatives gave birth. At the time we got pregnant, I had perhaps heard more about the problems of fistula in impoverished African women (thanks, Nick Kristof!) than about the process of giving birth in upper middle class America.

After I gave birth, I discovered that many of my friends really wanted to know details, but they were sometimes reluctant to ask. Commonly, a group of labmates would hover until someone managed to ask the question--"Did you have an epidural?"--and then all heads would swivel, waiting for the answer. I think both the curiosity and the reluctance to ask are symptoms of how little many of us hear about this basic physiological process. Mainstream depictions tend to focus on the pain, often (e.g. Kirstie Alley movies) for comedic effect.

During pregnancy I found women's stories as reported in a few birthing books (Birthing From Within; Ina May's Guide to Childbirth) to be more helpful than the more clinical presentation of, say, What to Expect When You're Expecting, or the (truly awful) Your Week by Week Pregnancy. As Birthing From Within author Pam England puts it: Millions of women have given birth; how can there be only one right way to do it?

So here's my version, for Arlenna, for other pregnant readers, and frankly for anyone who would like a little demystification of this secret act. Consider it the happy finale to the IVF series.

The first surprise was that it was early. Conditioned by friends and relatives that first babies are generally late, I was expecting an early September arrival for our late August due date. (One nice benefit of IVF--you don't waste time speculating about the accuracy of the dating!) One week prior to the due date, I was happily planning an upcoming week of analysis. As I left work, my advisor called out, "It could be any day now!" and I laughed at him as I walked away.

So that night, while eating the zucchini, tomato, and pancetta pasta that Dr Hyde had prepared, I was nonplussed to feel some cramps. Unlike Braxton-Hicks, the painless if sometimes intense contractions that had been constant companions in the third trimester, these cramps were mildly painful, like minor menstrual cramps, and reached all the way around both belly and back. "Just early contractions," I thought, "probably irregular and will go away." Regular contractions spaced five minutes apart is considered the threshold for visiting the hospital, but most women start out with irregular contractions 10-15 minutes apart.

But after dinner, just to see, I started timing them. Six minutes from the start of one to the start of the next. Then six minutes for the next. Six minutes. And, hmm, six minutes. I called my doulas.

A doula is a woman who accompanies you throughout the process of labor and childbirth. Unlike a nurse, midwife, or doctor, she will not leave when the shift changes; nor will she (necessarily) participate in any medical evaluation or treatment. Her role is to support and encourage the laboring woman and her partner. A doula's presence significantly reduces the rate of Caesarean birth, epidural anaesthetic, prolonged infant hospitalization, rate of forceps/vacuum usage, length of labor, etc. etc. [1, 2, 3]. (Also, more breastfeeding [4].) In other words, doulas are good for women and babies.

Our hospital offers volunteer doulas, pending availability.However, I wanted to meet a doula ahead of time and make sure I liked her. How to find one?

There are websites where you can search for local doulas, but I found mine in an unorthodox manner. The woman sitting next to me on the bus one day had a bag with the name of a doulas' organization on it. I asked her about it and it turned out that she was not a doula, but had a friend who was. She put us in contact, and Dr Hyde and I went to interview her.

Doula S and her partner Doula D were so awesome that I decided not to interview anyone else. They were both midwives as well, so if I wanted to labor at home for a while before going to the hospital (which I did), they were qualified to evaluate my progress. Most important, they were clearly committed to helping me have the experience I wanted, and not imposing on me their vision of how labor "ought" to be.

During several prenatal visits they spent an hour or more answering our questions and asking us some too, to establish our preferences. Were we seeing a midwife or an obstetrician? How did I feel about epidurals and other forms of pain relief? What painful experiences had I had, and how had I handled them?

Eventually the plan we settled on was this: I switched from obstetric to midwifery care, once it was clear that the pregnancy was going normally. At our chosen hospital, this meant that I could labor in the midwife-run birth center, which has big tubs and is generally cozier than the standard OB-run labor & delivery ward. If at any point I decided to have an epidural, or if something was not going well with the labor, I would be transferred a couple of floors to the regular L&D. Also, with our doula/midwife help, I would labor at home for as long as I felt comfortable doing so. The idea was to delay an epidural as long as possible, and perhaps even avoid one.

Why this route? Epidurals typically provide pretty good pain relief, but they're not without drawbacks. Epidural anesthesia requires an additional IV line for fluids; in addition to the numbness produced by anesthesia, this keeps the woman tethered and less able to stand or change positions. Epidurals slow down labor and increase the chance of vacuum, forceps, and Caesarean deliveries. The greater risk of infection and fever increases the usage of antibiotics, and therefore the likelihood of thrush. A urinary catheter is also normally required, again with associated risk of infection, antibiotics, and thrush. (Why this emphasis on thrush? A woman in my breastfeeding group had it and said she'd rather go through labor a second time than have thrush, the pain was so bad.)

At the same time, I certainly wasn't ruling out the magic epi. The prospect of being in a lot of pain for 24 hours was daunting, to say the least. My philosophy was that I'd never given birth, nor even seen someone else do it, and that it would be presumptuous for me to declare ahead of time how things would go. The last thing I wanted was to set up an expectation of unmedicated childbirth that would make me feel like a failure if I chose an epidural after all.

So the official position was--default no epidural, try to use the hot tubs to get through it; but easy access to Plan B if and when I changed my mind.

After I let my doulas know that contractions had started, around 9 pm, we sprang into action. That is, Dr Hyde did the dishes and went to bed; I had a beer and went to bed in the guest room. The beer took the edge off and helped me relax, so I was able to doze between and even through the continuing contractions. Around 2 am I got up and took a lovely hot shower, which helped ease the pain a bit. An hour or two later, I decided that misery would like some company, and woke up Dr Hyde.

The next eight hours or so were not terribly unpleasant. I moved around the house, rocking during contractions and groaning or humming as the mood took me. The nice thing about much of labor is that the time between contractions is calm and painless. If you've ever hiked a steep mountainside, contractions are like the switchbacks, while the intervals are like the straightaways where you regain your breath and appreciate the scenery again.

Around 5 am Doula D came over, freeing Dr Hyde to go out for food. Midwives and doulas will usually encourage you to eat and drink in labor, on the theory that you need to keep your energy up over the long haul. Labor & delivery wards, by contrast, often have no-food policies. The concern is that a woman may require emergency Caesarean and that under general anesthesia she is at risk of aspirating her own vomit. Truly emergency Caesareans--the sort where you don't have time to put in an epidural/spinal catheter if there isn't already one in place, necessitating general anesthesia--are fairly rare (Wiki cites as 5% of all C-sections, so perhaps 1.5% of all deliveries in the US?) While it's understandable that the L&D ward wants to err on the safe side, in practice this means that the other 98.5% of laboring women are denied food.

I'm a good eater, and I get cranky fast if I don't eat for ~6 hours. So I knew I would want to eat during labor (another reason to labor at home or in the birth center, which permits this). Accordingly, Dr Hyde picked up some food, including, on my request, raisin bread. I don't know why I was intent on raisin bread. Normally I eat it perhaps twice a year. But raisin bread I demanded! Must have!

So throughout the labor, I snacked on eggs, fruit (cold grapes were a magical godsend--something about the high water content, mild sweetness, and ease of consumption--I ate them nonstop), peanut butter, and of course, raisin bread. This strategy worked well for me. Some women vomit during labor as a physiological reaction, whether to pain or some other aspect, but I noshed like the high-metabolism lady I am and it all stayed down.

Much of the morning (around 8 am - noon, 12-16 hours into labor) was spent in the bathtub. You enjoy a hot compress for muscle cramps? Labor is just like that, times 10. I grew bored in the bath, so Dr Hyde sat in the bathroom and read Harry Potter 7 to me. We were both rereading it at the time because we'd just seen the movie of HP6, and now I will forever associate Harry's peregrinations in search of the Elder Wand with labor. Occasionally I dozed between contractions, then made Dr Hyde reread whatever section I'd slept through.

At some point, my doula checked my cervix and said I was around 5 cm. I was pretty chuffed. "Halfway there," I thought, "and this is totally manageable. I am fantastic! I am champion!" Those of you who have been through labor, feel free to start laughing.

Around noon, I started feeling like I wanted to get to the hospital. Contractions were still livable, but I was starting to feel a shade of panic, an urge to be In The Place. We called the hospital to verify they had an open room in the birth center, packed up, and headed over.

to be continued