The obstetrics and gynecology written board exam made everything seem cut and dry. A patient with fibroids causing heavy bleeding? Management options include hormone treatment, minor surgical procedures, or major surgical procedures like myomectomy or hysterectomy. A pregnant patient in labor with a fetal heart rate deceleration? The next step is to shut off the oxytocin infusion, turn the patient on her left side, administer intravenous fluids, and give her oxygen via a nasal cannula. A patient who has ruptured her membranes at 28 weeks? That’s an easy one: magnesium for neuroprotection, latency antibiotics, prenatal steroids, neonatalogy consult. Straightforward.

At the end of June, I was grateful for my residency experience – even though some of it seemed hectic and haphazard – because it ensured that I understood the reasoning behind these multiple-choice questions. But then I started my maternal-fetal medicine fellowship this past July. I was learning the names of new residents, attendings, and nurses, and having to orient myself to an entirely different hospital system. Even labor and delivery board sign-out was completely different. I reassured myself by thinking: Obstetrics is obstetrics. The rules and guidelines of obstetrics are universal, practiced at every level, and always make sense, right?

Not so fast. I had left a world of black and white and entered a whole new world of gray. It was no longer enough for me to use protocols from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) to handle even “typical” high-risk patients. I had been lucky to be exposed to patients in residency who were very complicated: They were morbidly obese (BMI of 80-plus kg/m²), had diabetic ketoacidosis, had a quintuplet pregnancy, and even had eclampsia. I became skilled at recognizing the diagnosis and then putting into action the management plan, but most of the time I was not responsible for creating that plan. Suddenly I was the high-risk “specialist” being asked the question, “Well, what do we do now?” Just a few weeks before I had been the resident doing the asking.

One day I had a patient come in with chronic, refractory immune thrombocytopenia. Her plan for delivery was induction at 37 weeks after our hematology colleagues used medications we had never heard of to finally get her platelets into the 100s. But upon admission, her platelets were down to the 70s. I wondered, should we induce anyway because her platelets are likely to drop even further if we wait? Or do we give her the slew of medications that didn’t completely work initially as a last-ditch effort to boost her platelets again before delivery? I looked at practice bulletins, hematology guidelines, and numerous other publications and still I could not find a protocol for this specific kind of patient. After discussion with anesthesiologists, hematologists, maternal-fetal medicine specialists, labor and delivery nurses, and the patient herself, we came up with a plan. We gave her additional doses of thrombopoietic agents and steroids and continued to monitor her platelet count. Within a week, she had an uncomplicated vaginal delivery with an epidural.*

Taking a lead role in the decision-making process and organizing a management plan made me feel like I was the quarterback of a football team, with a healthy mother and baby substituting for a game-winning touchdown. The decisions we make in maternal-fetal medicine are not supposed to be easy. However, I’ve heard over and over that when our colleagues ask for our input, the guidance they want to hear is “deliver” or “don’t deliver.” Over the last several months, I’ve learned that there is so much more to it than that. I now examine the entire patient and fetus in two ways: as one physiologically inseparable unit, and as two patients, weighing the neonatal risks of delivery against the maternal risks of the pregnancy itself. Determining an appropriate time for delivery is just part of it.

There are also the questions about antepartum fetal testing. Should we do additional monitoring for patients with isolated polyhydramnios? What about patients who are at advanced maternal age? What about patients whose fetuses have “decreased growth velocity” but not growth restriction? Should these patients get umbilical artery Dopplers, too? ACOG and the SMFM often do not give us specific monitoring guidelines, which forces us to make a plan based on each individual clinical scenario.

In other words, we must practice in that ever-changing, ever-frustrating, and confusing gray area. I hope in fellowship I learn to not only navigate through this area effectively, but to one day confidently hold out my hand to others to help guide them through it, too.

Dr. Grossman recently completed her residency in obstetrics and gynecology at Albert Einstein College of Medicine–Montefiore Hospital in the Bronx, N.Y., and is currently a first-year maternal-fetal medicine fellow at Weill Cornell Medical College in New York. She reported having no financial disclosures.

*This article was update April 21, 2107.

Beyond Residency: No more black and white