Monday, April 29, 2013

The nursery: DON'T forget to ask these important questions

Attending more births at various hospitals, and working in a postpartum hospital setting for several years now, has gotten me fired up lately on the topic of the nursery (and postpartum floor in general) as pretty darn important in terms of your "birth" experience. Postpartum recovery and breastfeeding are important parts of birth (and the reproductive life cycle in general), and the policies and practices at hospitals can vary as widely in the postpartum setting as they do in labor & delivery. Most people will spend more time - sometimes 2-4 times as long - on the postpartum floor, yet most lists of questions patients are encouraged to ask are largely limited to the portion of their time in L&D.

That includes, I admit, the resources in my own advice kit. Even the questions that are suggested - "are babies given formula routinely?" - your obstetrician and even your midwife are very unlikely to have a clue about. Doulas are aware of, and often frustrated by, differences between nurseries, but I think even we don't see the full impact because we usually leave a few hours after birth. But I am starting to really bring it up when I talk to prospective doula clients or anyone who is thinking about where to give birth. When two hospitals seem equal on the L&D side, what happens after birth can really tip the balance.

DO NOT assume that a touchy-feely, midwife-friendly, natural birth-heaven L&D floor translates into great postpartum and breastfeeding support. They are usually totally different floors with different managers, policies, doctors, and cultures. A hospital in a city where I used to work has one of the absolute best reputations for L&D in the doula community - but a negative reputation for the postpartum floors. Among other issues, this hospital refused to hire lactation consultants because "all of our nurses are trained in breastfeeding support". People would come out of there complaining "everyone told me something different" and end up with really difficult breastfeeding experiences. Especially sad because so many of those moms had gone in so committed!

Why is this so important? How different can postpartum policies be, really? Here are some questions that suggest how nursery routines can have a real impact on the postpartum experience and breastfeeding. They are too detailed to be useful questions for everyone to ask - don't worry, I'll go over more practical questions later - instead, they are here to illustrate things that can make a big difference, but which few parents contemplate:

1) Admission: How quickly do the nursery nurses come to do the admissions? Within 20 minutes? Within an hour? How good are they about keeping the baby skin-to-skin AFTER the initial meet-and-greet with mom, or how pushy are they about getting their tasks done? How much stuff do they pack into the first session (are we seriously getting footprints before the baby has eaten?)

2) Routine separation: Is there routine separation of mother and infant for any reason? Car seat test, hearing test, circumcision, blood draws, exams? What about after a c-section? What about after a planned c-section?

3) Late preterm infants: What is the routine for a baby that comes between 34-37 weeks, also known as late preterm? Especially for the 36 weekers - are they routinely taken to the special care nursery even if they are doing well? On the other hand, are the babies that stay in regular postpartum given extra care and support, and are they held long enough before discharge to ensure they are feeding well?

4) Blood sugar testing: What is the protocol for testing babies' blood sugar? Is it tested routinely for all infants? Is it tested only for babies considered at higher risk, and if so, which babies are those (large for gestational age, small for gestational age, infants of diabetic mothers, etc. - what about a mother who is not diabetic who just happens to have a large baby?) What is the "cut-off" where the blood sugar is considered to be low - 45? 40? 35? Are babies allowed to breastfeed before being supplemented for low blood sugar? Does the hospital have donor milk available for supplementation?

5) Baths: When is the baby bathed? Within an hour of birth? After a delay of 6 or 12 hours? What about unstable babies - those with blood sugar issues, or late preterm babies, or breathing troubles - are their baths delayed until they are more stable?

6) Lactation: When are lactation consultants available? Days, evenings, nights? Weekends, holidays? Are they International Board-Certified Lactation Consultants (IBCLCs), the gold standard for lactation support, or are they RNs with other certifications? Are they dedicated to providing lactation support, or are they also RNs with their own assigned patient loads? What is the ratio of IBCLCs to patients - can you expect to see one every day, or only the day of discharge, or only if you verbalize to your nurse that you are having trouble? Are you guaranteed to see one? What training do the nurses have in providing lactation support?

Do these questions make a big difference? Let's draw an illustration of two nurseries:

Hospital A: Hospital A does not allow babies to stay with the parents after a planned c-section. They may greet and hold the baby for a few minutes, then it is taken for observation in the nursery. Stable late preterm babies are also held in the NICU for 12 hours before being allowed to room-in, but may be discharged after 24 hours if they are still stable. Babies do 20-30 minutes of skin-to-skin with mom after vaginal deliveries, then all babies are bathed within an hour of birth, whether or not they are in distress, and they are also weighed, measured, and footprinted. Their blood sugar is tested. Any baby with a blood sugar of 45 or lower is supplemented with formula to bring their sugar up. Hospital A trains all of its nurses in lactation, but only has lactation consultants available in the mornings, on weekdays - the nurses are expected to take care of most of their patients' breastfeeding support needs (while also taking care of 4-8 patients a shift). All tests and the pediatricians' exams are done in the nursery, so babies generally spend 2-4 hours a day in the nursery, where they are bottle fed formula if they get hungry.

Have you given birth in a hospital like this? I'm pretty sure thousands of people have!

Hospital B: Hospital B does skin-to-skin routinely in the OR after a c-section as long as the baby is stable, and the baby stays with the parents throughout recovery. All rooms are "LDRP" where the family stays in the same room throughout labor, delivery, recovery, and postpartum, so they do not have to move. Stable late preterm babies may stay with the parents, but are held an extra day past normal discharge to ensure they are doing well. Babies do unrestricted skin-to-skin after all vaginal deliveries, are are only moved after they have at least attempted to breastfeed, or if mom requests it. Admission procedures are done 1-2 hours after birth. Baths are done after a minimum of 12 hours to allow the baby to stabilize its temperature, and are held longer if the baby is unstable. Only babies at high risk have blood sugar tests. There is no nursery - parents room-in with babies 24 hours a day, and all tests and exams are done in the room. Lactation consultants are available every day until 7 p.m. and see every patient at least once before discharge. Hospital B is also training all of its nurses in lactation, with the goal of becoming Baby-Friendly.

Not many people get to give birth in a hospital like this - but I think almost all my doula clients, given the choice between the two nurseries, would like to be at Hospital B.

However, while you can start to get information and clues about how your OB or midwife practices, and by extension what the L&D may be like, all throughout prenatal care, you DON'T get the same experience of what postpartum will be like. It can be hard/impossible to find a pediatrician who you like with privileges at the hospital where you want to give birth; even then your pediatrician can only do so much to modify standard procedures based on your wishes, and can't wave their magic wand to make lactation consultants appear when you need them.

How CAN you get a feel for what the nursery is like? If your pediatrician does work at a hospital you want to know about, they are a good place to start. Even if they don't know about or can't control all the issues you bring up, it's useful for them to know what is influencing their patients' choices about where to go.

The next place to ask questions is the hospital tour. This is most informative if it's given by a member of the hospital staff, less likely to have much detail if it's given by volunteers who don't work there - but again, it's good for them to hear what matters to patients.

Next, and possibly most useful, is of course - your friendly local doulas. Doulas see some and hear more about what our clients experience in the postpartum setting. We will not be shy about telling you what we think - but you need to ask, and let us know that you want an honest answer.

So what questions SHOULD you be asking all these people? Here are my suggestions - additions and revisions gladly accepted:

For all parents

1) What is your policy on skin-to-skin after birth? If the baby and I are stable, is there any time limit on how long we can stay that way before they have to be checked?

2) When do you do the first bath? What if my baby is breathing a little fast or has low blood sugar, do they still get their bath then? Can we decline a bath? (you can always decline a bath - but if they say "no" you know you're working with less-than-flexible people)

3) What are the reasons you take babies to the nursery? Which tests and exams are done there, and which are done in my room?

4) Do you ever give breastfed babies formula for any reason? What about water or sugar water? Would you ask my permission before doing this?

5) Are there lactation consultants available? How many times can I expect to see one? What about if it's the weekend? What kind of training do nurses have to help with breastfeeding? Is the hospital Baby-Friendly or planning to become Baby-Friendly?

6) Do all babies have their blood sugar tested routinely?

For diabetic mothers, or women with a history of large babies

1) How often will you test my baby's blood sugar after birth (or will you test it if my baby is above a certain weight)? How long will it continue to be tested?

2) What is the cut-off for when blood sugar is considered to be low? Can I breastfeed to try to bring it up before deciding to supplement?

3) If the baby needs supplementation, do you have donor milk available? Can you help me spoon or cup feed or use a supplemental nursing system at the breast so the baby does not get confused between breast and bottle?

4) Can I pump or hand express colostrum before my baby's birth, freeze it, and bring it in to use in case my baby needs to be supplemented?

What to do with this information?

First of all, use the information you gather to inform your decisions about where to give birth. You might be considering two hospitals that both have L&D environments you like, but when you add the postpartum piece to the balance it really swings the decision one way. If possible, write a letter to the hospital you are leaving or deciding against and let them know what swayed your decision. If you can, definitely write a letter of praise to the hospital you chose and let you know what made you happy about your care!

Second, prepare. This lets you know what you may be up against in terms of routines at whatever hospital you choose. If the hospital routinely supplements babies in the nursery, keep your baby with you as much as possible and make a sign for the crib that says "No bottles!" for the times that you are apart. Or maybe you'll find out that you need to be extra-pushy about getting your skin-to-skin time - you can ask your support people to try to head off the nurse for you and protect your space.

If you have really important and pressing issues with the answers to these questions, the place to go is the nurse manager. You can't sit down and ask them your list of questions, or take up small issues with them. But if you know you will be having a c-section, and everyone you talk to shrugs and says "It's our policy to take the baby straight to the nursery for 6 hours even if you want the baby to stay with you" - you need to speak with the person who signs off on the policies. Ask to speak with the nurse manager of L&D and/or the nursery. Take your concerns to them as an informed consumer and someone with options - especially for a planned c-section, you can easily take your business elsewhere.

What about your birth plan? The postpartum experience generally does not get covered in most birth plans. A good, simple birth plan usually says something like "We plan to exclusively breastfeed, and we do not want to be separated from the baby; if the baby is separated from us for any reason [partner/family member name] would like to accompany the baby at all times". This is fine.

If you have very specific desires/needs, you can write out something VERY brief for your postpartum nurse. For example (for a diabetic mom): "Thank you for taking care of us! We appreciate your support while we are learning to take care of our baby. We are planning to exclusively breastfeed - please no bottles or pacifiers for any reason without discussing with us first. We know that our baby's blood sugar will be checked for the first 24 hours and have discussed it with pediatrician Dr. _____. If breastfeeding does not bring up a low blood sugar, we are OK with using formula but would like to give it in a cup."

Finally, remember as you are asking these questions and making these requests that you are doing it NOT just for yourself and your baby - but for the people who come after you. When hospitals see that these issues are becoming important to their consumers - their patients - they start to shift, however slowly it may happen. Just by asking, you make a difference!

Saturday, January 5, 2013

Happy New Year & links party! ...of randomness

Culled at will from my starred posts in Google Reader...there are so many. So, so many.

* I loved this post about A day in the life of breastfeeding support and promotion in public health. Pretty much exactly what I would love to end up doing someday (maybe with a little bit more clinical work mixed in).

* Interested in going for a career in international health or international development? Here are the bare bones of prepping for an international career. (Office work - who'd have thunk?)

* My friend Mollie (remember her?) did a great and long round-up of breastfeeding on TV and in the media. Love that pop culture knowledge!

* How about a beautiful homebirth transfer and CBAC story.

* The Well-Rounded Mama has been doing an awesome Plus-sized breastfeeding photo gallery. Please view, and submit a photo if you can! What a great resource when so many of the breastfeeding photos we see do not show the full spectrum of real moms' bodies.

* Rixa at Stand and Deliver posted an amazing series of recaps from the International Breech Conference. (Am I the only doula who reads these with the thought in the back of my mind that you never know when a mom is going to deliver precipitously at home, and surprise breeches do happen? I would never, ever, EVER try to deliver a breech baby, or think I knew anything substantive about doing it from reading a series of blog posts. But in an emergency with a baby emerging feet-first and no first responders there yet, I would want to be able to communicate effectively with the emergency responders on the phone, and understand what was happening and what could make things better or worse.)

* If you work in public health/development you quickly learn from people who are up close to these issues that orphanages in developing countries are problematic, and orphanage tourism? Really, really problematic. Don't do it. 

Monday, November 19, 2012

Five things I'll kick myself if I don't tell you about breastfeeding

This is kind of a companion piece to my "first time mama's advice kit", but breastfeeding-specific. I get questions from lots of people in my life about breastfeeding, and I notice them falling over time into similar themes. I also hear after-the-fact stories of what I consider not-so-good (or terrible) advice and I kick myself, mentally, for not having somehow headed this off before it ever became an issue. So here are five things I want you to know, in no particular order:

1) Babies want to eat. They eat a lot. Let them eat. I know it can be hard. If I hear "he's just using you as a pacifier" one more time, I might scream. Do not listen to people who tell you that, or listen to them while smiling, nodding, and ignoring. Yes, some babies suck for comfort past when they are hungry. That's not bad for them. The worst thing that happens for them is that they get more food and they increase your milk supply so they have even more food available in the future. And most babies, especially very young ones, are nursing frequently! I hear "I think he's just nursing for comfort" all the time during the second-night cluster feeding period, and from moms whose milk supply is a little delayed. I try to gently explain that while they are making enough milk for their babies, it's not coming very quickly. The baby acts like he's hungry and wants to nurse because, well... he's hungry and wants to nurse: he needs to eat pretty often to get enough food.

Do you feel like you can never put your baby down and are tethered to breastfeeding 24/7? My personal opinion is that it is not the end of the world to introduce a pacifier to your baby once your milk supply is established, and you have a good read on when your baby has fed well and is satisfied. Kellymom recommends 4-6 weeks before introducing a pacifier and I tend to agree (of course there are exceptions to every rule.) Until then, try to just let feeding frequently be the norm and let go of stresses or people who guilt you about "nursing him all the time".  Trust yourself, and your baby - it is okay to feed often.

Do you feel frustrated and unsure about whether all this frequent feeding=healthy and normal or frequent feeding=starving because not enough milk? See point #2, which is...

2) Please, please, see a good lactation consultant if you have any problems. Yes - it costs money, sometimes a lot of money, and you have just spent a lot of money on, you know... having a baby. But it will be worth it. If you really, really can't afford an LC, talk to WIC to see if they have someone available, call your hospital and see what the co-pay is to see their LCs (often they will take insurance when your local private practice LCs won't), call La Leche League for referrals, and talk to the private practice people about what insurance reimbursement looks like and whether they could work out a payment plan with you. But IT IS WORTH IT to have good, hands-on help.
You might be hesitant to see an LC because "I don't know if I really have a problem". If you feel like there is a breastfeeding problem - that in itself is a problem! If the LC watches the baby nurse, checks the intake, answers your questions, and then tells you it looks like everything is okay - awesome. For example, maybe she reassures you that your baby who "eats all the time" is just a normally frequent feeder and is eating and growing beautifully. You get some ideas for coping with this and are reassured that your baby is normal and healthy.

On the other hand, if the LC finds something you can fix - now you have a way to address your issues, and you can keep working on them together if needed. You might feel like a baby who can't be removed from the breast without becoming completely frantic "shouldn't be" a problem because isn't it normal for babies to "eat all the time"? But when you go to the LC because you're completely exhausted and never sleep, you might find that the baby has difficulty transferring enough milk . Now you can work on strategies for improving the baby's milk transfer, and have a follow up visit in a few days to see if they're working.

If the person you see does not help you/listen to you/really pisses you off, find someone else. This is just like OB/midwife shopping - some people are going to be a good match, some not so much. Note: the "lactation specialist", "lactation counselor", or "lactation educator" at your pediatrician's office may be very nice, but they are not IBCLCs, and neither is your pediatrician. They may be great - they may even be better than some IBCLCs - but I have seen patients really get burned thinking they saw an LC when they didn't.

I know I sound like a broken record on the topic of seeing an LC. But sometimes it's the difference between stumbling through a dark forest with your hands outstretched, and walking through with a flashlight and a map.

3) It's not thrush. OK, OK - it's probably not thrush. But it's really, really probably not thrush. We used to think almost all chronic nipple pain was due to yeast infection of the nipples and/or the baby's mouth. A lot of IBCLCs and other health care providers are now very wedded to the idea that nipple pain without any glaringly obvious latch issues = thrush. And yet when we actually culture the nipples and yeast. Yet moms with chronic pain will go through multiple courses of antifungal treatment for "thrush", and then "resistant thrush" and then "chronic thrush". While most nipple pain is typically not thrush, if you have treated for thrush and it has not responded, it's almost definitely not thrush.

What could it actually be? Bacterial infection, vasospasm, blebs, oversupply, dermatitis, tongue or lip tie... the list goes on and on. How can you figure out which one it is? See point #2.

If you really think it might be thrush - and fine, sometimes it is! - then go ahead and treat for it. But consider the symptoms before going with that diagnosis, and don't go through multiple rounds of treatment for thrush without considering other diagnoses.

4) Measure baby's weight on the right charts. This post kind of says it all. If your pediatrician isn't using the WHO charts, you can encourage them to follow the CDC recommendations and switch to these charts for all their infants. At least bring in a copy for them to use for your baby. If you don't do this, you may start getting worried looks at some point about how "she's falling off the growth curve a little" and "maybe you should start solids early". Measure breastfed babies on breastfed baby charts!

5) Most medications are safe for breastfeeding. Most healthcare providers do not know this. I have lost count of the patients and friends who have been told by doctors, nurses, and pharmacists "you have to pump and dump while taking ____". It has been true exactly twice. I have worked with people in the intensive care unit, people who are having major health crises, multiple surgeries, etc. - and all their meds were fine. And then I meet someone who got told to pump and dump for her mastitis antibiotics! NEVER pump and dump until you have independently verified that you need to - instead, pump, label the milk with the meds you are on, and save it. Then look up your meds on Lactmed and/or call Dr. Thomas Hale's Infantrisk hotline (Mon-Fri) and discuss what you learn with your doctor/midwife/pharmacist before making the final call (nb: most health care professionals are very reassured to hear that Lactmed is run by the NIH.) Jack Newman notes that the standard warnings on the label and in the Physicians Drug Reference are about legal liability, and not about the available research and understanding of med safety. PUMP AND SAVE! And educate your health care providers, if possible, to use Lactmed and Dr. Hale's hotline and book as references, not the PDR or ePocrates.

What have I forgotten? Anyone have things to add to this list that they wish they'd known?

Monday, November 12, 2012

Guest post: A doula's path through pregnancy/birth (Part 3: Birth story)

This is the last in my friend and fellow doula Chris's series on a doula's path through pregnancy and birth. Other installments are here:
Intro: All you have to do is be there
Part 1: Prenatal care and education
Part 2: Preparation - physical, mental, and more

I think this is a pretty amazing birth story - Chris has suggested, and I am planning, to do a follow-up post on one of the topics raised in it. Thanks again to Chris for working so hard on this series to share her experiences and knowledge, and thanks to Kevin for writing the birth story in such detail! They are great friends, great parents, and they have just about the cutest baby in the world.


Part 3:  The Birth

In the days right after you give birth, you think you will never forget a minute of it.  It turns out that’s not the case, and life with a baby (and probably some really awesome hormonal processes specially designed to help you forget pain) makes things get fuzzy very quickly.  Luckily, in the days following delivery while I was dozing with the baby, my awesome rock star amazing birth partner and husband Kevin took the time to write down a very detailed description of the birth from his perspective.  This is the birth story according to Kevin, with my notes added in italics.  

Christine’s contractions started about dinner time on the 9th of May, one day after the baby’s estimated due date.  Her parents were in town and came to the house to make us dinner.  It’s funny now to think back on the unintentional good decisions we made that evening.  For example, I decided to take a nap and then took a short run to perk up before eating a large pasta dinner.  I guess I subconsciously knew I would be working hard that night, so I needed to be in top form.  (I also enjoyed a glass of good whiskey and reflected on our pre-kid years).  

Around 8:45PM, after her parents had left, Christine told me she had a strong contraction that felt different from the Braxton-Hicks contractions she’d been having since the week before.  She hopped in the shower to see if that would soothe them.  When it didn’t, we figured this was the real deal.  Nothing left to do but wait patiently at the house until contractions were 4 minutes apart, drive calmly to the hospital, and push out a baby....easy, right?

By 10:45PM Christine was having trouble focusing on things other than the contractions.  We were halfway through a movie when she decided to move into the bedroom where it was quieter and she could concentrate on breathing through contractions.  She told me I could keep watching, but I knew better than that. My main focus for the previous 40+ weeks was supporting her, and I wasn’t about to start labor by neglecting her to finish watching a movie.

I remember that conversation.  I also remember walking away and thinking “I really should have told him to turn off the TV and just come with me.”  I also remember that he almost immediately showed up in the bedroom with his Birth Partner Game Face on.    

So we moved into the bedroom and started timing and working through the contractions.  Around 11:30PM we called Caroline, our doula, and asked her to come to the house.  While we were waiting for Caroline, I started packing the car.  I also made the mistake of making Chris laugh just before a contraction started. The combination of the two was pretty intense, and she started to 1) laugh harder, 2) cry, 3) shake, and 4) cry some more.  That freaked me out a little; I was worried she was progressing faster than we thought (that she had somehow hit transition) and that we would have to hurry to the hospital or call an ambulance.  Turns out, laughing and contracting were just not a good combination!

I was surprised at what happened when I laughed and contracted (I read a lot of Ina May Gaskin, and she is all about laughing through contractions).  But for me, when I laughed, everything just got all out of control.  I guess I needed to focus on the matter at hand.

Caroline arrived a bit before midnight and confirmed that we were definitely in labor.  We didn’t actually need her to confirm it for us, but it made Christine feel better to know we weren’t overreacting. (I was very concerned about going to the hospital too early).  By now the contractions were about 4 minutes apart, and Christine was working hard to get through them.  She was doing a great job focusing on her breathing and staying relaxed through and between contractions.  Then everything slowed down.  It was a little before 1am when the contractions spread out--first to 8 minutes apart (I thought I had missed one), then a couple at 10 minutes apart.  I figured maybe the baby was just being considerate and wanted us to sleep (I pictured us going to the hospital at 9am alert and totally well rested).  But she faked us out!  I had just made up the futon for Caroline when Christine’s contractions started again--right back to 4 minutes apart.  They were a little stronger, so Caroline suggested the tub.  Caroline helped Christine get situated and started pouring water over her belly as I packed up the last few items for the hospital.  This was the moment I remember thinking “I’m so glad we got a doula.”  

From 2:10 to 2:30 the contractions were 3 minutes apart and gaining intensity, so we decided to go to the hospital.  We hopped in the car and took what seemed like the slowest possible route to the hospital.  I felt particularly bad about the route selection while we were crossing through a neighborhood that had speed humps.  Of course, the contractions seemed to find every bump in the road.  Anyways, we got to the hospital at 3am and entered through the ER.  Caroline and Christine headed up to Labor & Delivery while I grabbed the ridiculous number of bags we packed and took care of check-in at the ER registration desk.  By the time I got up to L&D Christine and Caroline were getting settled into Room 3, which has a tub and is HUGE.  That’s why the staff call it the “Taj Mahal”.  It also faces east, which made for a beautiful ambience in the room a little later that morning.  

It’s important to note what DIDN’T happen when we checked into the hospital.  No IV was inserted, and I was not permanently connected to the monitors. (They hooked me up for the first 15 minutes or so, and after that only monitored me intermittently).  I didn’t have to get into a hospital gown, and there was no prohibition on food or drink.  No one made dreadful statements about my last chance to get an epidural or IV pain meds.  Full credit goes to the midwifery practice for making sure their practices truly support normal and unmedicated birth.  

Our arrival at the hospital marked the point where the labor turned into as much (or more) of a psychological challenge as physical.  When I got up to L&D, The charge nurse escorted me back to the room and asked for the details of the labor so far, and we showed her a copy of the birth plan.  Tanya, the midwife on call, came in to check Christine’s dilation and assess her progress.  We had met Tanya at an earlier office visit and really liked her.  She confirmed with Christine that at her last checkup (at 40 weeks on the dot), her cervix had been 90% effaced and in a good forward position but not dilated at all.  We had all assumed that 8 hours of contractions would have opened her cervix to at least 2-3 cm (Christine was hoping for more like 4-5).  Tanya could see the frequency of contractions from the monitors, and I think she expected to find Christine to be pretty far along as well.  That turned out not to be the case--Christine’s cervix was still completely closed.  

I’d been consistently impressed by the midwives during the pregnancy, so it’s hard to identify one caregiver who stands apart--but I think Tanya (and later Diana) were exactly the people we needed for this delivery.  Tanya immediately recognized that something was off with the progression of labor.  The contractions should have been producing more progress.  It turns out that about 10 years ago, Christine had cryotherapy to remove abnormal cells on her cervix that turned up on a pap smear.  Evidently the procedure left scar tissue on her cervix that was now preventing it from opening.  I’m still impressed that Tanya had the presence of mind at 4am to ask about this right off the bat.  She said she could clear the scar tissue with her fingers, and Christine gave the go-ahead to do so.  It was pretty intense and looked pretty painful, but Christine dilated to 2cm immediately, and her water also broke.  

This is where everything got very fuzzy.  I remember saying “yes, do it” when Tanya asked about clearing the scar tissue. She did it while I was in the middle of a contraction, and I remember intense pain and a gush that turned out to be my bag of waters breaking.  After that, labor felt like something I could just barely hang onto instead of something I was in control of.  It was almost like starting a second, entirely different labor.  It took a while to wrap my head around what had happened and what was happening, and I remember feeling very needy--like I really truly needed everybody in that room to be constantly telling me I was doing well and that it was going to be OK.  That emotion wasn’t one I had anticipated.    

The baby was now on the way for real, but Christine was pretty deflated to find out she wasn’t further along.  It’s also important to point out that dilating 2cm instantly is physically demanding.  Christine’s body was playing catch-up at this point, and the contractions became much more intense.  She got shaky and started shivering, and asked to get in the tub.  

We had talked through a lot of labor and delivery scenarios to try to be prepared for a curveball--what if labor stalls?  What if we needed an emergency c-section? What if the baby needs to go to the NICU? But this situation never crossed our minds.  In some ways it was harder than some of the other things we discussed.  Rather than presenting us with a concrete decision, it placed Christine on a different trajectory, and she dilated faster and delivered sooner than she would have if she had truly been at 0cm at 3am.  The labor went from feeling manageable for Chris to feeling like something that she could just barely hang on for.  

The contractions before and after my water broke were very different.  Before, I could stay in control and breathe through even the most intense contractions.  After, I remember feeling pushed to my absolute limit with every contraction.  I lost all composure and really needed Kevin and Caroline to help me refocus after each one.  I remember feeling restless or almost trapped, and having that back-of-the-throat almost-scream feeling.  They would talk me down and get me to breathe and relax and make productive noises.  

I’ve been able to provide pretty good detail so far, but things sort of blend together from this point onwards.  Christine stayed in the tub, and Caroline and I stayed next to her and did our best to help through contractions.  I would remind her to breathe and relax, and Caroline would provide comfort measures (hand holding, water on the belly).  Unfortunately, the hospital only has regular-sized bathtubs, so it’s difficult to get the belly all the way in the water.  Christine had great support, but she was doing all the work.  One thing I told her repeatedly was “No one is more prepared for this than you”.  It’s true--she was as ready physically and mentally as any first-time mom could be.  Some women would have caved under the mental strain and physical pain, but my wife is TOUGH.

One thing that didn’t cross my mind during labor but I have thought about a lot since then is the fact that, in accordance with our birth plan, no one offered me pain medication.  In the end, I think this made all the difference in my ability to have an unmedicated birth. I really believe that if someone had asked me when I was at about 7 or 8cm if I wanted an epidural, I would have said yes in a heartbeat.  But as it was, I was so far into the labor zone that I didn’t even think about medication.  And since no one brought it up, I just kept doing what I was doing and it turned out exactly how I hoped.  When I was a doula, I don’t think I understood how important the not-asking was.  I thought “Well, if they ask, you just say no.”  Now I get it.  Having an unmedicated birth depends on a lot more than just previous intention and willpower.  

One thing Chris needed a lot of was reassurance.  She really needed to hear “Yes, you’re making progress” and “Yes, it’s moving quickly”.  She asked Tanya to check her a couple of times while she was in the tub, and each time she had made progress.  By the time she was dilated to 6cm, I was standing in the tub to help support her through contractions and to give counterpressure.  Before I knew it we were at 8cm, we had moved back to the bed, the delivery instruments had been prepared, and we all thought Chris would be pushing at any moment.  It was about 6:30am, and Christine had dilated from 0-8cm in 3 and a half hours.  Christine’s mom arrived sometime around then, and I remember Chris asking “Mama, how did you do this twice?”.

We tried a number of positions on the bed, but Chris was most comfortable on her knees, leaning over the back of the bed (which we had put in the full-upright position).  By 7AM she was having a LOT of back pain.  I was applying counterpressure with each contraction, and LeeAnn (our nurse) and Caroline were pushing against Christine’s hips.  I was also massaging her back with raquetballs between contractions (I had lots of tricks in my gypsy bags).  It took almost two hours to get through transition, which was slower than anticipated given how fast she had gotten to 8cm.  The baby had been anterior all through the pregnancy and had been low in the pelvis for some time.  It seemed unlikley she would have rotated to a posterior position during labor, but the nurses and midwives started to wonder about it since things had slowed down and Chris was having so much back labor.  I was concerned because she had worked so hard all night long, and I was worried she would start to run out of steam if pushing was very difficult.  When she finally began to push (around 8AM), it wasn’t an overwhelming need.  She would push a little but then stop halfway through contractions, saying it was all she could do.  

I had lost all concept of time by this point.  I remember being upright on the bed, leaning over the back and moving my hips constantly.  I couldn’t stop it, even though I was so tired.  I remember Caroline standing by the head of the bed feeding me Craisins between contractions.  I remember that eventually, the pain never went away, even when I wasn’t contracting.  I think I said “the baby is going to come out of my back”.  And I remember that I did not like to push.  I never had an overwhelming urge, and when I did push, I could only do it for about half of a contraction.  After that the pain was too much and I just had to breathe.  But nobody was rushing me or counting or telling me to hold my breath and push for longer.  They let me figure it out on my own.

Around this time the midwives had a shift change, and Tanya handed the reins to Diana and Angela.  (Since Diana is new to the practice, Angela was there to back her up).  I took shift change as an opportunity to consider our options for getting Christine some rest or pain relief.  We wanted an unmedicated birth, and the nurses and midwives were great about not offering epidurals or other meds after the very first time (I think they were required to have her do the pain scale and confirm that she was aware of medical pain management options upon admission). But I wanted to talk through our options in case we didn’t get things moving again, or if Christine turned out to be too exhausted to push.  Christine was SO tired, and I thought that if we got something to cut the pain, she may be able to rest a bit and come back at it with more energy.  

Pushing was a struggle at first.  Christine had a hard time finding a comfortable pushing position on the bed and was struggling to activate the right muscles.  LeeAnn reminded her that you need the same muscles you use for a bowel movement, which may have been what got Chris thinking about the toilet, so we headed to the bathroom.

I also remember LeeAnn being really hands on.  She took my hands and looked right in my eyes and told me that I had to find the exact place where it hurt the most and push straight into it, even though that felt like the last thing I’d ever want to do.  And she was right.  She pretty much taught me to push.  

While Christine labored in the bathroom, I stepped out into the hall with several of the midwives to discuss what might come next if Christine was too tired to push.  We were all hoping no intervention would be necessary, but it seemed wise to have the discussion before things got urgent.  There was talk of Nubain to cut the pain and provide some time to rest, asking the MD on call to scrub in and see if the baby's head could be rotated into a more favorable position, and vacuum extraction as a last resort.  (I remember having the feeling that if I didn't start making some good progress with the pushing, people were going to start suggesting things that I didn't want to hear.  I was already pushing, but at that point I started pushing like never before.)  While we were talking, Diana (the new midwife on call) was with Christine while she pushed.  When she joined us in the hall, I asked for her thoughts on how things were going.  She replied that she wasn't sure whether the baby was posterior or not, but she felt like Christine was making progress with pushing and the best thing to do would be to give her some more time to work before suggesting anything else.  That's what we did.

Diana and I went back into the bathroom, and before too long the baby was crowning.  Diana told Christine that if she wanted to move to the bed, now would be the time, but staying put would be OK too.  Chris made an attempt to get off the toilet but could barely stand, and she promptly decided that moving was out of the question.  Diana said, "No problem.  We can deliver here."  So Diana settled in cross-legged on the floor, and the nurses brought the instruments into the bathroom (which, by the way, was huge).  As Diana was prepping for the delivery, a contraction started.  I was squeezed up next to the wall still giving counterpressure, and LeeAnn and Caroline were right next to me holding Christine's hands.  Christine needed to get further forward on the seat so that Diana could have a better angle to protect the perineum and deliver the baby, so I got behind Christine and held her up by the arms.  Diana kept asking me to move her forward more and more until before I knew it I was sitting on the toilet and Christine was on the ends of my knees and I was supporting her with my forearms.  I'm honestly not sure how long we pushed that way, but my legs were numb. With one contraction Christine got very loud, and I thought "this must be it!"  Diana looked up and said "Christine, get control of yourself, you're almost there, keep breathing."  I could tell a difference in the next push--Chris was squeezing my hands and I could feel her core muscles working.  With the next push, I think we were both screaming, and then I actually felt the baby come out--I could feel all of Christine's power while she was sitting on my lap.  There was a little tug, and then Chris relaxed, and moments later Diana lifted our baby Annie onto Christine's chest, and I was sobbing as hard as the baby was crying (she had powerful lungs from the get-go).  It was just after 9:00AM.  After a few minutes LeeAnn took over my position behind Christine so I could cut the cord, and then we helped Christine walk back to the bed and lie down.

Annie was the most incredible beautiful thing I had ever seen, and I was completely overwhelmed by the delivery.  Christine had been so strong and worked so hard to grow our daughter and bring her into the world.  Experiencing her birth that way was more powerful than I could have prepared for.  It is (and will remain) the most amazing experience of my life.  Our Annie girl was finally with us after so many months, and I fell in love with her in an instant.

I have snatches of very clear memories of the delivery--of squeezing Kevin's hands harder than I had ever squeezed anything, of bellowing louder than I ever expected to, of Diana's face asking me with intensity to get control and breathe, and of this huge feeling of relief when I held the baby for the first time.  I still don't know how I walked to the bed, because an hour later I couldn't stand.  I had second degree perineal tears that Diana stitched up, and the entire time nobody even suggested moving Annie off my chest.  We just rested together.

It turned out that the reason labor had slowed so significantly during transition (and the reason I had so much back labor) was that Annie was born with a nuchal arm--she had one arm extended by her head upon delivery, so she came out Superman-style. (Interestingly, she had an arm up by her head as early as the 20-week anatomy check ultrasound, and I wonder if she didn't just keep it up there!)  She was 7lbs 5oz, born perfectly healthy after around 12 or 13 hours of labor (though all the cervical dilation happened in the last 6 hours).  There was a lactation nurse beside the bed before I even realized it, and she helped Annie and I nurse for the first time maybe a half hour after delivery.  When we were ready, Kevin went with the nurses to do the rest of the newborn exams and give Annie her first bath while I ate some breakfast and moved to our room in the Mother-Baby unit.

If you ask most women who have given birth what they remember about the experience, they'll tell you that it's hard to remember much.  While preparing for Annie's birth, I had a hard time fathoming how one forgets such an important experience.  Now, nearly 6 months after the fact, I can tell you that the forgetting is the absolute truth--it faded a little bit every time I held the baby or nursed her or napped with her.  All those fuzzy details just got fuzzier (I'm so glad Kevin wrote everything down so soon after the delivery!), and what I'm left with is an overall impression of the experience.  I am very lucky that it's such a positive and empowering impression.  When I think back on the birth, I feel proud of myself, but more than anything I feel grateful--grateful for the support I had, grateful to have medical care that truly supported normal birth, grateful for the physical and mental strength to give birth the way I wanted to.  And most of all, I'm grateful for our beautiful daughter, who made such a memorable entrance and has been making life more exciting ever since.  

Saturday, November 10, 2012

Guest post: A doula's path through pregnancy/birth (Part 2: Preparation - physical, mental, and more)

My friend and fellow AmeriCorps doula Chris wrote her first post in this guest series, "A doula's path through pregnancy and birth", way back in April: Part 1: Prenatal care and education. As she notes at the beginning of this next post, time flies (for me, too!) so this next installment is a little delayed. But I think it's very well worth the wait - there's so much great advice and experience in here (check out the birth plan, for example.) Big thanks to Chris for working so hard on it!

Birth story is coming very soon!

(And if you haven't already, don't forget to check out Chris's intro post, one of my favorite doula stories from our year in AmeriCorps.)


So I had big plans of writing about how we were preparing for birth as we were actually preparing. Then life got away from me, and all of a sudden here I am writing about preparing for birth while my 6-month old baby girl is asleep.  The upside is that I’ve had a chance to reflect on how our preparations affected our experience of birth, and I can comment on the parts that (in hindsight) seem particularly important.  Here’s what we did, and soon you can read about how it worked out.  

Luckily my pregnancy proceeded without complication, and Kevin and I started preparing for birth pretty early.  Rebecca has a post about why you shouldn't "try" to have an unmedicated birth--you have to prepare to have one (like you prepare for running a marathon; you don't just get up and try it).  I think the comparison between endurance running and giving birth is apt.  Both require preparation in many different ways--physically, mentally, and emotionally.  Here's how we got ready.

Physical Preparation:
I started going to a prenatal yoga class quite early in the pregnancy, at maybe 12 weeks.  I felt a little silly at first, sitting in the room with all these women sporting huge bellies and due dates only weeks away, but my fantastic teacher Cundy says there is no such thing as too early or too late to start prenatal yoga--the important thing is just to get there.  I went to yoga once or twice a week almost every week for the rest of the pregnancy.  It was excellent physical preparation for labor--lots of pelvic strengthening work, lots of squatting, and lots of practice with deep relaxing breathing.  I think it was also an excellent mental break every week, and a chance to absorb positive messages about giving birth.

I did my best to stay active with cardiovascular exercise while pregnant.  I ran pretty regularly prior to getting pregnant, though that ended with the first trimester (I ran/walked the Athens half marathon at 13 weeks pregnant, and after that set my running shoes aside).  I walked all day every day for work as a high school teacher, and also made long walks part of my weekly routine.  As my belly grew my walks got shorter.  :)  Interestingly, when I was newly pregnant walking was about the only way I got any relief from the near-constant nausea.  I think it had to do with the breathing.

Looking back after the delivery, I can say that I am glad I stayed relatively active and I'm particularly glad I stuck with the yoga so regularly.  Though I remember feeling exhausted while in labor, it was more of the I've-been-up-all-night-can't-I-have-just-a-few-minutes-to-sleep tired, not the type of fatigue one feels from reaching the limits of what your muscles can do.  I felt strong even as I felt exhausted.

Mental Preparation
Pretty soon after realizing we were pregnant, I sat Kevin down and we watched The Business of Being Born.  (FYI: you can stream this movie via Netflix).  If you're on the fence about what kind of birth you want to have or if you're looking for encouragement to have a natural, normal birth, this movie is a must-watch.  You see a little more of Ricki Lake than you ever thought you would, but I know every time I watch that movie I come out of it thinking Ricki is pretty much a rock star.  It's also a great one to watch if you are trying to get a loved one on board with your ideas about birth, midwifery care, or how to avoid getting sucked into the medical monster.  Put it on your list!  We also watched the movie Babies (the one that follows infants in different parts of the world through their first year).  That baby in Mongolia is VERY cute.

My mama taught me that there’s no such thing as too much reading, and my doula experience exposed me to some titles that everyone planning for a non-medicated birth should know about.  So upon getting a positive pregnancy test, I busted out my copy of the trusty Pregnancy, Childbirth, and the Newborn by Penny Simkin and ordered The Pregnancy Book and The Baby Book (both by Dr. Sears), which I read in chunks here and there. I ordered my wonderful husband a copy of Simkin’s The Birth Partner.  He worked his way through it over the course of the pregnancy, starting with his biggest concern--how to deliver the baby in an emergency.  :)  I also enjoyed Ina May’s Guide to Childbirth, which was wonderful--I’m an especially big fan of her chapter on Sphincter Law.  It gave me lots to think about.  As the pregnancy progressed, the question “How on earth do you take care of a baby?!” occupied more and more of my brain, and I read the ubiquitous Happiest Baby on the Block by Harvey Garp, which backs up a lot of what the Sears book teaches.  One book that I thought would at least be funny but turned out to not work for me at all was The Girlfriend’s Guide to Pregnancy, which was recommended to me by pretty much everybody I know who has had a baby in the last 10 years.  I read some of it and wound up feeling fat and neurotic--two adjectives that I don’t think generally apply to me, pregnant or not.  I quit reading it about halfway through, and wouldn’t recommend it.  Later in the pregnancy I read a book on the Bradley method for childbirth.  Most of it didn't really suit me--I found it to be way too structured--but I did like the parts about visualization and relaxation during contractions.

After we hit 20 weeks, we started the most important mental preparation we did--our prenatal Centering program.  Centering is basically group prenatal care for the second half of the pregnancy.  Every other week, Kevin and I met with a midwife and a group of 3 other couples due at roughly the same time we were.  The meetings (which happened in the evening, to accommodate work schedules) started with individual check-ins with the midwife to listen to the fetal heart tones and discuss any private concerns.  We also checked our own blood pressure and weight and peed in the obligatory cup.  After that we sat down as a group to discuss anything that was going on with our pregnancies.  It was a great time to get ideas for dealing with discomfort, to see what other people were reading, and to get some reassurance about what was happening with our bodies and our lives.  We also did potluck dinners, which was really fun.  Finally, we would discuss a topic relevant to pregnancy and birth, and in that respect it was a lot like a childbirth class.  We covered the progress of labor and birth, options for pain management, breastfeeding basics, and how to take care of a newborn.  Our centering group really connected, and we've stayed in touch even now that all the babies are on the outside.

Because I had a very solid background in childbirth education through my doula work, and since we were already covering lots of relevant topics in Centering, we decided that a full-scale multi-week childbirth class was not for us.  But when the opportunity arose to take an independent one-day childbirth course taught by a very well-respected member of the Athens pregnancy/early-parenting community, we decided to go for it.   It turned out to be a good review for me and a great way for Kevin to run through everything we learned in Centering again.  We practiced with birth balls and rebozos, worked on breathing and relaxation, and focused on the principles that set you up for a normal birth.  We are very lucky to live in a community with excellent resources for prenatal support and education.  Between Centering, midwifery care, prenatal yoga, and our childbirth class, we both felt confident as I approached the end of the pregnancy.

In the last few weeks of the pregnancy, we created our birth plan.  At first I started with a list of things that I did NOT want, but after a little bit of writing I realized that type of birth plan was probably not the most useful approach.  I think I needed to work through some of the baggage I had from the difficult, medicalized births I had seen as a doula.  But through writing down what I was worried about, I came to the understanding that by making smart choices about my prenatal care, a lot of my concerns would not be an issue.  I didn’t need to write “no episiotomy” on my birth plan because not one of the midwives in our practice would ever dream of doing a routine episiotomy.  We'd had a chance to discuss a lot of potential hospital pitfalls during Centering, and I came away feeling confident that these midwives were for real.  Their very low c-section and induction numbers backed me up.  So I rewrote the birth plan and talked it through with our doula.  This is what we came up with:

We have been preparing for a normal, unmedicated birth.  Any suggestion or assistance that supports that goal is welcome.  Christine is aware of all medical pain management options and will ask for them if wanted.  We are working with a doula and her support is important to us.

Immediate skin to skin contact is a priority, as is early breastfeeding. We would like all newborn exams performed while we hold the baby. Kevin would like to cut the cord once it has stopped pulsing.

Newborn Care Preferences:

  • Christine intends to breastfeed--please no bottles or pacifiers.
  • We plan to use Dr. M as our pediatrician.  We will begin the baby’s Hepatitis B vaccinations through Dr. M’s office.  
  • We would like the vitamin K injection and eye ointment to be delayed until we have had some time to spend with our new baby.  
  • We would like the baby to stay in the room with us for as much of the time as possible. If it is necessary for the baby to stay in the nursery, Kevin would like to stay with her.
  • We would like to help give the baby her first bath.  

In case of cesarean:
We ask that as many of our preferences regarding delivery and newborn care as possible be respected (family-centered cesarean).  Kevin would like to be in the operating room, and we request to be included in all decisions related to the care of our baby.  

In case of baby in the NICU:
Just as with a cesarean, we request that as many of our above preferences as possible be respected, and we ask for any support available to promote breastfeeding.  We would also like to spend as much time as possible giving skin-to-skin contact.

Thank you!
Kevin & Christine

I think it's also worth noting what we did NOT do prior to the birth.  We did not spend one minute watching nonsense "reality" childbirth shows on TV. While this choice could most directly be attributed to not having cable, I wouldn't have wanted to watch that stuff anyways.  They present a sensationalized version of childbirth that makes having a baby look like a scary emergency every time.  If you want to have a normal, unmedicated birth, the last thing you need is a bunch of stories emphasizing worst-case scenarios and medical-model labor.  It's totally normal to be thinking about birth and the baby all the time, but if you want to immerse yourself in learning about birth, spend some time reading or go whole-hog and get MORE Business of Being Born, good old Ricki's new project that is an even more in-depth treatment of natural birth than the original BofBB.

People Preparation
One aspect of birth that I think can be easy to overlook is figuring out exactly who you want to be with you when it’s actually baby time.  Your caregiver and your partner are obviously very important, but it’s worth considering who else you want with you when you’re in labor.  It’s also worth it to start talking to the people who are important to you ahead of time and find out what their expectations are for the day of the birth.

Kevin and I were planning to have a doula and we eventually found one, but we waited probably a little too long to actually go about our search.  I think I got the impression that in a town like Athens, doulas were practically coming out of the woodwork.  That turned out not to be the case, and about 2 months before I was due, when we finally started getting serious about the doula search, we discovered that 1) it was hard to find a doula that wasn’t booked, and 2) doulas cost more than we anticipated.  In the end we found an apprentice doula who was available and within our budget.  We almost didn’t hire her (based on the idea that my prior doula experiences had left me better prepared than the average first time mom), but in the end, I came down firmly in favor of having a doula.  Here was my reasoning:  maybe we’d be fine by ourselves if everything went perfectly smoothly, but what if something came up?  If I had a 60 hour labor, I wanted a doula.  If I had to be induced, I wanted a doula.  If we had to decide about a c-section, I wanted a doula. And you can’t just call a random doula when you’re 6cm dilated and ask her if she can hop over to the hospital.

The other people we took into consideration when planning for the birth were our parents.  All four parents live within 2 hours of us, and this being the first grandchild on either side, we knew they would want to be involved.  However, I didn’t want a bunch of people camping out in Athens, waiting for me to go into labor.  I also wasn’t sure I wanted lots of people there for every nitty-gritty moment of the labor.  I was OK with the idea of both the moms being in the room at least part of the time because I knew they wouldn’t try to pressure me to do anything I didn’t want to.  My mother had 2 unmedicated births, and Kevin’s mom had 6 babies in 6 different ways.  I was lucky that they were on board with the idea of normal birth and that I never had to explain or defend our birth plan. But even though I have a very good relationship with both my mother and my mother-in-law and had no reservation about them being present at the birth, in my head, we would wait to call them until we were admitted to the hospital and knew that I was well into active labor.

Amazingly, that’s more or less how things worked out, and everybody seemed to feel good about it in the end. My relentlessly prompt parents did arrive on my due date, before any signs of imminent labor, and they literally camped out about 20 minutes away and waited on me to have a baby (which they assumed would happen fairly soon, given the genetic tendency towards promptness).  However, since I went into labor at night, we didn’t let them know what was going on until about 5:30 the next morning, when the delivery looked pretty close.  So my mom got to be there for part of the labor and for the birth but not for so much of it that I felt like I had an audience waiting on things to move along.  We called Kevin’s parents at the same time we called my parents.  But just to prove that you can never predict birth, when they arrived after their 2 hour drive I was still laboring.  Kevin’s mom chose to stay in the waiting area, but all four grandparents were close by when it was time to meet the baby.

We are lucky to have a very low stress family situation and to live in a community where it is possible to find doulas.  But for anybody preparing for birth, I think it’s really worth it to give some thought to who will be with you on the big day and to have those conversations early.  When it’s time to have a baby, you want to feel surrounded by support and encouragement.

Emotional Preparation
I wonder if perhaps the most important preparation we did for the birth wasn't the emotional work.  It's certainly important to be fit and educated when the time comes, but I think all of that work is for naught if you don't have confidence that you can have a normal birth.  For me, a lot of that confidence came from surrounding myself with people who shared that goal.  Our Centering group provided an important emotional connection to pregnancy and birth.  Kevin and I looked forward to the social aspect of Centering--we ate together, discussed progress and difficulties, and shared the process of beginning to imagine ourselves as parents.  I also found pregnant friends through yoga class, which was another powerful affirmation of the process of growing a baby and giving birth.  I think that if I only had one piece of advice for a newly pregnant woman, it would be to surround yourself with positive people who will help you stay confident in yourself and your body.  Find pregnant friends (and friends with young children) who share your goals and priorities.

Kevin and I are not usually huge fans of what we call "barfy baby stuff"--going to someplace like Babies ‘R’ Us to make a registry was so low on our list that it never got done. (Way better registry for people who hate shopping:  do one online through BabyList).  But the one thing we did that sounds like it's straight out of is take a babymoon.  If you can swing it, I totally recommend it.

My school's spring break fell when I was about 36 weeks pregnant--about our last chance to take a relaxing trip prior to baby go-time.  We drove down to a cottage in Florida belonging to some friends of Kevin's family and spent a very relaxing few days swimming, enjoying the beach, and just hanging out.  It was a really nice time spent just being together, getting ready emotionally for how our lives were changing.  I think pregnancy lasts 9 months not just to give the baby time to develop but also to give the parents time to prepare themselves.  A lot of that work is emotional.  Kevin and I had been together for a decade before getting pregnant, and I think we needed a minute to say goodbye to our exclusive little club and get ready to add a new member.

One of the sweetest memories I have of Kevin and I getting ready for the birth together happened at the end, when I was right at 40 weeks pregnant.  I was feeling stressed for all kinds of reasons, and I'm sure he was too.  But instead of escalating my little freak out, Kevin sat me down, rubbed my neck, and talked me through some relaxation.  He helped me breathe, and we practiced how I would relax when the actual labor began.  I'm not sure I managed to relax physically that same way during labor, but I know I went back to that emotional space when I felt overwhelmed by the experience of giving birth.  It was a really nice place to be.

In sum, I think the ideal preparation for birth (for anybody, not just me) puts you in a place where you feel confident in your knowledge, in your caregivers, in your support system, and in your body.  If you're getting ready for birth, take inventory of how you feel about each of those areas.  If you find that any one of them doesn't make you feel good about giving birth, make the changes you need to right now.  You will thank yourself later, and so will your baby.

Friday, November 9, 2012

Can we and should we measure "lactastrophe" rates?

This started as a links post, but my commentary on the first link got long enough to qualify it as a post in and of itself! It turns out I have a little more to say about this topic than I realized. First, please go read "How often does breastfeeding just not work?" from the Academy of Breastfeeding Medicine blog:

From a health and wellbeing perspective, however, I’m not sure that it matters whether we “count” both “biological” and “perceived” insufficient lactation together. The total burden of this problem is enormous, and mothers are suffering, whether they lack glandular tissue and or they lack self-efficacy and support. We need mothers for whom lactation doesn’t work to know that they are not alone. And we need to demand research to develop the tools that will identify the underlying problems and allow us to implement the appropriate treatment.

We also need to step back from assertions that every mother can breastfeed, if she just tries hard enough. As Neifert has written, “The bold claims made about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that ‘every pancreas can make insulin’ or insist to a devastated infertility patient that ‘every woman can get pregnant.’ The fact is that lactation, like all physiologic functions, sometimes fails because of various medical causes.”

It's a great post and great comments. The one thing I would add is that while it does us no good to bicker about whether this person or that person "truly" had a low milk supply, on a public health/policy level I believe having these statistics could help push for change. It's also not useful to spend time picking apart an individual's c-section as "necessary" or "unnecessary" - but when we look at two hospitals, select out their low-risk populations, and compare their c-section rates, we can start to see what might be attributable to environment and what might be unavoidable. It provides a basis for us to say to the hospital with a 40% rate, "Hey, all these surgeries might seem necessary to you, but let's see what might be some underlying causes."

I have been talking with a colleague about the idea of a prospective survey tracking a population of women who are getting "ideal" breastfeeding support - women delivering at a mother- and baby-friendly facility, who have good prenatal education and postpartum support for breastfeeding, and are generally very committed to making breastfeeding work. What is the rate of "unplanned undesired weaning"/"lactation dysfunction"/"lactastrophe" among women with near-ideal circumstances? (Or as ideal as you can get in a country with no mandated paid maternity leave...) I think the results would help guide us, not toward a way to pick apart whether an individual woman "could have made it work if she tried harder" or "didn't really have a low milk supply", but towards an understanding of what is possible. Sometimes I get tired of hearing "lots of mothers don't make enough milk" and "some people just can't breastfeed". I get tired of hearing these statements not because I don't believe they are true - they are depressingly true - but because they are recited as if they are unpreventable, unmodifiable facts. If the data is used carefully and correctly, it could serve as a benchmark for measuring how much farther we can go towards preventing "lactastrophes" for all mothers.

Still, I want to inscribe that last paragraph on a freaking 10-foot-tall stone tablet somewhere and make every parent-to-be, support person, doula, and health care professional read it out loud before they receive their first education on breastfeeding. Why do so many people imbue breastfeeding with a magical evolutionary resiliency that nothing else possesses? (Is it just an overreaction to the opposite problem, the attitude that breastfeeding is fragile and usually destined to fail?) Real people suffer when those around them adopt the attitude that "every woman can breastfeed." Nuance often gets lost in the rah-rah atmosphere we use to try to shore up most women's (dismal) expectations for their breastfeeding success, but it is so necessary right now when more women than ever are trying to breastfeed and more are confronting medical conditions that make it challenging or impossible.

Thursday, August 2, 2012

Reply turned post: The nightmarish vision of a baby-friendly hospital

Feministe, along with a few other things I've seen around the interwebs, has a hand-wringing post about New York City encouraging hospitals to adopt baby-friendly practices such as limiting staff access to formula, not advertise formula, not give free formula samples, etc. Caperton at Feministe describes this state-controlled gulag:
Starting September 3, baby formula will be a controlled substance at some New York City hospitals. Under the health department’s voluntary Latch On NYC program, 27 hospitals are literally hiding the baby formula under lock and key, tucking it away in distant storerooms and locked dispensaries like legitimate medications that need to be tracked. Nurses will be expected to document a medical reason for every bottle a newborn receives, and mothers will get a breastfeeding lecture every time they ask for a bottle of formula.
Cue lots of upset in the comments about how babies will go hungry.

My first response:

So many of these comments are ridiculously overdramatizing an already overdramatized issue. “Babies will be forced to wait an hour for a bottle!” No. I work as an LC at a hospital with these policies so let’s clear some things up:
1) You don’t want to breastfeed, you don’t. You get your bottles on admission and that’s the end. The LC doesn’t see you unless you ask to be seen for some reason, like engorgement.
2) You want to breastfeed, you breastfeed. Nurses can’t sneak formula behind your back. Before we started documenting the mother’s consent, there was a lot of “she said/she said” after the night shift left. The nurse claimed the mom asked for a bottle, the mom claimed the nurse gave it without permission. Now if there’s a bottle, everything is documented and no one can say they didn’t know.
3) You need a bottle, the nurse or NA brings it to you. There’s no “queue” and no one is waiting for an hour. The formula is in the cabinet with all the other supplies. (That is totally staff-facing by the way – it’s not like the parents ever know it’s locked up. So is the Tylenol and that’s not shaming people with headaches.) We limit the amount of formula we give per feeding in part because people will give insanely inappropriate amounts. A newborn has a stomach made to hold about a third of an ounce at birth. I have seen people give over two ounces at one feeding!! It’s considered an accomplishment by grandma that she got the baby to eat so much, but it is not good for the baby.
4) If you are asking for formula for personal reasons, we document the reason. If the baby needs it for medical reasons, we document that too. Again, this is not to shame anybody or demand they give us a good excuse, it is to push the medical/nursing staff to acknowledge that “the baby cried some” is not a reason to tell the mother “you need to formula feed or your baby will starve”. (You think people don’t do that? You are wrong.) Medical reasons to supplement include excessive weight loss, jaundice associated with poor feeding, etc.
5) No one gets lectured. The consent they sign does say that giving bottles may interfere with their STATED plan to breastfeed. That is the truth, so I don’t think there’s a big problem with it. I work with a lot of moms who choose to formula feed for various reasons, usually because they believe they don’t have enough milk. I disagree, and I explain why I don’t think that there is a medical need for supplementation. I say that while there is no medical need, it is their baby and they can decide whatever they want. Some parents hear my explanation, feel reassured, and keep breastfeeding exclusively. Some decide they want to go ahead and supplement. Their baby, their choice. So much for the heavy-handed police state – sorry if real life disappoints. I feel like so many of these comments are like a Tea Party vision of Obamacare.

My second comment:

@Caperton: “On top of that, we have arguments of Nurses are good and supportive and helpful and so this policy won’t have negative side effects vs. Nurses sneak formula and bottle-feed your baby behind your back and don’t honor your wishes, so they need extra rules. Whether it’s either or both…” It is both, and also Nurses can be pushy jerks about both breast and formula feeding (and a million other topics as well “stop picking up the baby when it cries!”) They do need extra rules. These are some of the rules.

 “…Whether it’s either or both, we still have a policy that’s based on locking up baby formula and dispensing it bit by bit like feeding a baby bird, rather than on treating new mothers like adults: educating them about breastfeeding, letting them know that support is available, and then trusting them to make their own choice. And then honoring that choice.” But see this is where I don’t get it. How does the status quo honor people’s choices? We DO have breastfeeding moms getting the runaround and staff disrespecting them. This policy is meant to address that. In the meantime, everyone still gets what they want. This obsession about the locking up is still so puzzling to me. No mother could ever go and help herself to the formula cabinet. She always had to call the nurse to get formula brought to her. The lock is for the STAFF. And actually, feeding a baby human IS like feeding a baby bird (except for the worms part). They only need very small amounts. And they are OK if you bring them one meal at a time; they don’t know or care where the next meal is stored.

Finally, I am ALL FOR maternity leave. This is a HUGE and important component of breastfeeding support. And you better believe breastfeeding advocates know it and talk about it A LOT. It doesn’t mean that the hospital isn’t important too, and is a place where public health officials can actually make a concrete, immediate difference. People who are sabotaged in the hospital don’t ever make it to 2-3 months out as it is. I did some number-crunching for a WIC office and 50% of their moms who initiated breastfeeding stopped in the first two weeks. There is a huge drop-off after the much-vaunted 90% initiation, and that actually starts in the hospital for many people.

In response to continued upset about the locked formula: 

@Lauren: “That’s a staff education issue, not a mother education issue. It’s not resolvable by locking up baby food.” Again, locking up the formula is PART of what they are doing for staff. When you call for a bottle, do you know if the nurse has to deal with a lock or not? Nope. But she can’t be snagging bottles left and right for moms who don’t want them. Staff education is also part of that; it’s still just so puzzling to me that people are acting like the baby itself will have to open a bank vault to get fed.

Now this evening an update to the original post: 

*Update 8/1, 6:30 p.m. According to Samantha Levine, deputy press secretary in Mayor Bloomberg’s office, the information on the Latch On NYC site was wrong, and hospitals will not be expected to keep formula locked away (although they’re free to do so). She says they’re correcting the FAQs to reflect that. It seems like a rather a strange thing to get so diametrically incorrect, but removing the lock-and-key element of the Latch On NYC initiative does help things immeasurably.


 ??? I do not get it. This is what our scary locked formula storage looks like. It's in the nursery.
You type your login, hit a few buttons, and open the door. FYI, the breast pump kits, nipple shields, etc. are in this too. It helps the people who restock track the par levels so they can keep any supplies from running out. No one is upset that because those things are locked up, they're discouraging breastfeeding.

Can anyone help me understand all the drama over the locked cabinet requirement, which once removed has "helped things immeasurably"? I'd say out of all the things commenters were concerned about (shaming, lecturing) it is the least relevant. Ask any of our patients who use formula whether we keep it behind a lock (besides the lock on the nursery door) and I guarantee not a single one will know. Is it just some kind of gut feeling?