Monday, November 30, 2009

In which a medal comes in the mail!

Sheridan of Enjoy Birth was thinking about the oft-repeated phrase tossed at women planning an unmedicated birth “You don’t get a medal for natural childbirth.”

As she writes in her blog:

I started thinking, “Why Not?”

When you run a marathon, you prepare for months ahead of time and then the day of the race you run and run and run and work SO hard! I am sure when you cross the finish line you are just so happy and proud because you DID it, you accomplished your goal! You didn’t run the marathon FOR the medal. But you do DESERVE a medal!

She designed a medal for moms who worked hard and long and deserved a medal at the end of their labor marathons. But:

Then while I was in the process of doing all of this, I had a mom who needed a surprise cesarean for a breech baby. I realized that she deserved a medal just as much as the other mom. I thought about all the sacrifices different moms make and realize ALL moms deserve medals.

Suddenly my idea was so much bigger than what it started as.
But that is how all great things start, with a small idea. So hence Moms Deserve Medals was born. Because ALL Moms Deserve a Medal!

I was surprised and touched to receive an e-mail from Sheridan a few weeks ago saying she appreciated my blog and the info it offers women, and offering to send ME a medal! And pretty soon, it arrived:

I love this medal and am honored to get one, and I am already thinking about how I want to hold onto this for a little while and then pass it along to a doula client who deserves one. And I know one will come along, because thinking back on recent doula clients, I realized that as Sheridan points out ALL moms really do deserve medals! Every one of the moms I have worked with this past year has their own reason for deserving a medal! Women who trusted and listened to their bodies, women who researched their options and made their own decisions, women who bravely endured frightening medical complications, who underwent long and difficult inductions, who did everything they could to protect their babies' health. As Sheridan points out, they don't do it FOR a medal, but they DESERVE one!

Sheridan, thank you for this great idea and for the medal!

Wednesday, November 25, 2009

Reply turned post: Warning: this post contains the word "rectal"

Jill at the Unnecesarean recently wrote about out-of-bed birth and the Captain Morgan aspects of one of her births (you have to read it to fully appreciate). MidwifeNextDoor commented:

"Good for you! I am a CNM presently (reluctantly) working in the hospital. I've only done two out of bed births so far, but it freaks the nurses out! One nurse's chart notes on a patient went like this (the woman was pushing when she arrived at the labor ward):

"Patient REFUSES to give urine sample. She is standing by the side of the bed. I have repeatedly told her to get up on the bed, but she refuses. She stated, 'Women have been giving birth standing up for thousands of years and SO CAN I! And then she pushed the baby out. I did put gloves on before the baby was born."

This client of mine was a VBAC client, by the way! I didn't make it in time for the birth, obviously. I've done one bathroom birth, with mom on hands and knees, and one side of the bed birth with mom standing. There is so much fear surrounding anything different from the cockroach position (flat on your back, legs in the air) that it makes me stressed.

Would love to see more women refuse to get into bed."

This jogged a doula memory for me and I contributed my own comment/story. Since several people thought it was pretty funny I thought I'd repost it here:

"MidwifeNextDoor, your comment about the nurse's charting was so funny!! It reminded me of a birth one of my fellow doulas attended when we were in AmeriCorps together. There was a new CNM at the very by-the-book, public hospital we often attended births at, and she had trained in birth centers down in New Mexico. I can't imagine she's still there but at the time she was fighting to carve out a little sphere for normal birth, and we loved her for it.

One day she paged for one of our doula team to come in to a birth there because she knew the mom wanted to go unmedicated and felt like the nurse wasn't going to give her enough support. My teammate was on-call and told us the whole story later. I can't remember the exact details anymore, but it went something like this: When it came time to push, the unsupportive nurse really couldn't handle the hands-off approach. Mom began pushing standing up next to the bed and the nurse freaked out and said "She's pushing!" "Yes," the midwife said calmly, "she is." The nurse began to get huffy and started charting about the patient pushing STANDING UP. "What's her dilation?" the nurse asked. "Oh, she was almost fully dilated," the midwife said, "I'm sure she's complete now." The nurse went back to charting about how the midwife did not check but just SAID the patient was complete. The nurse at this point swings the computer around so her back is to this travesty. Whenever the midwife asks for a chux pad or anything else she needs, the nurse gets it for her and then goes back to charting with her back turned, so the midwife starts asking the doula to hand her things. As the baby descends, the midwife takes note of signs of progress and says "Could you please chart, 'positive rectal bulging'?" "WHAT?!" says the nurse. "POSITIVE RECTAL BULGING," the midwife says loudly, and she and the doula grin at each other. (Fortunately mom was Spanish-speaking and probably not paying any attention anyway so she wasn't privy to all this banter.) Shockingly, baby is born without any need for mother to get into bed, or for nurse to do much but stand with her back turned and chart ;-) "Positive rectal bulging" became a catchphrase around the office for a while.

Side note: after the baby was born, mom did get into bed to rest and cuddle with the baby, and the doula told the mom what a great job she did, how impressed she was, etc. She asked half-jokingly, "So, do you feel like you could do anything now?" and the mom looked up and very matter-of-factly said, "Oh, YES." "

Monday, November 23, 2009

Why I'm a doula, and what a doula can do for you

Posted as part of the Science and Sensibility Healthy Birth Blog Carnival #3. I've meant to participate in the previous carnivals, but I just couldn't miss this one: on step 3 of the Lamaze Six Healthy Birth Practices, "Bring a loved one, friend, or doula for continuous support."

By way of talking about continuous support is so important, I want to talk about some reasons that I am a doula.

I am a doula because of the woman I worked with whose husband drew me into the corner as she went through transition. He was worried. "Is this normal?" he asked. "Is this OK? She'd really like to know how much longer this will go on." I reassured him she was completely normal, doing beautifully, and that while no one could predict the course of labor, she would probably be done soon. He went back to his wife's side with renewed conviction and was constantly whispering encouragement and praise into her ear. Their baby was born just a couple of hours later.

I am a doula because of the first VBAC I attended. I was working as a volunteer doula, and her nurse paged me in because this woman became nervous whenever the medical staff would leave her alone. I sat with her, brought her cold washcloths, watched her rock back and forth furiously in the rocking chair, and let her crush my hand. (She kept asking "Am I hurting you?" and I lied and said no.) She said, "No one told me how to do all this last time to bring the baby down. They just said I wasn't making progress and did the surgery." Later that night, she pushed her baby into the midwife's hands.

I am a doula because of the young woman who labored so instinctively despite being restricted to a hospital bed. She spontaneously flipped to her hands and knees, to her side, rocked her hips and made noise. I just watched and told her what a beautiful job she was doing and that she should listen to her body. Her labor lasted longer than any of us expected it would, but she remained strong through the end.

I am a doula because of the woman who was so anxious about her labor that she couldn't relax and rest. I sat next to her and talked quietly to her, visualizing a beautiful labor, a healthy baby, trying to put a smile on her face and let her welcome the next stage of labor. The next morning, her baby was born and placed directly into her arms.

I am a doula because of the family who forgot their camera in their car - I ran down to get it and came back just in time (on the way promising the ladies at the front desk that someone would be back down to move the car as soon as the baby was born!) Baby was born quickly and there were beautiful pictures galore.

I am a doula because of the woman who, as soon as her baby was born, began asking "When can I breastfeed her? When will they give her back? When can she start nursing?" I sidled over to the pediatricians several times to say, "You know, she'd really like to start nursing, whenever you're ready..." When they finally got the baby back to her delighted mom, she latched on like a champ and went on to breastfeed for over a year.

I am a doula because of the family I spent 26 hours straight with, sleeping sitting up in a chair. They went through multiple shifts of nurses and midwives and doctors, but I was there to say "This morning she was feeling nervous about ____, can you discuss it a little more?" They had a long and difficult labor to contend with, and I have never been gladder that I didn't call my back-up and stayed through to the end.

I am a doula because I can make a hot pack out of towels and chux pads, I know where to find the extra stretchy disposable underwear, and I carry lanolin sample packets in my doula bag in case someone forgot their chapstick.

I am a doula because somehow, the things I offer are so simple and yet seem to mean so much. Someone to be a familiar face, to be a reassuring presence, to offer a little extra information, to facilitate with care providers, to bring food or forgotten items, to provide touch and ice water and hot packs, to be a hand to hold, to press in just the right spot, to just be there. It seems like a miracle sometimes that such simple things can mean so much, and yet it does; even the research says so, and just as importantly so do the women who are served by doulas. I have to trust them, because it's hard to believe I can do so much, and have so much fun at the same time!

A loved one or friend can be a fantastic doula, and many people will swear by their husbands, partners, mothers, or friends as doulas. The important thing is to have someone who can provide those simple and necessary things, and who understands the importance of their active participation in the process. Don't bring spectators who will sit in a row on the couch and watch you like a TV show; or people who will undermine your confidence; or people who bring their own issues or focus to the room. If you can't find that person among your personal support circle, or want more back up, consider hiring a professional doula. But no matter what guise they come in, bring doulas to your birth!

Sunday, November 22, 2009

What an induction looks like

Want an induction? Ask yourself if you want this:

Monday 9 p.m.: Arrive at hospital. Change into hospital gown, get in bed, be connected to contraction and fetal heart rate monitors (external belts). Cervix hard, thick, and high. Receive one dose of Cytotec (medication to soften the cervix, an off-label use of this medication which has serious risks).

Monday night: Sleep, intermittently interrupted by the nurse to adjust monitors, take temperature and other vitals, etc. Another dose of Cytotec around 3 a.m.

Tuesday 7 a.m.: Checked by incoming shift. Little change. Place another dose of Cytotec.

Tuesday during the day: Some contractions. Skip a dose of Cytotec to be able to go off the monitors, shower, eat, and walk the halls for an hour or so.

Tuesday 7 p.m.: Checked by incoming shift. 1-2 centimeters. Agree to Foley bulb catheter to expand cervix. Two hours later, Foley bulb falls out. Now 3 cms. and ready to start Pitocin. No more eating, drinking, or going off the monitor (so no walking around, limited movement).

Tuesday night: Sleep, with intermittent contractions, as Pitocin is ramped up.

Wednesday 7 a.m.: Checked by incoming shift. 4 centimeters. Doctor breaks bag of water (=AROM, Artificial Rupture of Membranes). Intense, strong contractions immediately ensue. Intrauterine pressure catheter (IUPC) placed to monitor contraction strength. Hour-and-a-half wait for anesthesiologist, who is in back assisting at a c-section. Receive epidural. Labor slows down again, Pitocin is ramped up.

Wednesday during the day: Some wearing off of the epidural effects. Cannot get up or move around to help with pain because even somewhat ineffective epidural doesn't allow for enough control of legs. Still not allowed to eat or drink. Constant itching from epidural. Nurse comes in frequently to adjust baby heart rate monitor. Nurse checks cervix and says 5-6 cms.; doctor comes in later and says only 4. Now attached to 7 different wires: oxygen saturation monitor, blood pressure cuff (worn continuously, going off every 30 minutes), external fetal monitor, IUPC, epidural catheter, bladder catheter (can't get up to pee), and IV line.

Wednesday 7 p.m.: Checked again, 7 cms. Anesthesiologist has come in twice to try to fix epidural and comes in a third time for one last try. Re-upping medication helps slightly; sleep intermittently for 20-30 minutes and then epidural stops working well again. Still itching - nurse says she can offer Stadol for the itching, but that will cause a lot of sleepiness/loopiness and "out of it" feeling; decline the Stadol.

Thursday 12 a.m.: Checked again - completely dilated to 10 cms. Begin pushing. Back begins spasming, possibly from being in bed so long, makes it difficult to continue pushing but do so anyway. Push for 2 hours. Baby's heart rate begins to drop and doctors suggest a vacuum extraction. Also give oxygen - now connected to 8 different things.

Thursday at 2 a.m.: Vacuum extraction successful; baby is born crying and vigorous but immediately taken over to the warmer because of the heart decels and use of the vacuum. Doctor repairs perineal tears while peds team checks over baby. Finally get to hold baby after 45 minutes, but baby is not interested in nursing yet. Nurses impatient to take baby to nursery for first bath; give baby to nurses, be unhooked one by one from all wires and medical team leaves. Wait in empty room until it's time to be transferred to the postpartum floor.


I have attended many inductions, and this is based on a composite of multiple inductions I have witnessed. I think it accurately represents the experience of many women who are induced without any cervical readiness for labor (and even some who are induced with greater readiness).

It's not a very nice story. Do I write it to "scare" people? "ZOMG, if you get induced you will be in labor forever and in pain and your baby will need to be pulled out." That's not what I'm aiming for; there are inductions that go smoothly and quickly (although more often when the body is ready and willing).

Instead, I write it to inform. There was an online workshop offered this summer for doulas called "Do You Dread Inductions?" because the answer is YES! We only wonder why our clients don't dread them more, and the best answer I can come up with is that people don't understand what they're consenting to. I think the impression many women of an induction is that it's similar to regular labor, but you just get to pick your day. Let me be one of many doulas who can tell you: this is not the case!

When you start regular labor at term, it's because a complex set of signals and changes in your body say "This baby is ready; let's get it out." (One way to measure whether the body has begun preparing for labor is a Bishop's score.) When inducing labor, medical staff try to replace those natural signals and changes with manufactured ones: promoting cervical softening and dilation using prostaglandin gels or misoprostol (Cytotec), inducing contractions with artificial oxytocin (Pitocin).

As this cervical ripening and early dilation is generally the longest part of labor anyway, and is much less efficiently done by medications than by normal physiological processes, all of this takes a long time. Often by the time a woman in spontaneous labor would be showing up at the hospital (4-5 cms) you have already been in the hospital 12-24 hours, and still have a ways to go. You're also likely to experience a more intense, painful labor because induced contractions are different from natural contractions, so you're more likely to need pain medications.

In addition, when you induce without your body being ready (aka a low Bishop's score) you increase your chances of a c-section, and even if you avoid a c-section you increase your chances of a long, drawn-out experience that may not be what you are prepared for. Don't be electively induced, and understand the legitimate reasons for induction vs. the convenient excuses.

If you need an induction for medical reasons and your body is not ready, be prepared! Eat and drink as much as possible while you are still "allowed" to. Advise family and friends that it will be a long wait and make sure everyone gets a lot of rest whenever possible. Don't accept phone calls from people asking "Is that baby OUT yet??" As long as baby is doing OK, don't be afraid to ask for assists like telemetry (wireless) monitoring so you can move around more freely, and breaks to go off the monitor while nothing is actively being done. Get out of bed as much as possible whenever you can, because it can be hard to avoid an epidural and that will restrict your movement later on. Delay breaking the water as long as possible, because it starts the clock ticking for delivery. Use different positions for pushing - even if you have an epidural, it's possible to move around in the bed, and it helps counteract the position problems that can arise from a long stay in bed.

If you have to be induced, be informed. But if you don't HAVE to be induced - don't take the decision lightly. Wait for your baby and your body to tell you it's time.

Friday, November 20, 2009

Friday night movie

I have a lot of posts that I want to write, am writing, or am revising. But in the meantime the end of the semester is coming up, and I have to remind myself that I don't get any credit for blogging! (Darn.)

In the meantime, here's a beautiful movie of a baby born underwater and in the caul (with the amniotic sac still not ruptured).

(Via Birth Routes.

As somewhat off-topic side note: You can see the baby hanging out for a while after the head is out, until a midwife reaches in to help bring the body out. While this baby does not to my eyes seem to have anything resembling shoulder dystocia, seeing this patience and willingness to wait for the body made me think about shoulder dystocia...this is pursuant to a birth I was at recently. I'd like to learn more about the importance of when and how it's "diagnosed" and whether attendants give baby the opportunity to rotate properly before becoming aggressive.

Monday, November 16, 2009

Milk's up! The breastfeeding gang sign

It's always nice when I notice a mom nursing in public (challenge those norms!). But, being paranoid, I worry that if someone notices that I'm noticing that she's nursing, she'll interpret it as disapproval. So usually I go for a brief glance and a big smile. But this is a cute idea too: a sign to give props to moms who are out, about, and nursing. You can skip to around 3:10 to see the sign in action:

Would you use it? I'm going to wait for it to become more widespread before I spring it on anyone, but I think it's a really nice concept.

Sunday, November 15, 2009

Not-good-things that nurses do

I love some L&D nurses; they can be awesome, a huge help to the patient's goals, an advocate with the doctors/midwives, a doula's best friend. But I have a few pet peeves:

* Nurses who tell women they have to be in bed because they can't trace the baby otherwise. You know what happens after you get the woman in bed? You still have to mess with the monitor to trace the baby. Why didn't you try doing that when she was on the birth ball, instead of assuming the baby would be untraceable that way?

* Nurses who tell women they have to be in a specific position (ahem, on their back) because they can't trace the baby otherwise. You know what else could help? If someone was holding the monitor on where it needed to be. I've seen nurses be that "someone" - why not you? Or if you're willing, I can do it; it's not rocket science. But when I walk out and see you chatting at the nurses' station, I wonder if you could have done it after all.

* Nurses who tell women it's good to change sides in bed, and don't actually come in and encourage her to do it regularly, which an exhausted mom will probably forget to do. Or don't come in to help her at all, instead letting a mom with an epidural struggle to move herself around.

* Nurses who tell women how good it is to walk and move around, while doing all of the above.

Can you tell I'm frustrated? I promise to write a good post about good things that nurses do too!!

Tuesday, November 10, 2009

Giveaway - Breastfeeding with Comfort and Joy

Ooooh I want this book. I have checked out some of it via "look inside" on Amazon, which makes me want it even more! I would love to have a really beautiful breastfeeding book to show and share. (Who am I kidding - I give away my birth/breastfeeding books almost as soon as I get them because I see someone who I think needs them more than me - but I'd try to hold on to this one for a while!)

Kathy at Woman-to-Woman Childbirth Education is hosting a giveaway - check it out!

The Stupak amendment.

[Note: I posted this yesterday, then heard an NPR piece that made me think I hadn't understood the Stupak amendment's restrictions. I was heading out the door, so I didn't have time to revise; I took the post down until I had time to research and make sure I was right. This is something I feel very passionate about and I wanted to make sure I was as accurate as possible. Slightly revised version below.]

I called, on Saturday, but what more could I do? Mostly I just tracked the news and crossed my fingers. The fact that this came out of nowhere (at least for me) and was over with in a day feels so utterly unfair.

In case you are not familiar with the Stupak amendment, it is part of the recently passed House version of the health care reform bill. The amendment restricts the ability of public and private insurance plans, offered in government health exchanges, to provide coverage for abortion.

Read that again: AND PRIVATE. This is where I was unclear yesterday, but it is clarified today by this extremely helpful post from legal experts at Planned Parenthood. I'm quoting it extensively because given what I heard on NPR yesterday, I think there is still some confusion out there about the realistic effects of the Stupak amendment on abortion coverage availability in the exchanges:

The Stupak-Pitts amendment prohibits any coverage of abortion in the public option and prohibits anyone receiving a federal subsidy from purchasing a health insurance plan that includes abortion. It also prohibits private health insurance plans from offering through the exchange a plan that includes abortion coverage to both subsidized and unsubsidized individuals.

Thus, if a plan wants to offer coverage in the exchange to both groups of individuals, it would have to offer two different plans: one with abortion coverage for women without subsidies and one without abortion coverage for women with subsidies. These private insurance plans would need to be identified as either providing or not providing coverage for abortion.

Health insurance plans are highly unlikely to operate in this manner, and it is not even clear that this is feasible under the administration of the exchange and affordability credits. As one alternative, the Stupak amendment purports to allow women to purchase a separate, single-service “abortion rider,” but abortion riders don’t exist. In the five states that only allow abortion coverage through a separate rider, there is no evidence that they are available.

Furthermore, women are unlikely to think ahead to choose a plan that includes abortion coverage, since they do not plan for unplanned pregnancy. In addition, it is not clear that health plans would even be allowed to offer two separate plans under other provisions of the act, such as the anti-discrimination and guaranteed-issue provisions. Those elements of the bill, which are very important to consumers, may make it impossible for plans to provide two separate plans, one that includes abortion and another that does not.

Realistically, the actual effect of the Stupak-Pitts amendment is to ban abortion coverage across the entire exchange, for women with both subsidized and unsubsidized coverage.

(emphasis mine)

Why the Stupak amendment? The argument is, as best I can tell, that those people who can't use all their own money to buy health insurance will be eligible for a government subsidy. This will probably be me at some point very soon (like after I graduate from school in May) so let's take me as an example. I could use the subsidy to buy a health insurance plan that covered abortion. Then I could use that money (along with my OWN!) to buy a private plan. Then, if I needed an abortion and that insurance plan covered it, the government would have somehow, indirectly, kinda sorta had a hand in making it possible for me to get a legal medical procedure.

Did I say legal medical procedure? I also meant abortion. They're the same thing, so sometimes I use them interchangeably.

We have had the Hyde amendment in place since 1977, exempting abortion from Medicaid. Poor women, expendable: check. Apparently health care reform is an opportunity to go even farther: to reach into PRIVATE health insurance, paid for with PRIVATE money, and effectively take abortion coverage out of that, too. This applies not just to individuals, but to businesses; companies that buy plans through the exchange? All their employees' families will lose any abortion coverage they had. All women, expendable: check.

The fact that this amendment comes from the party that has been ranting and railing about "government taking over health care" and using scare tactics like death panels and rationing of care...well, I guess irony has been dead to the Republican party for a long, long time, so we shouldn't be too surprised.

Besides women who need abortions, who else will this hurt? How about women who have miscarriages? Is maternity care next? Keep in mind, this comes from the same party that says health insurance shouldn't cover maternity care, because men don't need it.

This just...disgusts me. Last year I went to a talk by Dr. Nick Gorton and blogged about how he predicted this very outcome - that reproductive health care would be one of the issues to suffer when government stepped into health insurance. At the time, I mused about how we could protect abortion and other political hot button issues in health care reform - but reform seemed so theoretical. I guess I haven't been paying enough attention - but that's going to change. I agree, let's not just be satisfied with keeping Stupak out of the final bill - let's go after Hyde.

If you'd like to take further action now, this is a great place to start: While there's a wall of shame for Dems who voted for Stupak and against reform, there are some bright spots. Those are Democrats who voted AGAINST Stupak and FOR health care reform - despite being in highly vulnerable races next year. Click here to donate to those reps, reward their courage, help keep them in Congress, and send a message to the party: Do NOT allow the Stupak amendment into the final bill.

Monday, November 2, 2009

If you have a problem when you breastfeed, then you have a breastfeeding problem!

Recently I went to visit with former doula clients. (It was so nice to see them. They are such wonderful people and have such a cute baby. And I got to hold the baby for a long time! I know not all doulas/midwives/other birth professionals are baby fans, but I am definitely a huge sucker for an itty bitty baby. But I digress.) Their baby breastfed beautifully all through the hospital stay - frequently, happily, no concerns whatsoever.

Apparently when they got home the baby went in for a check-up. Due to weight concerns, the pediatrician told them to supplement with 1 oz of formula after each feeding, and they did, reluctantly. Fortunately baby soon became more wakeful and interested in eating (my guess is, the baby just got a few days older and grew out of the sleepiest phase). They weaned off the supplementation rapidly and are back to exclusive breastfeeding.

But ack! That was the first line of a tale too often told...weight problems, doctor recommends supplementation, leads to supply problems, leads to more supplementation, more supply problems, and now we're in the downward spiral.

I say to all my clients at our immediate postpartum visit, "Just call me if you have any problems or questions about breastfeeding." But this has happened more than once: I find out weeks or months later that the doctor recommended supplementation, and I don't hear about it until long after the fact. Mulling it over, I decided that maybe not everyone perceives the need to supplement as a breastfeeding problem. And I think it reveals the norm in our culture of: "It's good to breastfeed, but when it's not working supplementation is the answer". When instead, the norm should be "Women make enough milk and babies transfer it effectively, and if this does not happen there is a problem that needs to be solved".

If I had talked to them when they got that recommendation, I would have recommended they make an appointment with an LC to make sure baby was transferring milk effectively and that mom's supply was OK and being maintained. I would also have talked to them about ways to avoid confusion while supplementing with the bottle, and/or alternative supplementation methods to prevent nipple confusion. Am I glad that they didn't need this help? Yes, but it's that dodged-a-bullet feeling.

I asked one of the LCs about how she gets people to call when they get the order to supplement, and she said she tells parents, "If the doctor tells you to supplement, please call me so I can show you how to supplement without using a bottle." I think that's a good way to 1) avoid nipple/flow confusion and 2) get in to assess what other problems are contributing to the situation. I'm going to try that line in the future.

And pediatricians: Hello. You have a mother in front of you who wants to exclusively breastfeed. Her baby is not gaining enough weight on exclusive breastfeeding. Obviously, the first thing to do is always "FEED THE BABY" (as a page in my breastfeeding educator manual says in huge bolded letters). So now you have fixed ONE problem by ensuring the baby is eating enough. Take another step to get to problem number TWO: what is going on with breastfeeding and how can it be fixed? Yes, this is your responsibility, particularly since your fix to problem one is likely to make problem two even worse. It is so discouraging when pediatricians talk a great line on breastfeeding but don't do much to support it.

I'm not hating on all peds; there are great, supportive, knowledgeable pediatricians out there, and they can and do give excellent advice and refer to lactation consultants when needed. It just sucks when you run into the ones who do NOT.

IBCLC training update

Last week one of the LCs at the hospital was out sick, and I ended up not really being able to shadow and going home early. It reinforced to me how much I enjoy my LC shadowing and miss it when I don't get to do it!

But I did spend some time, while waiting around, thinking about how I want to structure my LC training. Our course gives us a basic framework, but as it's the first year of the course and there has been some instructor upheaval, a fair amount is on us to organize. And I do feel the need to make sure I am exposed to a the whole range of LC practice; we get to see interesting cases at the hospital, but it's a little catch-as-catch-can and I feel it's important to seek out exposure to problems I might not encounter there. In addition, going once a week I miss the continuity and follow-up process. One of the LCs at the hospital (who, like us, came from a non-nursing background) showed us a "blueprint" notebook she used to organize and document her learning and training. It seemed so useful for making sure all the pertinent issues are covered; I'm thinking about getting one myself. Anyone have thoughts/other suggestions on helpful ways to make sure you're covering what you need to in IBCLC observation?

So far I haven't been putting in the suggested extra hours each week outside the hospital, at LLL meetings or other venues. I started the semester overwhelmed by my class load, assistantship, and extracurricular commitments, but now that things have stabilized a little it would be good to get the outside observation going. I am also laying big plans for next semester, when I will only be taking my LC course, one online course, and writing my master's paper (additional info on master's paper to come, but hopefully I will be working with a local Centering Pregnancy program!) That's when I really want to set up a schedule shadowing outside (non-hospital-based) LCs, attending breastfeeding support groups, and generally maximizing my exposure to lots of different breastfeeding concerns/situations. Once graduation rolls around (May) I will have two months left until the certification exam, and I am hoping to pack more observation and experience into that time...along with studying. Lots and lots of studying.

The week before last I had my first "hands on" experience. The LC had me go in and do the assessment and assistance with the mom, while she observed. Fortunately it was a sweet mom who was so excited about her new baby and about breastfeeding, and just needed a little reassurance and teaching. I forgot a couple of teaching items (I need a checklist), but fortunately the LC was right there to fill in those gaps. I corrected a couple things about the latch (lower lip tucked in, jaw not down well) and the LC agreed with me and we got the baby latched on and eating great.

I was feeling good until we went to the next room. The LC stepped out to get something while I helped the mom latch on one side. She seemed to feel OK and baby seemed to be sucking fine. When the LC came back, she helped the baby latch on very deeply to the other side. "Oh, wow, this latch feels so much better!" the mom said. So I think I missed seeing a shallow latch on the first side, and it felt discouraging to have missed something that simple, something I generally feel very confident about assessing in my doula role. Looking back, I think I was not assertive enough about getting in there and checking. The women I'm working with know I'm a student, and it makes me nervous about being too hands-on and taking over the LC role too early, especially if my preceptor isn't right there. I need to either step back until I get that confidence, or call up some of that confidence and use it! Anyway, hoping for more hands-on experience this week... and a confidence boost.