Tuesday, June 14, 2011

Misinformation's Role in Breastfeeding

A friend of mine is a doula as well.  She had a client deliver a baby in an uncomplicated, unmedicated full term birth last week.   There were no complications, the baby latched on within the first hour of birth, and was nursing every 2-3 hours in the first days after birth.

Everything was going about as perfect as it could be.

Until she went to the doctor when the baby was three days old. 

The baby, who weighed about 7  pounds at birth, had lost a few ounces.  Mom's milk wasn't in yet. 

The pediatrician recommended formula supplementation due to the concerns about the baby's weight.   The baby, who again, was full term and was not experiencing any problems with blood sugar or jaundice.

This is an example of a place where the medical system is failing families.

Did you know that most medical schools provide very little, if any education at all, about lactation?  How exactly are the physicians supposed to teach patients about nursing if they've had little education in it themselves?

Most pediatricians and obstetricians are given huge supplies of free formula to distribute to their patients as "gifts".  What's the harm in taking a sample, right?  The harm, I would argue, is tremendous. 

The truth is that healthy, term infants almost never need supplementation.

Babies are supposed to drink only the colostrum the mother produces for the first few days.  This early milk is incredibly nutrient rich, and serves as a laxative to help the baby purge the meconium from their system to help avoid jaundice.

It is those first few days, with only the colostrum, and the increasing hunger of the baby, that causes the mother's milk supply to come in adequately.  Giving a bottle here or there will interfere with the supply being established correctly.

Feeding a newborn a bottle will teach them that food comes immediately.  In my experience, this will interfere with nursing perhaps more than anything else.   It is because in nursing, the baby has to latch and suck long enough to trigger the let down reflex.  The milk does not start flowing immediately.  Giving the baby a bottle, which works immediately, interferes with the baby's natural feeding process.

Thousands, if not millions, of well -intentioned first time moms have reluctantly supplemented after being told their babies were losing weight in those first few days.  Trouble is....THIS IS NORMAL.  Healthy, term babies can easily tolerate losing up to 5-10% of their body weight in those days.  It isn't a cause for alarm, especially before the mother's milk comes in.  Unfortunately, this is where doctors begin to show concern and mothers start to doubt their body's ability to nourish the baby without artificial assistance. 

Once that doubt sets in, it's a recipe for disaster.  Loss of confidence in nursing undermines the overall confidence in parenting.  Moms can start to feel like they are failing their baby.  They give a bottle, then the baby gets frustrated quickly at the breast.  They eventually give up.  And for what reason?  The loss of a few ounces that the baby is designed to lose anyway? 

The better guideline is that a newborn should be nursed on demand, but not less frequently than every 3 hours, timed by the start time of the feeding.  They should not lose more than 10% of their body weight, and should return to their birth weight by two weeks.  If those goals are not reached, it still does not automatically mean that formula is the solution. 

Often, the best way to reassure a new mother that the baby is eating well is to weigh them before and immediately after a feeding.  Many breastfeeding support groups have scales available for this purpose.  This reassure mothers that they are indeed producing an adequate supply. 

Another big misconception is that pacifiers will create nipple confusion.  I do not believe this to be true for the simple reason that pacifiers do not feed the baby.  A baby will learn quickly that milk does not come from a pacifier, and will use it for sucking needs that exist outside the need to eat.  I encourage new mothers to wait until nursing is established and the milk supply fully in before giving a pacifier.  Beyond that, if the baby has a high suck need, by all means, use a pacifier. 

Bottle feeding can be a great way for the father and other family members to bond with the baby.  Again, as with pacifiers, once nursing is well established, it can be added to the routine without major incident.  Wait until the milk supply is fully established, then give a bottle every other day or so at one feeding.  For the first few months, the mother should pump during every bottle feeding.

When bottle feeding, it is important that breast milk not be combined in the same container as formula.

I could write books about this subject, but I will stop here for now.  I will address pumping, milk insufficiency and formula feeding in later posts.  If you have any specific questions, please feel free to ask!

Sunday, June 5, 2011

Am I in labor?

Labor is the culmination of months of gestation, the precursor to birth, and the turning point of the greatest significance in a pregnancy. 

Yet, it's often one of the hardest things about pregnancy to define.

In this day and age, most women go into their pregnancies, particularly their first ones, with expectations about how it will go.  They've been brainwashed by television and movies, about the sudden arrival of labor, usually by a dramatic burst of water.  Screaming and yelling ensues, and shortly thereafter a baby arrives.

Trouble is, it hardly ever works that way. 

I'd like to try and clear up some of the misconceptions about labor here, and help you determine when labor actually begins.  It's not usually a black and white issue, more shades of gray.

- Only about 10% of women will have their amniotic sac rupture prior to the onset of labor.   Far more likely, you will experience hours or even days of contractions prior to a spontaneous rupture.  Left alone, most women will not have their water break until they reach about 5 or 6 cm dilation.  If your water breaks, even if you aren't in labor, you need to go to the hospital or call your midwife.

- You only have a 5% chance of having the baby on your actual due date.  Some babies come early, some babies come late, very few of them actually show up on the day you circled on that calendar.  Most women should be prepared to labor anytime after 37 weeks, though it can begin earlier for some.

- Your due date isn't an expiration date.  Left alone, most first pregnancies would go postdates.  What this means is that if you get to your due date, then pass it, and still don't have a baby, it doesn't mean that there is anything wrong.  The average first pregnancy left alone would be closer to 41 1/2 weeks, not the 40 we are accustomed to.  Healthy women with uncomplicated pregnancies can go two to three weeks past their due date without medical concern usually.

- You may not know when you are actually in labor, especially if it's the first time.  Assuming that it begins on it's own, labor is a very gradual process.  You experience an increase in Braxton-Hicks contractions, which eventually turn into pre-labor contractions.  Those eventually turn into early labor, and it's often difficult if not impossible to know when you've crossed the line for good. 

- Many women have false alarms, particularly as the Braxton-Hicks contractions increase.  They can occasionally become a little painful even.  It is normal to have these false alarms, but still frustrating.

- The hallmark of true labor are contractions that do not go away with changes in activity.  Towards the end of your pregnancy, you may notice that you have contractions when you are tired or have over-done it.  Dehydration can also trigger contractions.  Getting rest and staying adequately hydrated will lessen these type of contractions eventually.  If they keep coming no matter what you do, it is more likely to be true labor.

- Most women have digestive problems prior to the full onset of labor.  You may become nauseous or have diarrhea.  You may not feel like eating at all, but should focus on light meals.  Many women also have headaches and backaches before labor.  Nesting is common, a sudden urge to clean or organize the baby's room.  None of these are slam dunk signs that labor is near, but they often are precursors.

- Early labor can last for hours or even days for some women.  At this stage, you have decent breaks between contractions, and they still may be somewhat irregular.  You aren't too uncomfortable and can go on with your normal activity levels.  Many women never realize they are in this stage, particularly with a first baby.  In this stage, you should focus on resting when you need to and eating lightly. 

- The average first labor is 14 hours.  This is the time that mother perceives labor, though in most cases it has undoubtedly been longer than that.  The natural labor process brings with it a gradual increase in endorphins, which enables the mother to tolerate the increasing discomfort from the contractions.  Having said that, 14 hours is an average.  Some women have very rapid labors, some have very prolonged labors.

- It is common to wake up in full blown labor or having had your water break.  This is because of the fact that it's often possible to sleep through the earliest stages of labor.  Your body is in a relaxed state during sleep, and the contractions are often far more effective than they are when you are awake. 

- I don't rely on any time frame or charting to decide when to go to the hospital.  From my personal experiences, and those of my clients, they are good tools generally, but seem not to apply more often than they do.  I'm referring to the 1 minute contraction, every 5 minutes, for 1 hour rule.  Some women have extremely effective contractions every 10 minutes.  Some can contract every 5 minutes for 12 hours with almost no cervical change.  I look to the other symptoms for guidance of when to go.
    * Drastic increase in discharge, or bloody show
    * Increased pressure
    * Back pain with contractions that increases over time
    * Inability to talk during contractions

- You really can't judge how you will do with tolerating labor until you've been there.  Some women have astonishingly high pain tolerances, others sense every twinge and it becomes unbearable quickly.

- Most hospitals will not admit you unless you are 3-4cm and having regular contractions at least every 5 minutes. 

If you aren't sure you are in labor, it never hurts to call your doctor or midwife.  Chances are that they will want you to come in and be checked.  Good luck!!! 

Thursday, April 21, 2011

Postpartum Recovery

When you are pregnant, you imagine what it's going to be like after the baby is born.  You have these visions in your head of maternal bliss. 

Then you get there. 

And it's not very much like you thought it would be.

You are sore, and you ache.  You are tired and emotional.  And you are overwhelmed.

Here's a practical guide of what to expect and how to get through the first few weeks.

Dizziness and Instability - Right after birth, you may feel dizzy and unstable.  Ask your partner or nurse to help (or stay close) when you get up to use the bathroom and shower for a few days.  You've lost a lot of blood and fluid.  It is very important to stay hydrated.

Sleepiness and/or Insomnia - Both are common.  You've just been through a tremendously exhausting experience, and the adrenaline keeps you going for a while.  After it wears off, it is common to be extremely sleepy. 

Bleeding and Discharge - You will bleed, whether you had a vaginal delivery or c-section.  The first few days will be heavier, bright red blood with occasional clots.  It is normal to pass small clots.  If you pass anything larger than a quarter, let your care provider know.  Usually, passing a lot of clots can be a sign that you are overdoing it.  Rest and let your body heal.  After a few days, the discharge will gradually change to what is referred to as lochia.  It can be pinkish, brownish or even white, and will last for a few more days to a couple weeks.    Before you are discharged from the hospital, ask for some of the large maternity pads to take home, as well as a spare pair or two of the mesh disposable panties.  They are so unattractive, but will be your best friend.

Cramping - You will experience cramping for weeks after birth, the most noticeable in the days right after.  The cramps will be stronger with nursing, and will continue until your uterus returns to it's pre-pregnancy size, about 6 weeks from birth.  You can use over the counter pain relievers to help manage the pain.

Muscle aches and pains - Some women come out of labor feeling a bit like they've been run over by a truck.  Labor is hard work.  Pushing is hard work.  It's common to feel soreness in areas you aren't expecting to, like your arms or back.

Headache - These are common after birth, often due to sleep deprivation and dehydration.  If you had an epidural (or spinal)  have a sudden very painful headache, it's possible it is a spinal headache.  Let your nurse know immediately, as there are specific treatments for those headaches.  One of the best ways to know if it is a spinal headache is if it resolves by laying completely flat.  If so, it's probably a spinal headache.  They can last a few days if not treated.

Incision pain - If you had a c-section, you will have a two-fold recovery.  In addition to the recovery from the pregnancy itself, you are recovering from major abdominal surgery too.  Resist the urge to just lay down and rest all the time, you are better off if you keep a low, but tolerable level of activity.  Check your incision daily for signs of infection.  Do not lift anything heavier than your baby for 6 weeks (this includes the car seat carrier - let someone else do that).   Let people help you.

Swelling - Many women experience significant swelling in the postpartum period, often even worse than the swelling at the end of pregnancy.  The best thing you can do is to continue to drink lots of fluids, and maintain a tolerable level of activity.  If your swelling continues to worsen, discuss it with your care provider. 

Fear of using the bathroom - This is very common.  Particularly if you experienced any vaginal tearing or hemorrhoids, it is common to resist the urge to have a bowel movement.  Don't.  Waiting will only make it worse.  Use stool softeners, and be sure to eat lots of fiber rich foods. 

Vaginal tears and swelling- Whether you had an episiotomy or not, many women have some degree of vaginal tearing after birth.  Immediately after birth, they will place on ice pack on your perineal area.  If this helps, you can ask for more ice packs while you are in the hospital.  Ask your nurse for a squirt bottle, and use it with warm water while urinating and defecating.  It will dilute the acidity of your urine so it stings less, and help cleanse the area as well.  In addition to the squirt bottle, witch hazel pads can help with swollen tender areas.  There is also a spray called "epi-foam" that works to numb the area temporarily.  Ask your nurse about these items as soon as you get into the recovery room.   Also, even the day of birth, start doing Kegel exercises.

Trouble urinating - This is also quite common, especially if you had a large baby or vaginal tears.  Using the squirt bottle can help trigger urination and make it less painful.  If you truly find that you cannot urinate, let your nurse know asap.

Hemorrhoids - These pesky veins make their appearance for some women toward the end of pregnancy or after pushing.  They can be internal or external, and can swell quite large and even bleed.  Ask your nurse for witch hazel pads, and be sure to use stool softeners until they are reduced.   Keep your activity level up, and try to avoid sitting in one position for too long while you have them.  If they get worse, contact your care provider.

Intense hunger - It's said that a woman in labor burns as many calories as a marathon runner, and I've found that to be the case.  You emerge from labor voraciously hungry.  Be sure to eat balanced meals, full of protein and fiber.  You need to ensure you are drinking enough water as well.  While nursing, you will need about 500 more calories to produce milk, make them count. 

Rapid weight loss - At the time of birth, you will lose about 10-15 pounds automatically between the baby, the amniotic fluid, the placenta and blood.  You will continue to lose weight over the next few weeks, from a decrease in blood volume and fluid.  Do not expect that your body will go back to the way it was before, though.  Your uterus doesn't even return to it's pre-pregnancy size for 6 weeks.  You can begin exercising around 6 weeks with your physician's advice. 

Roller coaster emotions - There will be some dramatic ups and downs in the days and weeks after labor.  This is common and expected.  If you feel, however, that you are spending more and more time feeling sad or detached from the baby, let your partner and care provider know.  The baby blues are very common and will pass, but post-partum depression is a more serious matter.  Do not be afraid to ask for help.

Hair loss and skin changes - It is very common to lose a lot of hair in the first few weeks postpartum.  Do not be alarmed.  Many women break out in acne after birth too.  If you developed stretch marks during pregnancy, they may begin to fade.  Eventually they will lighten to a whitish color, but the elasticity may never return.

Breast swelling, tenderness and warmth - Your breasts will swell in the first few days after birth.  Immediately after birth (and before as well), your body is producing pre-milk called colostrum.  It is nutrient rich and provides all kinds of benefits to newborns.  Just because there isn't a lot of it doesn't mean it isn't enough.  Healthy, term breastfed babies do not need supplemented in the first few days.  As your milk begins to come in, you may experience excessive swelling, referred to as engorgement.  This is temporary.  Expressing a little milk before each nursing session may reduce the swelling enough to help the baby latch.  Your breasts may feel heavy and warm and quite sore to the touch.  Ice packs can help some women, heat packs help others.  There are cooling gel packs you can place in your bra as well.  You should have some soft, stretchy bras to wear in the first weeks, as you will probably feel better with light support, even at night.

Leaky breasts - It is very common to experience leaking, especially with a first baby.  Your body is trying to figure out how much milk to make, and it's not a perfect system.  Often when nursing, the other side will leak.  There are disposable breast pads, but I found that washable cotton ones worked better. 

Sore nipples - The first few weeks of nursing are a time of trial and error.  I wish that it was always a natural, beautiful, easy thing.  It's not.  Work with your nurse and a lactation consultant before leaving to hospital to ensure that the baby is latching on correctly.  You may feel sharp stinging at first, but it should not last through the entire nursing session.  It will get better with time.  To ease nipple soreness, let them air dry as often as possible.  Lanolin creams help as well.  The best thing you can do is make sure your position is good, the latch is correct.  With time, your body will adjust. 

Overstimulated - After going through the birth process, it's common to feel touched out.  Too many people have seen too much, you have been too exposed, too many demands have been and are being placed on your body.  It's normal to feel this way.  Try to find time to relax and soothe your self, take long showers while someone else is watching the baby. 

Postpartum Check-up - If you had a c-section, your doctor will probably want to see you in a week or two.  If you had a vaginal delivery, it is more likely to be six weeks.  In the meantime, take care of yourself.  Rest when you can, don't over-do it.  If you have any of the following warning signs, contact your physician immediately:
  •     soaking more than a pad an hour
  •     vaginal discharge has a foul odor
  •     you have a fever over 100.4F
  •     you are passing large clots
  •     you develop a severe headache
  •     your incision is not healing properly
Good luck!  This is a short period of time, and it is completely worth it!  Relax, rest, recover.  And love on that baby.  :)

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