Book Review: Nursing Mother, Working Mother

I found this book damn near perfect. It seamlessly combines all the practical advice a working mother needs about pumping and storing her milk with the emotional wisdom about how to meld the two spheres of a working mother's life in a way that is mutually beneficial for all parties involved, especially her baby. The authors also give a nice nod to all of the working mothers in our anthropological history and point out that the phenomenon of stay at home "homemaker" mothers is a relatively recent one. The book continually emphasizes that a healthy attachment is the best way to minimize the effects of frequent lengthy separations on mother and baby. There were great tips on living life as a nursing, working mother unapologetically in both realms. I really enjoyed the discussion of how women are often encouraged to "compartmentalize" their lives, minimizing their role as a mother in the workplace in order to be seen as able to compete with men. Women entered the workplace often attempting to emulate men, while the authors postulate that a better option is for women to offer our unique set of strengths and talents. There are some excellent tips for maintaining credibility in the workplace after having a baby and avoiding the "mommy track."

Inspirational and empowering, I highly recommend this to all mothers, working outside the home or not, to foster respect amongst ourselves for all the different shapes and forms motherhood can take.

Big Push!

Want to protect and promote midwifery care? Get thee to the Big Push for Midwives, which launched this week.
"Increasing access to the Midwives Model of Care in all settings is essential to the health and well-being of childbearing women and their babies. The National Birth Policy Coalition supports legislative initiatives that promote the autonomous practice of Certified Professional Midwives and Certified Nurse-Midwives, and that ensure the availability of safe, evidence-based care during pregnancy, labor, birth and postpartum."
If you live in one of the states that has legislation coming up in 2008, please consider getting involved in the Push's efforts to get midwifery regulated and licensed there. Women deserve access to the gold standard of care for their reproductive health -- and that means we need midwives!

Birth Options & Reproductive Rights

There's a lovely post about birth choices as part of the spectrum of reproductive freedom over at RH Reality Check today.

What many of us have missed in our critique of these shortcomings is that the same oppressive cultural mechanisms that restrict women's abilities to make fully informed decisions about when to have children also affect their decisions regarding where, how, and with whom to birth those children.

Yes! Go check it out.


Birth Setting and Its Impact on Breastfeeding Initiation and Success, Part 2

Fun fact: In a completely normal, non-interventive birth, the newborn baby has the ability to crawl up its mother's abdomen, locate the nipple, and latch on all by itself. Babies are born with amazing abilities and reflexes to ensure bonding -- and their very survival -- that many people never see. Newborn self-attachment (or the "breast crawl") is a cool phenomenon, but it's not the only way to get breastfeeding off to a good start. What's another method? See a midwife for your pregnancy, birth, and postpartum needs!

What Do Midwives Do to Support Breastfeeding?
The number one thing midwives do to support breastfeeding is that they don't interfere unnecessarily in labor and birth. Midwives understand normal, physiological birth, and they respect breastfeeding as an intrinsic part of the birth process.

Immediately after a midwife-assisted birth, the baby is placed on its mother’s abdomen or in her arms. Assuming all is well (and it usually is), basic assessments, toweling off, and other immediate needs can be addressed while the baby stays right there. The first breastfeeding can take place as soon as mother and baby are both ready, often within moments of birth. Weighing, measuring, the newborn exam, vitamin K, etc. can all wait for an hour or two while the new family bonds and enjoys each other.

What's happening in these first minutes of life? A complex, amazing hormonal fiesta, for one.
The star of the show is oxytocin, the "love" or "mothering" hormone. Oxytocin is secreted during sex, orgasm, labor, birth, and breastfeeding. Mother and baby also experience surges of adrenaline and endorphins (which may play a part in bonding because endorphins function similarly to opiates). Finally, prolactin, the main hormone responsible for making and secreting breastmilk, peaks at birth. In these first minutes of life, the baby adjusts to the world outside the womb. The parents get to marvel at the new person they have made. Depending on who you ask, the first minutes and hours of a baby's life may even play a large role in who that baby becomes as a person.

When mother and baby are ready to nurse, the midwife offers guidance and advice, if needed. She will also note whether there are any factors that may have an impact on breastfeeding (such as tongue-tie) and make the mother aware of them. She will also add to her prenatal education of the couple by reiterating what is normal, what isn't, and making sure the mother is comfortable in this new role.

The midwife stays with the family for several hours following birth. She returns three times in the first week of life, and is available to her clients for additional counseling, support, and home visits if needed. If a new mother experiences difficulties breastfeeding, her midwife likely has all the skills needed to help her. She can also make referrals to La Leche League leaders, lactation consultants, and pediatricians, all of whom can play a role in supporting the breastfeeding relationship.

A baby who is assisted in its entry into the world is a lucky -- and almost certainly breastfed! -- baby indeed!

This about sums it up...

This quote from a birth center midwife in Florida explains what we mean about unravelling the tangled threads about birth better than I can (bolding mine):

"For hundreds and perhaps thousands of years, women have listened with rapt attention to other women telling the story of birth: what it feels like, how it progresses and what can happen.

In that regard, nothing has changed. Pregnant women still yearn to hear the truth about the transformation of their bodies and the mystical event that is birth. In fact, they are as curious as ever! But what used to be an intimate conversation between a women and her doctor or midwife, or a woman and her female family members, has become a much larger, more scrambled conversation."

— Sheri Menelli
Excerpted from "Positive Birth Stories," Midwifery Today, Issue 84

A beautiful thing one of my doula clients told me today that many women she knows, her husband, and even her mother have been telling her that they think her birth is going to go well, and that it will be smooth and easy. What a refreshing change from what most pregnant women hear, which is "well, we'll see. I was planning a natural birth too until happened and I was begging for the epidural. And thank goodness for my C-section or my baby would have died."

How could our birth culture change just by this simple shift in consciousness? Instead of regaling the expectant mother with stories that only inspire fear, to simply say "I believe in you. I trust your body to give birth." Studies have shown that birth outcomes by having a doula simply sitting in a chair in the room, doing nothing fancy. Could it bit that having another woman there inspires that much trust and confidence in the birthing mother?

Currently most pregnant women learn about birth from the media, the sensational, line-in-the sand drawing media. The debates rage on about scheduled cesareans for those "too posh to push", drawing quotes and attention from those few physicians who feel an elective cesarean at 38 weeks is safest for everyone. The media bickers about everything from epidurals to homebirths, to VBAC and everything in between. These debates are chosen based how good the sound byte is, not usually because there's any compelling reason to be discussing it. Long before women in America get pregnant they have seen countless birth "emergencies" played out on sitcoms, where the expectant mother races off to the hospital just moments after her water breaks in a public place (a phenomenon that occurs less than 14% of the time, by the way.) Most women of childbearing age today are daughters of mothers who experienced the beginning of the wave of technological birth that has yet to peak. We are daughters of cesareans, spinals, Demerol, episiotomies, enemas, and some even of twilight sleep. Is it any wonder we don't draw much power from the stories of our mothers?

I imagine a world in which little girls and boys grow up hearing stories about the beauty and magic and power of birth. When they can listen to their birth story and want to hear it again and again because their mother recalls it with a smile. I want the fabric of our culture to change, where we stop the stories of horror and encourage women with positivity. Where children have an understanding that by and large, birth is a normal and physiological event, and that yes, sometimes things don't go as planned and every once in a while we need the trained hands of a surgical specialist. This is the world in which I want my daughters to grow. They will hear their birth stories as many times as they care to listen, and I hope they will see the work I do as important and special. Most of all, I want more for their possible future births than what the system offers the vast majority of American women today.


Fill your belly, feed your baby: the importance of nutrition in pregnancy

What if there were a way to decrease complications of pregnancy and birth like pre-eclampsia, anemia, and hemmorhage? If you could be free of common pregnancy ailments like morning sickness, heartburn, muscle cramps, even itchy skin and swollen ankles? What if you could feel full of vitality throughout your pregnancy and beyond, helping to assure an abundant supply of breastmilk for your baby during the exhausting post-partum newborn days? And if you could do all of these things with absolutely no risks or side effects for your baby, other than being born healthy and plump? If I told you that this was as big of a factor in determining a healthy pregnancy as your genetic disposition, except that you only you can provide these healthy advantages and are in complete control of them, would you be interested? Eating well provides all of this and more for you and your baby throughout pregnancy and beyond. Yet all many care providers tell pregnant women about nutrition is “Just eat a good diet and you’ll be fine.”

Do we know what a “good diet” is? In our culture of fad diets, quick fixes and fast food, where do we find the resources to help us reap the rewards of eating for two? In our society of Western medicine, nutrition is overlooked even though it is often the most obvious solution to our health problems. We have dozens of pharmaceutical remedies for lowering cholesterol and preventing heart attacks, but how many people on these drugs could benefit just as much if not more by altering their diet and exercising? How many of us suffering from chronic pain rely on the constant use of analgesics instead of working to discover the source of our pain? In the midwifery model of care, nutrition is the foundation of a healthy pregnancy, used to prevent problems and complications of pregnancy and birth rather than attempting to treat them after they arise.

What we eat directly affects all of our body systems. Quite literally, we are what we eat. Our body is constantly rebuilding and repairing itself, and it uses the nutrients from food to do this important work. Especially in early pregnancy, what you eat directly affects the life your body is building and supporting. Growing a baby also means growing a placenta, membranes, and drastically increasing your own blood supply. This is all powered by the food you eat. Your baby needs the most iron, protein, and calcium in the last eight to twelve weeks of pregnancy, so it is never too late to improve nutritional status. Certain vitamins have been identified as playing huge roles in preventing problems for the baby, such as folic acid, which taken preconception and in early pregnancy can reduce the risk of devastating neural tube defects by as much as two thirds. Mothers who are at risk for developing hypertension benefit from calcium supplementation. These are just two examples of what scientific studies have proven to be true about nutritional remedies, and new compounds are constantly being discovered in food. A good diet could prove to have benefits we don’t even know about yet.

We do know that the days of limiting weight gain and attempting to grow small babies in hopes of easier deliveries are gone. The vast majority of modern women are unaffected by rickets, a skeletal disease which led women to have difficulties in childbirth due to misshapen pelvises. Today, we understand that women rarely grow a baby that they cannot birth, and that the pelvis is much more flexible than we once imagined. Women often imagine that it is easier to deliver a smaller baby than a large one, but the largest part of the baby, the head, varies in size only slightly between a 5 pound baby and a 10 pound one. Babies lose weight during the first few days after birth while waiting for the mother’s milk to come in, so it is imperative that they have some extra ounces to lose. Extra fat helps cushion the baby down the tight squeeze of the birth canal. Your baby is also building the store of iron she will draw upon for the first six months of life. Babies need their mothers to fill their bellies with yummy, nutritious food! Mothers also need to put on extra fat in preparation for breastfeeding. There is no need to worry about pounds gained from healthy food, these will be pounds used in producing milk.

Every pregnant woman needs a treat sometimes, and eating should be fun and pleasureable in addition to being healthy. The purpose of encouraging expectant mothers to eat well is not to create anxiety or promote analyzing every bite of food. If you're in Albuquerque and are interested in learning more about pregnancy nutrition, please join us for a class on the last Monday of every month from 6-8pm at the ABQ Birth Network, 123 Wellesley SE. Check http://www.albuquerquebirthnetwork.org/ for more details and information on other classes.


"When precious minutes count"

Actual slogan for the Labor'Lert device being hawked to expectant mothers.

It comes in four attractive colors and handily counts down to your due date -- by month, day, and hour! Oh, and "only Labor'Lert accurately times the length and frequency of your contractions" (you didn't think you could do it yourself, did you, foolish woman?), and tells you exactly how long it's been since your last one (so you can anticipate the next one with glee!).

On the plus side, it is shaped like an egg. Since my three-year-old thinks babies come out by cracking their mothers' uteri like an egg, I guess that's kind of appropriate.


Birth Setting and Its Impact on Breastfeeding Initiation and Success (Part 1)

While you may already be aware that women who birth with midwife support have higher breastfeeding initiation rates and greater long-term success, you may not know that women who birth in the hospital without the support of a midwife may have their breastfeeding relationship undermined -- often before the baby is even born.

Management of Labor and Birth
Let's take a look at some of the ways breastfeeding may be undermined in a medically managed childbirth. Any of the following factors in isolation can hinder breastfeeding; in combination, they may prove to be extremely tricky for any but the most determined mother.

Drugs for Pain Relief
Narcotics, nitrous, epidural, oh my! The potential cocktail of drugs that may make their way into a laboring woman's body (and, crossing the placental barrier, the infant) is staggering. Narcotics can make both mother and baby sleepy and uncoordinated, and they run the (rare) risk of infant respiratory distress and/or unresponsiveness, which can last several days. Every anesthesiologist has his/her own b
lend of drugs for epidural anesthesia, so the effects of epidural vary. However, epidural pain relief is associated with fetal distress, drowsiness, poor sucking reflexes, and other newborn complications such as jaundice, which may impact the breastfeeding relationship.

Pharmaceutical pain relief of any stripe increases the potential need for interventions such as vacuum extraction, forceps, or cesarean delivery, all of which have their own associated breastfeeding impact. Other drugs during labor that can affect breastfeeding include pitocin, diuretics, anti-histamines, and magnesium sulfate.

Drugs ingested by the mother post-delivery also affect the breastfed baby. In fact, the FDA recently warned post-op mothers taking codeine (which the body converts to morphine) to watch for sleepiness and other side effects in their infants. A significant portion of the population metabolizes this drug so quickly that high levels of morphine will be present in their breast milk. In addition to the overall worry about overdose, a sleepy baby can be difficult to interest in nursing. Less suckling leads to lowered milk supply, as the supply/demand cycle of milk production relies on regular stimulation by the baby of the mother's breast.

IV Fluids
Bag after bag of IV fluids overload the body, causing edema (swelling). This can be problematic for the new mother because it can make the tissue under and around the areola too firm, even having a somewhat flattening effect on the nipple; it can also add to existing engorgement after her milk comes in. Babies need and expect a soft, pliable nipple and areola, so the swelling can make latching on painful or difficult.

IV fluids also pose the risk of artificially excessive weight loss in the infant in the first few days after birth. Because fluid overload can affect the baby as well, its birth weight may be inflated; when he or she processes and eliminates these extra fluids in the days following birth, that weight loss may prompt a misdiagnosis of breastfeeding difficulties, leading to more interventions.

Although it is occasionally indicated to help clear the airway, routine suctioning of the newborn's mouth and nose has been proven unnecessary, many doctors continue the practice vigorously during every delivery. This can traumatize the baby, especially if suctioning is roughly done or causes the baby pain, and lead an aversion to anything touching or entering the mouth. In extreme cases, the infant will attempt to reject any contact with its mouth or lips following this experience. In addition to the obvious mechanical difficulties suctioning can cause for breastfeeding initiation, feelings of rejection by her infant can undermine a mother's confidence in her ability to nourish him/her at the breast. A mother who states that her baby "didn't like" the breast likely had a traumatic suctioning experience or received early supplementation from a bottle.

Maternal Discomfort
A mother who receives an episiotomy during vaginal birth, or who delivers via cesarean, is likely to be in some pain (perhaps necessitating more drugs... see above). Just finding a comfortable position in which to nurse can be a barrier. New mothers should, ideally, be able to maneuver themselves and their nurslings into different positions to alleviate sore nipples and accommodate personal positional preferences for both mother and baby. Not being able to do so can aggravate problems and frustrate the mother.

According to Dr. Ruth Lawrence, "comfort sucking and formation of nipple preference are genetically determined behaviors for imprinting to the mother's nipple." Though some dispute the phenomenon of "nipple preference" in babies whose first feeding comes from a bottle, research clearly indicates that these babies have to be reprogrammed for the breast. Even a pacifier can disrupt early breastfeeding efforts.

Babies considered high risk for hypoglycemia (cesarean deliveries, large babies, those born to mothers with diabetes) may be supplemented with glucose water or formula even without a diagnosis of any blood sugar issues. Unfortunately, this can make the babies' blood sugar rise and then crash later. Colostrum has plenty of lactose to help elevate baby's blood sugar, and it also has plenty of protein to stabilize it. Breastfeeding every two hours is almost always the best treatment for hypoglycemia; even just skin-to-skin contact between mother and baby helps regular infant blood sugar.

Separation of Mother and Baby
Breastfeeding early and often is the most basic and effective way to ensure success. The first nursing should take place within at hour at most; delaying that first feeding disrupts hormone levels, impacts the milk supply, and even delays mature milk's arrival. The baby may be at risk of dehydration or excessive weight loss, which can lead to formula supplementation.

Babies also need as many feedings of the first milk, colostrum, as possible to receive its full immunological benefits and protect them from hypoglycemia and jaundice. When the nursing dyad's first feeding is delayed by hours, the baby will likely receive supplementation with formula (causing nipple confusion issues as addressed above, and often resulting in many supplemental feedings in those first critical days).

Unfortunately, constant mother-baby togetherness is the exception rather than the rule in the hospital environment. Even with a normal, healthy delivery, babies are usually removed from mothers' arms for assessments. Check-ups by the on-call pediatricians, baths, weighing, and administering medication are usually performed in the hospital nursery for convenience's sake -- at the expense of bonding and breastfeeding. And despite the increasing ubiquitousness of rooming-in, many L&D nurses will still offer to take newborns to the nursery for an overnight stretch to "let mother rest."

With a c-section delivery, you and your baby will likely experience all of the above, and more. We've covered how pain, drugs, separation from the baby, and (likely) supplementation can affect breastfeeding. Cesarean delivery also poses an increased likelihood of long separation (sometimes several hours, making supplementation more likely). Women also lose about twice as much blood during c-section as during vaginal delivery. It is normal for a mother's milk to take an additional 1-2 days to come in following c-section. More worryingly, however, is the increased likelihood of anemia for these mothers, putting them at high risk of insufficient milk supply.

Lactation "Support" (Or Lack Thereof)
In the medical model, the language and protocols surrounding pregnancy and birth undermine women’s confidence. Women who want a natural birth are warned not to be disappointed if it doesn’t happen. They’re told that breastfeeding is best, “if it works out,” and if it’s not going well, they’re told to “stop banging their heads against the wall." Unfortunately, having this negative language surrounding these normal physiological processes leads many women to doubt their ability to perform them. And if they do encounter difficulties, they are more likely to give up.

Most doctors don’t receive any training in supporting breastfeeding mothers and some aren’t even aware of all the benefits. The “help” moms get with their first breastfeeding in the hospital from a doctor or nurse may not be all that helpful; it’s frequently very high-pressure and ignores the baby’s cues. Lactation specialists, if a hospital has them on staff, often only work 9-5 on weekdays. Sadly many women never receive any specialized assistance with breastfeeding and are left to figure out solutions on their own -- or not.

And On That Happy Note...
Obviously, many nursing dyads overcome all these obstacles and more -- or never even experience them as being obstacles to a satisfying nursing relationship. However, it's important to be aware that everything we do to a woman in labor, even if it seems innocuous, or even if it's just hospital policy, can have an impact on her ability to breastfeed her baby.

In upcoming posts, I'll address how midwifery care differs in its support for breastfeeding, and also cover some tips for overcoming the breastfeeding hurdles posed by routine hospital interventions.


The Business of Being Born

Last night Texas State University screened Ricki Lake's new documentary The Business of Being Born. Having seen the film twice now, I am officially in the thumbs-up camp. I think those of us who are in the birth community are so familiar with this stuff that we get jaded, and we forget that the audience of BoBBB is largely comprised of consumers -- the very people we want to reach. It's an up-to-date, well-produced, interesting film, and there are some real "aha!" moments in it that I could hear the audience around me responding to.

I had the privilege of sitting on a panel after the movie with two wonderful local midwives, Illysa Foster and Samantha Evans, a homebirth client, fellow doula Jessica Atkins, and (drumroll please), the inspiring and impressive Robbie Davis-Floyd, who is featured in BoBB. We fielded questions for almost an hour and a half, and my husband claims that the panel discussion was as good as the movie. I thought most of the comments/questions were very thoughtful, and I was extremely moved when a young woman in the audience said, "I want to be a midwife. How can I learn more and see some normal births?"

To answer her question for anyone who might be reading this brand-new blog, here are a couple of suggestions:
  • Attend a doula training and start looking for clients. Amie and I highly recommend ALACE workshops.
  • Find out who your local midwives are, and see if they are taking on apprentices, or are willing to let you shadow or assist them.
  • View movies like The Business of Being Born. Nothing compares to the thrill of being at a birth in person, but this can give you an introduction.
Of course, the key word in her question was normal, and that's not easy to find (especially if you are unlucky enough to live in an area where midwives have been banned from the hospitals). But maybe you can be the one to change that!