A proactive approach to breastfeeding

Desiree of Hitting My Stride, 6 months pregnant with her first baby and planning to breastfeed, recently asked me this question:

Do you know if there's a way to help my chances of being able to breastfeed?  Everything I'm reading says that it's not a problem until it's a problem and there's not a lot you can do proactively.

Great question! I would argue that there is a lot you can do proactively to ensure a successful breastfeeding relationship. A proactive approach to nursing your baby covers three main elements:

1. Individual choices
2. Institutional policies & care provider actions
3. Uncontrollable circumstances

Nursing my newborn son minutes after he was born

Individual Choices
Let's look at the first element, the one you have most control over: your individual choices. These can include your knowledge about and familiarity with breastfeeding, the use or avoidance of pain medications and certain interventions during labor, and your parenting choices.

First, let's discuss knowledge and preparation. Most of us grew up and live in a culture of bottlefeeding. Often, bottlefeeding norms become deeply embedded, without us even realizing it. For example, if we are used to seeing babies drink from a bottle, we might unconsciously hold our babies and position our breasts in their mouths as if we were feeding with a bottle. Bottlefed babies are held on their backs, facing the ceiling. The bottle's nipple is centered in their mouth. Breastfed babies, however, are held stomach-to-stomach, wrapped closely around their mother. They latch onto the breast asymmetrically, placing their chins deep into the breast and taking in a large amount of the lower areola. I love Laura Keegan's illustrations of how bottlefeeding norms affect breastfeeding in her book Breastfeeding With Comfort and Joy.

Unless we have grown up surrounded by nursing mothers, we might lack essential knowledge about breastfeeding: how to get a baby latched on, how to help the baby empty the breast efficiently, normal newborn eating and sleeping patterns, and solutions or preventive remedies for common breastfeeding challenges (plugged ducts, sore nipples, etc). Books, websites, videos, lactation consultants, and breastfeeding support groups fill this role today.

As I mentioned in a Breastfeeding Carnival post about "What I didn't expect when I was expecting", when I was pregnant with my first baby, I read extensively about breastfeeding. My favorite book was Dr. Jack Newman's Ultimate Breastfeeding Book of Answers. I read the book several times and watched the videos on his website. By time I was full-term with my daughter, I knew what a good latch should look and felt like, how to position the baby properly in relation to the breast, how to identify and solve common breastfeeding problems, and when to get help for more serious issues. There are many fantastic breastfeeding resources, too many for me to list here; please refer to my top birth and breastfeeding books or browse through my book reviews.

Next, there are many choices we can make during labor and in the immediate postpartum period. Our choices about pain medications, timing of the birth (i.e., elective induction or cesarean), place of birth, and care provider can influence breastfeeding outcomes. For example, both intravenous and epidural/spinal pain medications during labor negatively affect breastfeeding rates, even among mothers who intended to breastfeed and/or who had already successfully breastfed a previous baby. The amount of skin-to-skin contact right after birth affects breastfeeding success; the more skin-to-skin, the higher the rate of exclusive breastfeeding upon hospital discharge. Breastfeeding rates are also higher in Baby-Friendly institutions; if you are lucky enough to have access to Baby-Friendly care (whether officially recognized or not), this might influence where you decide to give birth. I won't go into detail here about how various labor interventions & practices affect breastfeeding. For more information, read Linda Smith's book Impact of Birthing Practices on Breastfeeding.

Finally, there are the choices we make as we parent our babies: Do we nurse on cue? Do we feed on a strict schedule? Do we sleep close to our infants, either in the same bed or the same room? Do we use pacifiers or introduce bottles, especially in the first several weeks? Some of these choices will help establish a successful breastfeeding experience; some may negatively impact breastfeeding. Take the time to think about and research these options.

Institutional Policies & Care Provider Actions
A second element of breastfeeding success depends on institutional policies and care provider preferences. We have less control over these factors than we do our individual choices. For example, if you give birth in a hospital with a policy of routine nursery observation for healthy newborns, keeping your baby at your side may be an enormous challenge. This is where careful decision-making in the prenatal period is key--to the extent that you have choices, of course. Many of us are constrained by insurance restrictions (only X hospital is covered, not Y or Z), state regulations (whether home birth or birth centers are legally allowed), or care provider preferences (in some areas, no physicians will attend VBACs or vaginal breech births).

Labor management and postpartum routines can influence breastfeeding success. For example, going into labor spontaneously, using non-pharmaceutical pain relief during labor, and having immediate, uninterrupted skin-to-skin contact after the birth all contribute positively to breastfeeding rates. This is not to say that you will not be able to breastfeed if you have an epidural or a cesarean, just that those circumstances can lead to more breastfeeding challenges. Educate yourself about which birth practices or postpartum policies are most likely to enhance your ability to breastfeed and how to overcome challenges that may arise if certain interventions become necessary. Make wise, thoughtful choices--as much as you can given your geographical location, your financial situation, and your insurance coverage--about where and with whom you will give birth.

Uncontrollable Circumstances
Sometimes breastfeeding is challenging due to circumstances beyond our control, no matter how carefully we planned and prepared. Some of these factors might include tongue tie or cleft lip/palate, prematurity, Down's Syndrome, NICU stay, low supply due to hormonal imbalances or insufficient glandular tissue, overactive letdown, and so on. We might have a baby who just won't latch on well, despite all the right techniques! A proactive approach to breastfeeding means knowing how and where to get help if these challenges arise. For example, knowing about tongue tie might help you identify that as a potential culprit if breastfeeding is unexpectedly difficult and painful, despite doing everything right.

Before you have your baby, be sure you know who your local IBCLCs are and if insurance covers their services. Know when and where your local LLL or other breastfeeding support group meets. Ask around about breastfeeding-friendly family physicians or pediatricians, so if your baby has certain medical complications that affect breastfeeding, you'll have someone on your side. Gather together a supportive network of friends or family members who can help if you encounter breastfeeding challenges.

In sum, can you take a proactive approach to breastfeeding? Yes you can!

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Blessingway

I spent the morning and afternoon getting the house cleaned and ready for the Blessingway. I went outside and cut just about every daffodil in our yard and put them all around the house. I found these lovely peach and white daffodils on the east side of our house. I never knew they came in that color.

My friend Julie arrived in the afternoon with her 14-month old Joyce. She is a fellow LDS graduate student and home birther who lives about an hour and a half away. She found me via my blog a few months ago, and we started emailing and talking to each other. She's finishing her master's degree and just got accepted into a PhD program and will probably be focusing on some aspect of childbirth. We had arranged to meet in person at least three times before the Blessingway, but one or both of us had had to cancel each time at the last minute. So we saw each other in the flesh for the first time yesterday! It's good that we felt comfortable around each other, because one of the first things I did was strip down to a bikini and ask her to take some belly shots of me. She took some lovely ones, which I'll post soon.

Setting up chairs and chatting.

My friend Julie, turned away from the camera, talking with my midwife and a friend of mine (both of whom are pregnant). Julie on the left and my mom holding Julie's daughter. Zari kept asking to play with her today.

Once we were all sitting down, the guests took turns introducing themselves and describing how they knew me. There were several women I had met at church, some friends who are Eric's collegauges (or faculty spouses), the midwife and her four assistants/apprentices, my mom, my sister from Dayton, and my friend Julie, who organized the event.

Each of us also shared a favorite memory either of our own mothers, or of being a mother. Some were very poignant, some quite funny, others sweet and simple. My story was a recent one. A few weeks ago, Zari and I watched Eric play intermural indoor soccer. The teams were shirts vs. skins, so there were a lot of bare-chested men running around. Zari kept saying something with the phrase "little tiny." I finally turned closer to hear, and this is what she was repeating to me as she was watching the men play soccer: "He has little tiny breasts." I tried not to laugh as I told her, "yes, he does." Then she turned to me, patted my chest, and said, "Mama has big breasts." Best of all was when she pointed to a more...ahem...pudgy man and said very earnestly, "He has big breasts too."

Julie then invited my midwife to give a short thought/devotional. She talked about overcoming fear & pain in childbirth. Each of us spoke about things that had given us fear or anxiety during pregnancy or motherhood.

Next, we took a break to stretch our legs and feast on all of the delicious food my guests had brought. Then it was time to do a henna tattoo!Most everyone took turns drawing this tree of life design on my belly. I was quite impressed. Notice the knot hole on the tree (aka my belly button).

While we were doing this, I had my guests read cards and hold up the quilt squares that my out-of-town friends and family had sent in. If you are one of those who are still working on your squares, this is a friendly reminder to send it to me soon so I can put the quilt together!

To finish the evening, each of the guests presented me with a bead they had brought. Once I get the necklace put together, I'll take a picture and explain some of the symbolism behind the various beads. A fun project for this weekend.

I spoke about some of the blessing ceremonies that Mormon women did over 100 years ago as they prepared for childbirth. Julie concluded the evening by reading Audrey Lorde's poem "Forever With Child."

We were going to do a belly cast after the Blessingway, but my midwife thought that it would be best to wait a few days, since I still had wet henna paint all over my belly. Instead, we did a quick prenatal visit, and I spoke to her assistants about my expectations for their role at the birth. (I won't have all four of them at my birth, of course; it depends on which one is available when I go into labor.) I peeled the dried henna off this morning, and now there's a lovely pale red tree decorating my belly. I hope it lasts until the baby arrives!

Thanks to everyone who participated in my Blessingway. It meant a lot to me to feel your love and support.

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Belly shot: 34 weeks pregnant

34.4 weeks from LMP. I changed shirts in part because I wanted to compare this with pictures from my last pregnancy.
For kicks, here's a picture of me at 35 weeks from LMP with Zari (33 weeks gestation):
Yeah, quite the difference--and I still weigh less this time around! Blame it on my (lack of) transverse abdominals, eh?

I started cleaning out our upstairs room, where I plan on having the baby. It's a large bedroom with a small full bath attached. It's really quiet up there and feels totally separate from the rest of the house, almost like I'm up in a nest or a treehouse, so I think it will be perfect for getting away from everyone & everything else during labor. I blew up my La Bassine birth pool and cleaned it out. I'm going to give it a trial run soon. My pond/fountain pump just arrived, which will make emptying the pool a breeze. Pictures coming soon once the room is organized.

We did a fun project yesterday: making a sandbox. I scavenged the 4x4s from a nearby abandoned lot where a house had been torn down a few months ago. The play sand (250 lbs) and screws cost $18 total. I still need to make a cover to keep the neighborhood cats out. Zari was thrilled.

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Do your homework

In Homework is the mother of prevention, Monica Dux argues that careful research and preparation during pregnancy are important, and that adopting a "wait and see" attitude might leave you with undesired results.

Despite all the rhetoric about the importance of consent and respecting the patient's wishes, my experience of giving birth in a big hospital is that women are encouraged to take a passive role, to defer to both their doctor's opinion and to the institutional imperatives. If you argue, you are often told "that's just the way we do things."...

Many of the medical procedures that are routinely offered — such as episiotomies, epidurals, and forceps — are significant interventions that can have consequences for the health of the mother or the baby, and for the progress of the labour. Waiting until the maelstrom of labour engulfs you is not the time to investigate whether these procedures are right for you. If you do, the likely result is that you will simply agree to whatever is suggested.

Dux is a writer and co-author of The Great Feminist Denial. Read the rest of the article here.

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If breastfeeding is natural...

"...then why is it so hard?"

A question many people ask, and frankly I don't have answers to. My own experience breastfeeding has been flawless. Can I attribute that to good luck? good karma? good boobs? good education?

I did educate myself a LOT about breastfeeding before I gave birth. I read Jack Newman's book The Ultimate Breastfeeding Book of Answers twice, and watched several video clips on his website to know how to get a proper latch, and what it should look and feel like. I also had a completely uninterrupted third stage and was able to breastfeed immediately for as long as Zari wanted to.

However, I know many women who have similarly prepared themselves, had fantastic unhindered births, and then had tremendous difficulties nursing--baby losing weight, painful latch, bleeding nipples, you name it. So to say that education and preparation will ensure a smooth nursing relationship is obviously too simplistic.

We could ask the same question about giving birth, actually: if giving birth is natural, why is it so dysfunctional today? Why do over 30% of women have cesareans? Why are so many women's labors induced or augmented?

Do you see parallels between breastfeeding and giving birth? What accounts for the high rate of "failed" or struggling breastfeeding? Let's discuss!

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Preparing for Labor

A woman on one of my internet birth groups recently posted these thoughts about how she prepared for labor:

When we decided to have a homebirth with a midwife, I (being an intellectual) bought as many books as I could, went to my childbirth class very early, read the corresponding book to the class, went to homebirth meetups, watched every video I could, including the ones on TV with hospital births. I wanted every possible tool in my bag for when the time came, uncertain which method would ultimately prove beneficial once in labor.

The last video I watched was at my childbirth class. It was, yet again, another South American video. I was disappointed with this after so many videos, because I couldn't understand what was being said in labor. I knew everything I felt I needed to know about the actual birth by then, but I wanted to know more about a natural LABOR at that point.

Well, as was typical in the Latin videos, the woman had her family there with her, both in and out of the tub, and she QUIETLY gave birth to her baby while her children watched her normal, natural birth. Then suddenly the video switched to an American home birth in a blow-up pool in the family's living room. The woman moaned and cried and wailed and had that typical wild-eyed, American labor look of "Who Is Going to Rescue Me Now????"

The stark contrast was what helped me know that every tool in my bag was completely unnecessary and useless. I was looking to trust everything but my baby and my body. I threw away my bag of birthing tricks. I understood then that we Americans are heavily convinced that birth is super difficult and have been indoctrinated into the mindset of we weak women need to be saved by the knight in shining armor. I was NOT going to be that. I believed thoroughly in the natural process of birth. I believed that my body was made to give birth. And, most importantly, I believed that just as my baby and body knew when it was time for my body to labor, my baby knew how to be born.

I was very quiet during the three days I was in labor. My midwife did not even come over until late the third morning. By then I was finally in active labor. I was quiet throughout the entire day until transition. After an hour of transition, during the last 30 minutes of transition I began to ask if I could really do this. My husband and my midwife's apprentice talked to me after every contraction and reminded me that I could and to stick with just one contraction at a time. (The transition contractions were the worst for me, because I thought I would throw up. What they didn't know was that I would rather have contractions any ole day than be forced to vomit. Just a personal preference thing.)

All at once I felt a wave start from my head and flow through my body and out of my vagina, and my body pushed with it. It did it again on the next contraction, and I felt the ring of fire. I jumped up out of the bed and headed for the tub. My midwife reminded me that I didn't have to have a waterbirth just because that was what I had planned, but I didn't even listen for a second. I KNEW the water was where I needed to be.

The water eased the contractions remarkably. My friend, husband, midwife, and midwife's apprentice were all in the bathroom talking to each other while I was in the tub with my head at one end and my feet touching the other end. Absolutely NO ONE knew I was pushing (actually not even I knew). I asked for a rag that I instinctively held with my hand between my legs.

Suddenly I felt a "pop" and asked my midwife what it was. She turned around and looked down at me and said, "Oh! The head is out!!" She insisted that I pull my legs up then (my knees were still together when the head was pushed out), and Ania was born a few seconds after.

My point is that I turned into myself. I listened to my body. Found the position that worked for my body. Walked when my body knew I needed to walk.

It was the closest I've ever been to God. The world went quiet and faded away. I was in touch only with each breath of each second of each contraction. Two months of third trimester discomfort and swearing I would never ever never have a baby again had me wanting another almost immediately because of the childbirth.

Was it painful? Yes, in all honesty it was painful during that 1-1/2 of transition. Was it my mindset that got me through it? Absolutely. I welcomed the pain, knew it was natural, knew it was not permanent, knew labor pains would not be listed as the cause of my death. I just fell into labor, didn't fight it, didn't question it, didn't question the process. I trusted birth. THAT is the only real tool you need.

Posted with permission from M. Morrow.

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What does a pregnancy cost?

I was recently going over my finances and asked myself "what has this pregnancy cost me?" Here's the breakdown:

Medications & supplements:
$60 for Crinone progesterone gel copays (I had some low progesterone concerns early in the pregnancy)
$100 for prenatal vitamins, vitamin B6, fish oil supplements, etc

Maternity clothes
$300

Books & DVDs
$200
(These were also for my dissertation research)

Chiropractic care
$60 for 6 visits (my copays are about $10 now that I have met my annual deductible)

Fetoscope
$20

Doctor or midwife visits
$0
(Okay, technically I spent $20 to see my family doctor about getting my Hemoglobin levels checked and getting a prescription for a postpartum Rhogam shot if needed. However, she refused to help me with those things. Luckily the midwife I work with recently checked my Hg for free, and said she'd help me with the Rhogram prescription.)

Birth Supplies
I already had most things at home. Here are the costs for things I had to actually go out and purchase:
$20 for anti-hemorrhagic tinctures
$7 for afterbirth herbal bath
I'll probably spend a little more money on things like extra secondhand towels, hydrogen peroxide (takes out blood like a charm), and disposable mesh panties for the first few days postpartum.

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Prenatal care

One question that I often hear when people learn I am giving birth at home is "but are you seeing a doctor or a midwife for your pregnancy?" The short answer is no. This post is the longer answer about what prenatal care means when you're not seeing a professional.

First, true prenatal care is NOT going to a doctor once a month to be weighed, measured, and examined. Prenatal care is how well you take care of yourself in between those visits. This includes eating an excellent diet, exercising, getting enough sleep, eliminating stress, and taking the initiative to remain healthy.

So, what do I do to take care of myself?

1. I try to eat a whole foods diet, focusing on adequate protein, calories, whole grains, fruits and vegetables, fluids, and salt. We rarely eat processed foods or sweets (except very dark chocolate, which is actually good for you! My favorite is 86% cocoa, although 70% is quite good as well).

2. I exercise regularly. I walk at least 2-3 miles per day, thanks to my lovely Dalmatian Zeke. We go down to the bike path every morning for a brisk 2 mile walk. He runs off leash, chases ducks and deer, and splashes in the creek. I usually go on a shorter walk or two with him in the afternoon or evening. I also swim 3/4 mile (24 laps) three times a week.

3. I take good quality prenatal vitamins and some supplements. I don't feel this is truly necessary, but it's a good idea unless you can eat all organic, free-range foods. I use Rainbow Light's Complete Prenatal System. They're big, green, and smell like grass. Mmmmm. I also take fish oil capsules because we don't have access to good seafood here in the Midwest. (Read Michel Odent's fascinating article on the role of fatty acids from seafood.) I took vitamin B6 supplements during my first trimester. I didn't really get sick at all--just a few weeks of feeling blah and "off." Was it the B6? Who knows...

4. I keep track of my uterus' growth by measuring fundal height. I note how my fundus is growing in respect to certain landmarks--3 fingers above the belly button, etc. I also get out my handy dressmaker's measuring tape and measure in centimeters from the pubic bone to the top of the fundus.

5. I listen to the baby's heartbeat and placenta with a fetoscope. I bought the cheapest model I could find for $13 and was able to locate the heartbeat around 16 weeks. I usually count the heartrate when I listen. So far it's been consistently in the 150s. It's fun to locate the placenta; it makes a swooshing/rushing noise in synch with my own heartbeat. Last I checked, mine was on my left side about waist high.

6. I weigh myself occasionally. So far I have gained about 18 lbs (as of 28 weeks gestation). Most of the weight gain occurred while I was in France over the summer.

7. I pay attention to the baby's movements and enjoy the acrobatics. As the pregnancy advances, I've noticed more distinct kinds of movements: kicks, punches, rolls, stretches. This baby likes to move its hands on my lower left side, and kick on my upper right.

8. I checked my hemoglobin level 2 weeks ago. It had fallen from 13.6 pre-pregnancy to 12.9. A stable or rising Hg level is the earliest indication of an inadequate blood volume expansion (due usually to inadequate nutrition), which if unresolved can lead to metabolic toxemia. I was reassured that my blood volume had expanded, although I am still vigilant about my nutrition.

9. I sleep as much as my body needs. I can usually get enough at night, despite waking up several times to go the bathroom, but I take naps if I feel the need.

10. I check my blood pressure occasionally, perhaps twice so far. I haven't checked it since I went to France, so I might again out of curiosity. Blood pressure can fluctuate tremendously depending on a woman's environment and stress level, so it's not something I am terribly concerned about monitoring.

11. I read, read, read. I love my textbooks by Anne Frye (Holistic Midwifery vols 1-2 and Understanding Diagnostic Tests). I talk to my midwife friends if I have questions. I search the internet. Most of all, I enjoy my pregnancy and the sense of discovery that comes when you take care of yourself, rather than waiting for someone else to tell you if you're healthy or not.

12. I keep track of these things, and more, on these nifty "Moon Charts" that I made. They're loosely based on fertility charts from the book Taking Charge of Your Fertility, but with lots of extra columns added for pregnancy stuff. I just started my 8th moon chart (they are 4 weeks each).

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