Is it good enough?

I used to worry that reading my experience would scare expecting moms.  But now I realize that while breastfeeding skill doesn't always come "naturally," if you are on the lookout for these "Breastfeeding Booby Traps,"  you have a better chance of overcoming problems. Here's my list of tactics for pre-emptively overcoming the "breastfeeding booby traps" at your birthplace (in my opinion, the place where we need the most help).

You call your hospital and ask about lacation consultants.
Their answer: "Yes, we have a lactation consultant."
Is it good enough?  No. You need to hear, "Yes, we have full-time international board certified lactation consultants available to you around the clock during your stay." 

You ask them about breastfeeding after Caesarian, and what their intervention rate is.
Their answer: "We don't have a protocol to support breastfeeding; the doctors treat the babies on a case by case basis.  Our intervention rate is average."
Is it good enough: No.  You need to hear: "Yes, our breastfeeding after ceasarian protocol is to give no baby any nutritional supplement, unless medically indicated and approved by you or your representative.  And the chance of your having a Caesarian to begin with is much lower than average."

You ask if they routinely give healthy babies formula or other supplements.
Their answer: If it's anything other than a resounding, "No," it's not good enough.

If their answers aren't good enough, call around to see if there are other hospitals in your area that give better ones.  If there aren't, plan to to find supplemental help on your own from a traveling lactation consultant and be vigilant and unapologetic when asking everyone caring for you and your baby to abide by your requirements--verbally and in writing when possible, and plan to have your partner, doula, or support person be responsible for tracking what's happening with your baby at all times.

A higher level of barriers

In a previous post, I talked about the most common reasons moms quit breastfeeding: latching problems, breast refusal, low milk supply, and pain.   Looking back, I realize that I stopped because of extreme pain caused by latching problems from extreme engorgement and a frenetically, energetically hungry baby with a very strong suck.

United States Breastfeeding Committee commissioned a new report to help "combat the barriers to breastfeeding success."  It lists the major barriers as "hospital practices, provider skills, social and workplace support, and media and marketing."  These are the societal barriers that either cause or hinder solutions to the many personal or physiological problems (like pain) that new moms deal with when trying to breastfeed.

At the time my son was born, I felt that my hospital gave me good support, I think because I was so emotionally overwhelmed that I mistook good emotional care for good medical care.  (The hospital where Sam was born is not recognized as a Baby-Friendly Hospital by Unicef, though they did meet many of the Ten Steps.)  But with a year of hindsight, asking myself whether the medical services did the best they could for me and my baby, the answer is no. Here's why:

1. There was one lactation consultant on staff at the hospital, but she was also a full-time nurse with regular shifts and only saw nursing moms in her spare time between rounds or as overtime.  During my stay at the hospital, I saw her once a day, and afterward, once a week.  What I needed was access to a certified lactation consultant round the clock while at the hospital (anytime I tried to nurse) and on call at home.  Initiating breastfeeding is an hour-by-hour challenge.
2. The other nurses tried to help with breastfeeding, but their advice was, though well-meaning, inconsistent and not very helpful, except for the emotional aspect.   A commonly-cited article from the Journal of Obstetric, Gynecological, and Neonatal Nursing reported that "nurses have limited knowledge of breastfeeding, although no variable consistently predicted breastfeeding knowledge."  (Anderson, 1991.)
3. The nurses gave Samuel colostrum mixed with glucose water, despite medical recommendations against glucose water to prevent hypoglycemia.  (Orr, 1997.) 
4. One of my symptoms was edema, which made engorgement worse and latching extremely difficult.  The lactation consultant said the IV fluids I was given contributed to this, but I don't recall edema being one of the potential side effects of my pain treatment.  (Walker, 2000.)
5. I expected my doula to see when there was a problem and help me find solutions, but her job was done after the baby was born, except for one follow-up visit.  Next time I will secure my own help (from doula or otherwise) for longer.

These fall under "hospital services" and "provider skills," I could also list other problems I experienced under "social and workplace support" and probably even "media and marketing."  What combination of problems did you experience, and which of the higher-level barriers (hospital practices, provider skills, social and workplace support, and media and marketing) did they fall under?

1. Orr, Edie and Crase, B.  "Hypoglycemia and the Breastfed Newborn." From NEW BEGINNINGS, Vol. 14 No. 4, July-August 1997, pp. 107-8

2.  Anderson, E., N, MS and GEDEN, E., RN, PhD, FAAN^{.  "}Nurses' Knowledge of Breastfeeding."  Journal of Obstetric, Gynecologic, & Neonatal Nursing, Volume 20, Issue 1, pages 58–62, January 1991.

3. Walker, Marsha, RN, IBCLC.   "Breastfeeding and Engorgement.  from Breastfeeding Abstracts, November 2000, Volume 20, Number 2, pp. 11-12.

My baby-feeding story, abridged

Day 1

The focus of pregnancy for many women is childbirth, as it was for me.  I read the books, took the classes, imagined all the possible scenarios through which my child could be born. I felt that if I could get through childbirth, I could get through anything.  Parenthood, including breastfeeding, was a bridge I would cross when I got there, but felt sure that with a good partner and support system, it would be manageable.

My son’s birth was much like I expected: it was one day of the worst pain of my life, and then he was there, Samuel Sleigh, strong and healthy, with dark, observant eyes.

After he was born late in the evening, I held him skin to skin.  My doula, my nurses, and my husband Max kept encouraging me to place him at my breast, but I thought he would make his own way there, the way newborns did in the birth videos we watched in childbirth classes.  I thought it was only a matter of time and he would be suckling away, a hungry little baby.  Finally, I maneuvered him to help him get started.  He got mouth in the right place but would not suck.  He only fell asleep over and over again.  So, we let him sleep, and we slept.

Sam, Day 1

Day 2

The next day, my milk came in. The nurses were a bit surprised, as this normally does not happen until day 3 or 4.  I took it as a good sign; I was excited because I knew then I could feed my baby as soon as he was ready--no worries about lack of milk.

But all that day, Sam slept, and when we managed to rouse him and get him to my breast, he still would not suck.  The pediatrician and nurses assured me that this was not cause for alarm and that he would nurse soon.

Day 3

On day 3, the hospital’s lactation consultant, Suzanne, visited me.  She showed me how to manually express milk to entice the baby to nurse. She put on a latex glove and gently touched the roof of his mouth with her pinky.  He did not suck, which puzzled her.

She suggested I try a breast pump to get some colostrum—the early, nutrient rich milk--for Sam.  The nurses introduced me to a Medela hospital-grade pump and showed me how to use it.  I marveled at the few drops of yellow liquid, amazed yet again by my own body. 

The nurses mixed that tiny bit of food with some sugar water and fed it to my baby with a tiny plastic cup.  Watching this I felt sad, already feeling that I’d failed somehow.

Day 4

The next day, the pain started.  I thought now that I was starting to heal from the birth, I would feel better all around soon.  But trying again and again to nurse made my nipples tender and sore, and the fullness had escalated to engorgement.  My breasts were hard to the touch, the skin stretched and shiny.  

Early that morning though, with the help of a nurse and in just the right position, Sam nursed.  It was a tiny victory, the first in a series of battles to come.

Suzanne returned and examined me.  She said the engorgement was made worse by a case of edema, or water retention from the IV fluids I received during labor.  This also made it harder for Sam to latch—like trying to suck on an over-inflated balloon.  We kept nursing though, and I breathed through the pain.

On day 4, we took Sam home.  We were on our own, away from Suzanne and the caring nurses at the hospital.

Days 5-7

The first few days at home were like a dream, the three of us waking and sleeping at odd hours, not eating real meals, not leaving the house.  I made a home on the couch where I napped and tried again and again to feed the baby.  He would latch, then fall away, and latch again a short while later, each time more painful than the last.  It made my toes curl.  I would get into the shower afterward and cry.  I called the nurses at the hospital, but all they could tell me was that it would get easier soon.

I would work myself up for a feeding, and with Max maneuvering Sam’s tiny little mouth, nurse him through the excruciating pain.  I began to dread feedings.  I started to feel afraid of my hungry baby.  My nipples were broken and cracked like a boxer’s knuckles, and the engorgement persisted.  I was feeding him, but I wasn’t sure how much longer I could stand the pain.  It was a rollercoaster of emotions.  A disastrous one would follow a successful feeding.  It wasn’t getting better.

Days 8-10

On day 8 I went back to the hospital for a consult with Suzanne.  She suggested I try pumping with my Medela double electric pump for 24-48 hours to let my nipples heal, and cup- or syringe-feeding Sam the milk.  She also suggested heat to get the milk flowing followed by cabbage leaves and ice for the engorgement.  She demonstrated putting downward pressure on Sam’s lower jaw and flipping out his lip for proper positioning.  I also got two prescription ointments, “gelpads” for sore nipples, and a bit of silicone called a “nipple sheild.”  It seemed an arsenal, and I felt hopeful.

Newborns need to eat every 2 hours.  That meant 30 minutes of heat, then pumping for 20 minutes, then applying medicine, then lying with ice packs and cabbage leaves pressed to my chest for an hour, while feeding the baby the pumped milk.  This involved tricking him into sucking on a finger while sneaking the milk into his mouth on the side with a large plastic syringe. (We were warned of “nipple confusion” in which a baby rejects the breast after being introduced to a bottle too early.) He seemed confused and overwhelmed, milk overflowing from his mouth, and I felt awful for doing it.  This was our routine, around the clock.  I barely ate or slept for 2 days.

On day 9, my damaged nipples had begun to heal, but since everyone had told me that the pump isn’t as efficient as the baby, I felt I had to start nursing again to ease engorgement.  The searing pain in my nipples began anew.  Not so much as a cotton shirt could touch them without stinging.

Sometime in this week Sam developed a new habit of flailing wildly when hungry, making nursing even more difficult.  Each feeding became an upheaval in our house, with baby and Mommy crying and Daddy assisting as best he could. My doula and family members said, “It will get easier, just hang in there.”  I began to wonder how we would cope, and started thinking about giving up on breastfeeding. I was facing failure. At this point I became undeniably depressed. I was afraid I would be unable to do the only thing I cared about then: feeding my baby.

Days 11-13

By late in Sam’s second week of life, the pain was nearly unbearable.  We researched infant formulas, unsettled by the long ingredient lists.  I began to mourn breastfeeding, gradually accepting potential failure.  I didn’t know how much more I could handle, physically and emotionally.  I was afraid it was affecting my ability to bond with my son.  I began to feel intimidated by him.

The day before he turned 2 weeks, early in the morning hours, I stopped nursing, pumped breast milk, and fed Sam with a bottle. We had just had an awful late-night feeding, with howling baby and weeping mommy. This is just not working, Max and I said to each other.  We were giving up.

That day, I felt a sense of relief for the first time since first trying to nurse.  The depression lifted.  It wasn’t what we’d hoped for, but we had a feeding solution.  I would gradually stop pumping and Sam would be one of the many healthy, happy, formula-fed babies of the world.

Week 3

Then, during the week after I stopped nursing, something happened: the Medela pump started to work.  I kept pumping at regular intervals, and gradually the engorgement eased. The pump was much gentler on my body.  There seemed to be plenty of milk, and the baby slurped hungrily at his bottle.  Gradually, the pain subsided. We didn’t need the formula after all. I thought I had accidentally invented a new baby-feeding solution.  But as it turns out, I was not the only new mom to exclusively bottle-feed breast milk. 

This is how I came to feed Sam breast milk from a bottle, exclusively.