The Birth-Breastfeeding Continuum

May28

Birth professionals have long been aware that there is a connection between birth and breastfeeding, but in recent years experts are making this link more explicit and the inextricable nature of the two experiences is becoming clearer. Birth and breastfeeding exist on a continuum. They are not discreet events. As speaker and author Dia Michels says, “we need a new word—birthandbreastfeeding.” Human women are mammals and the same things that disrupt bonding and breastfeeding for other mammals also apply to women. Darkness, quiet, no disruptions/interruptions, safe, upright, mobile, easy access to food and drink as they choose….these things support healthy births for female mammals! In brief, a normal, healthy, undisturbed birth leads naturally into a normal, healthy, undisturbed breastfeeding relationship. Disturbed birth contributes to disrupted breastfeeding.

New mothers, and those who help them, are often left wondering, “Where did breastfeeding go wrong?” All too often the answer is, “during labor and birth.” Interventions during the birthing process are an often overlooked answer to the mystery of how breastfeeding becomes derailed. An example is a mother who has an epidural, which leads to excess fluid retention in her breasts (a common side effect of the IV “bolus” of fluid administered in preparation for an epidural). After birth, the baby can’t latch well to the flattened nipple of the overfull breast, leading to frustration for both mother and baby. This frustration can quickly cascade into formula supplementation and before she knows it, the mother is left saying, “something was wrong with my nipples and the baby just couldn’t breastfeed. I tried really hard, but it just didn’t work out.” Nothing is truly wrong with her nipples or with her baby, breastfeeding got off track before her baby was even born!

Problems with breastfeeding often start before baby is born. According to Linda Smith, BSN, FACCE, IBCLC, co-author of the book Impact of Birthing Experiences on Breastfeeding (2004), birth practices that impact breastfeeding include:

Mechanical forces of labor (positioning of baby, positioning of mother, etc.)
Chemicals (drugs) used in labor
Injuries to mother or baby
Treatment of mother during labor
Treatment of mother after birth
Separation from mother after birth
Procedures that alter behavior

Linda Smith also notes that a mother’s confidence and trust in her body’s ability to give birth is related to her confidence in her body’s ability to breastfeeding. There are several birth related risk factors for breastfeeding problems (please note that not all babies with risk factors will actually have problems):

Induction of labor
Epidural and/or narcotic medications
Cesarean
Instrumental delivery (forceps or vacuum)
Post birth suctioning of baby’s airway

Additional procedures that affect baby’s ability to breastfeed if they are done before baby’s first breastfeeding include:

Separation of mother and baby for any reason.
Weighing and measuring
Vitamin K injection
Metabolic tests
Circumcision
Infant hypothermia

According to the Academy of Breastfeeding Medicine (www.bfmed.org), “unmedicated, spontaneous, vaginal birth with immediate skin-to-skin contact leads to the highest likelihood of baby-led breastfeeding initiation.” Immediate skin-to-skin contact restores the biologic continuum begun during conception.

When I was in graduate school, one of my professors used the following analogy to make a point and I now use it with my own students:

There is a river running through town. Daily, emergency workers are called upon to rescue people from the river who have fallen in and are floating downstream drowning. Day after day they pull the gasping people back to land until one of the workers suddenly realizes, “maybe we should go see what is happening upstream and try to stop these people from falling in to begin with?”

My professor then encouraged us to always remember to go “upstream” when working in the helping professions rather than only addressing the immediately presenting problem. Childbirth professionals are in an “upstream” position when it comes to protecting the birth-breastfeeding continuum!

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For more about the value of keeping mothers and babies together following birth, check on Healthy Birth Practice Six: Keep Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding from Lamaze.

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References:

If my mom were a platypus: what we can learn by studying mammal lactation, presentation by Dia L. Michels, La Leche League of Missouri Conference, November 2007.

Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum. Mary Kroeger and Linda J. Smith, Jones and Bartlett Publishers, Inc.; 1 edition (February 2004). ISBN-13 978-0763724818.

Mother-Baby Togetherness, presentation by Dr. Nils Bergman, La Leche League International Conference, July 2007.

The Power of Touch, presentation by Diane Wiessinger, La Leche League of Missouri Conference, November 2007.

Winning at Birth, presentation by Linda J. Smith, La Leche League International Conference, July 2007.

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This article is adapted from “Celebrating World Breastfeeding Week and the Birth-Breastfeeding Continuum” by Molly Remer, MSW, ICCE, published in the International Journal of Childbirth Education, June 2008.

Information ≠ Knowledge

May24

Last week I attended a webinar about the ethics of childbirth. The presenter, sociologist Raymond De Vries, noted that choice is central to each of the ethical questions surrounding birth and then made the point that the problem with choice is that information does not equal knowledge. (He also mentioned the “ritual” of informed consent.) In the context of the webinar, the point was being made about ethical issues of prenatal testing, birth planning, and asking women to make decisions while in labor, but I think it has broader implications for our work as childbirth educators as well. We spend a lot of time informing and educating women about their choices surrounding birth and are often then surprised that this apparent information does not translate into experience once in the birth room. Obviously, this is partially because the birth room is a context impacted by a large number of social, cultural, psychological, and environmental factors, but I believe it is also because with all of our information we still haven’t managed to help parents develop knowledge and the two are not the same. Parents are often not able to recall or to mobilize information resources while actually embroiled in the birth experience. They need an inner knowing and inner resources to draw on for coping.

While I have known this for a long time, I still find it difficult to translate my conviction into practice. How do people develop knowledge about an experience that is ultimately unknowable until they are in it?

I do think that within the field of childbirth education, Birthing from Within is the method that most attempts to address this issue and I really value these two quotes from Pam England:

“A knowledgeable childbirth teacher can inform mothers about birth, physiology, hospital policies and technology. But that kind of information doesn’t touch what a mother actually experiences IN labor, or what she needs to know as a mother (not a patient) in this rite of passage.”

“While all of your (birth) planning may spin a cocoon of security, in actuality, the course of your labor is unknowable…your critical task is to prepare for a birth that has NO script.”

Personally, though, even with the practices and ideas offered by wonderful resources like Birthing from Within, I find I am still working on the actual execution of the how in my classes of translating information into knowledge…

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Edited to add…I’m working on resolving this discrepancy through my new plan to offer birth workshops as part of a birth network, rather than as an independent educator.

In-Utero Practice Breathing

May15

During my pregnancy with my first baby I had a somewhat unique experience in that I was able to feel him practice breathing in the womb. Babies practice breathing movements with increasing frequency towards the end of pregnancy, but usually this is only seen via ultrasound and the mother can’t feel OR see it happening.

A mysterious sensation

38 weeks pregnant with baby #1

I was about 32 weeks pregnant when we had a prenatal visit (and I was up to a whopping 140 pounds—looking back, that seems very thin, but at the time I felt like I had gained a lot of weight!) . Since 30 weeks I’d been feeling what I thought was the baby practicing breathing. My husband was able to feel it too, as well as occasionally physically see it—a rhythmic sort of pulsing sensation located where the baby’s back was and feeling like a rising/falling breath type sensation (like a cat under a blanket). I noticed it once or twice daily. Very different than the hiccups, which I also felt often. I wanted to mention it to the doctor to see if that was really what I was feeling, because lots of books and things say you won’t be able to feel those movements, but I didn’t want to be wrong and be embarrassed for having a kooky idea about feeling him breathe. (When we mentioned the feeling to my mom, she looked at us like we were quite nutty to think we could feel it!)

A prenatal appointment and a doctor’s surprise

At the prenatal appointment, I laid down to have my fundal height measured (32) and the baby’s heartbeat checked and he was conveniently doing the breathing thing at that exact moment! My husband asked the doctor about it and told her we thought it was breathing. She quickly disregarded the breathing hypothesis, saying it was unlikely we’d be able to feel that, but she was fascinated by the movements and listened with the Doppler trying to figure it out etc. She thought for a minute that it had something to do with my pulse and checked that, but it didn’t match, plus was just on one side of my belly where his back is. She also felt with her hands, etc. It was particularly strong that day—usually I felt a sort of pulsing and could also feel it with my hand. On this occasion, it was like the left side of my belly was rising and falling rhythmically in a very noticeable way. She said she’d never felt or seen anything like it before.

Then (this was the weird part), she said that maybe I should have an ultrasound to see what the baby was doing in there. This doctor was a crunchy-mild-mannered-has-you-call-her-by-her-first-name-homebirth-attending -birth-center-low-intervention-doesn’t-break-your-water-unless-the-baby-is-born-in-the-sac sort of doctor, so I was really shocked by that. I said I really didn’t think that was necessary, because I wasn’t worried about it we just thought it was breathing (again, we get a look that vaguely implies that we are nutty). She kept saying she’d never seen it before and said she was going to call one of her consulting doctor friends, “just because I’m curious,” to see what he thought about maybe needing an ultrasound.

After she left to call him, I started to feel nervous that something might actually be wrong. I knew how this doctor was and she did not seem like the type at all who would be calling other doctors unless she was a little worried about something. My husband kept saying that, “no, she is just curious about what it is,” but the “curious” wording felt to me like a don’t-want-alarm-the-mother-but-I-think-something-is-up type of doctor speak. Also, I knew her well enough to know that running off to call other people in the middle of an appointment wasn’t in character for her, especially since the mom (me) was saying it didn’t seem necessary. So, I briefly became petrified that the baby was having seizures or something.

Trust the mother!

She came back in a bit and had consulted with her ultrasound doctor friend who had said, “let me guess. This mom is thin and very healthy” and then confirmed that it was just the baby’s breathing movements we were seeing. He told her that you usually don’t see them on the outside, just via ultrasound, but it is still normal and just means that the baby is healthy and he is getting good practice. When she came back, the doctor also brought the practice’s midwife in to see, since the midwife had never seen anything like it either, but it had mostly stopped by then. This doctor has been in practice since 1992 and has had four kids of her own and the midwife has six kids and a 20-year practice. The doctor explained that she’d seen the breathing movements on ultrasound before, but they were always more like occasional gasp-type things, not steady and pulsing like that and not visible externally. She thanked me for teaching her something new 🙂

I liked being right about what was going on (trust the mother! She usually knows what’s up!) and I liked that my pregnancy had something “new” or special to it to show to someone for whom pregnancy is quite routine. Being able to feel my baby breathe in the womb was one of the special things about this first pregnancy.

(Side note: the doctor then said, “I’ll bet he comes out screaming” and as a matter of fact this baby did begin to cry when only his head was sticking out of my body!)

Note (added 3/2/2013):

A lot of mothers come to this post because of concerns similar to my own…what if my baby is having seizures in the uterus? Of course I am not able to tell you with 100% certainty that your baby is not having seizures, but here are two things to pay attention to that may set your mind at ease and allow you to enjoy this special connection with your baby:

One way to help you feel confident that it is practice breathing is to pay attention to whether it happens at the same time(s) each day. There’s usually a pattern to it.
Another way to tell with almost total accuracy is to notice if the baby gets hiccups shortly after and “episode.” A lot of babies will practice breathe and then get hiccups from their practice.

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This post is modified from a message board posting that I made shortly after the events described above.

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Empowerment Recipe for Moms

May9

Happy Mother’s Day!

I wanted to share this “empowerment recipe for moms” that I got from the book Celebrating Motherhood by Andrea Gosline and
Lisa Bossi. I thought it was a fitting recipe for Mother’s Day as well as for general happiness as a mother 🙂

Empowerment Recipe for Moms

In a long day, mix:

A walk in the park

Ten minutes reading a positive book

Uplifting and relaxing music

Some time spent on a hobby or personal project

A cup of tea in the afternoon

A little quiet time alone

A twenty-minute nap

An adult conversation with your spouse

Lots of hugs and kisses.

–Cindy Angell Keeling

It has taken me a while to find my rhythm and it is easier now that the children are older, but I do actually manage to include most of these recipe elements into my daily life. I drink my cup of tea in the morning (my husband fixes it and leaves it for me, so when I get up it is ready to drink) before my daily yoga practice. I don’t get to nap anymore, but when I had a napping child, I used to always get a fifteen minute nap in every day and it was a good thing. My husband and I walk together in the evenings for about 30 minutes a day and that allows us time for adult conversation (though sometimes people are riding bikes around our feet at the same time!). I read every night while lying down with the kids to put them to sleep. I don’t have time each day for ALL of my personal projects, but I usually have time for at least one of them. I journal every morning, practice yoga every morning, and usually get some writing time in at least once a week (hopefully more frequently!)…

Film Review: Sunshine

Apr27

Film Review: Sunshine

By Karen Skloss
PBS, Independent Lens, 2010
60 minutes

www.pbs.org/independentlens/sunshine

Reviewed by Molly Remer, MSW, CCCE

I was very excited to receive a review copy of the independent film, Sunshine, airing on the PBS series Independent Lens on Tuesday, May 4. Through personal narrative, Sunshine chronicles the changing social definition of family and cultural attitudes towards “unwed mothers” and “single moms.” Filmmaker Karen Skloss explores her answer to her question, “does history repeat itself?” as she considers her own history as a baby given up for adoption in 1975 by her nineteen year old “unwed” biological mother (Mary) and her personal experiences of giving birth to her daughter Jasmine as a “single mother” in 1999. Since I teach Human Services classes at the college level as well as teaching private childbirth education classes, I was intrigued in the film’s subject from both perspectives—that of someone in the field of social work at the academic level and that of someone deeply invested in work with pregnant women and new mothers.

The images chosen for the film are pieced together from home movies, family snapshots, interviews, and current footage of Karen and her family—both biological and adoptive. Karen and her biomom also make a pilgrimage of sorts to visit the Texas home for unwed mothers in which Mary lived before she gave birth. Karen co-parents her daughter with Jasmine’s father in a fairly unusual arrangement in that they share care 50-50—Jasmine lives with her father half-time and with Karen half-time. Jeremy, the father, also receives some screen time in the film and has some interesting comments to make about how he is perceived as a single father and how that compares to perceptions of single mothers (i.e. as a single father he is viewed as “hero” and not as someone who is just doing what anyone should do). The footage is mostly of the mundane—everyday life: bike riding, walking, people at kitchen tables—and the content is mild. No biting commentary or sweeping sociological conclusions. The story is an engaging one and an emotional connection is quickly formed. Though the content is nondramatic on the surface, the narrative is a multilayered representation of the complexity of the everyday lives of “normal” people and I was moved to tears on at least three occasions.

My medium is the written word—I read and write prolifically—so Sunshine was a change of pace for me. And yet, it unfolded like a personal essay “written” in visual form. I was fascinated in a way I have not been before by the use of film to tell a personal, human-sized story.

The Human Services professor in me would have liked to see a little more sociopolitical commentary—the viewer is left to draw their own conclusions about larger social issues that could give context to the personal story. The childbirth educator in me was delighted to see some footage of what appeared be a gentle, positive homebirth with Karen laboring in a birth pool and then giving birth in a supported squat on the floor. This footage is without commentary, but appears to be a midwife-attended homebirth with both Karen’s biomom and adoptive mother present as well as the father of her child.

As the film concludes, Karen states that, “it is hard to understand the times you’re living in, because you’re living in them.” Sunshine is a compelling portrait of one woman’s efforts to explore those times.

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Disclosure: I received a complimentary copy of this film for review purposes.

Cesarean Awareness Month

Apr10

April is Cesarean Awareness Month! My favorite resources about cesareans are the International Cesarean Awareness Network (ICAN) and The Unnecesarean.

In honor of the month (and in recognition that the national cesarean rate has risen again–to 32.3%), I went back through some of my posts and pulled out some of the things I’ve written about cesareans:

One of my “pet” subjects centers around the question of, “why would someone be upset over a cesarean, at least she has a healthy baby?” and this post partially addresses that: Birth and Apples.

I believe that a cesarean is often an act of personal courage and wrote about this here.

I also wrote about the same in this post on when birth doesn’t go as planned.

And, finally, here is a post I wrote about cesarean trivia.

Following Your Body’s Urges to Push…

Apr2

Sense and Sensibility is having a blog carnival around Healthy Birth Practice #5: Avoid giving birth on your back and follow your body’s urges to push.

For this blog carnival, I feel like sharing my own personal experiences with following my body’s urges to push. I gave birth to my first son over six years ago in what was the only freestanding birth center in the state (related side note: when I told my landlord that my new baby was born in a freestanding birth center, she said, “oh, so does everyone there have them standing up?”;-D). When I arrived at the birth center, I was surprised to be ten centimeters dilated already. Fortunately, the midwife on duty said, “go ahead and push when you feel the urge,” and went about her business, rather than encouraging me to push simply because I was at ten or exhorting me to push with loud counting and the near-aggression as is so frequently depicted in the media. After some time, I decided to experiment with the “pressure” feeling I’d been feeling for several hours—as soon as I gave a couple of small, experimental pushes like that, my water broke. I stayed on my knees on the floor for some time—head and arms on the bed—and eventually the doctor suggested that I get up on the bed, where I ended up giving birth to my son in a semi-sitting position.

During this birth, I was very sensitive to suggestion and to “being good,” and so when the bed was mentioned, I felt I had no choices even in such a gentle birth setting. I feel if left to my own urges, I would have stayed kneeling on the floor.

With my second son, who was born at home, I was alone with my husband for nearly the entire labor. As I got closer to giving birth, I felt “driven” to my hands and knees where I began to push spontaneously (and again my water broke with the onset of pushiness). It was a very wild and rapid birth and I barely had conscious thought of whether or not I felt like pushing—it just happened! After several pushes on hands and knees, my son eased out where he was received by my midwife after her arrival five minutes prior.

My third son (second trimester m/c), was born at home with just my husband present. My labor was again extremely rapid and I found myself kneeling on the floor in child’s pose. This position felt safe and protective to me, but I finally coached myself into awareness that the baby wasn’t going to come out with me crouched on the floor in that manner. I told myself that just like with any other birth, gravity would help. So, I pushed myself up into a kneeling position and my water broke right away. I crouched forward again—feeling fearful—and then told myself to move upright again. As soon as I was back on my knees, some blood clots emerged. I stood then, with knees slightly bent, and my baby was born.

For me, being nearly alone is the best way to follow my body’s own promptings. I feel it can be difficult to heed our bodies’ own wisdom when other people in the room are encouraging directed pushing or are “cheerleading” loudly. Freedom to move as desired and to push spontaneously according to the body’s own urges is a mother and baby friendly approach to birth.

Some of my other posts about second stage labor include: pushing the issue of pushing; waiting before pushing; and thoughts about pushing.

For more information about spontaneous pushing check out this video from Mother’s Advocate.

And, don’t forget my handout: helpful ways to use a hospital bed without lying down.

Consumer Blame

Mar31

Two things came to my attention today that made me think about how ironic it is that the medical system “lets” or doesn’t “let” women do so many things with regard to pregnancy and birth care and yet if something goes wrong, the locus of control shifts suddenly and it is now her fault for the situation. I see this often with things like “failure to progress”—“she’s just not dilating”—and even with fetal heart decelerations (“the baby just isn’t cooperating”). With induction—“her body just isn’t going to go into labor on its own”—and with pain relief—“she’s just not able to cope anymore” (yes, but is she also restrained on her back and denied food and drink?!). There are other ugly terms associated with women’s health that blame the “victim” as well such as “incompetent cervix” and “irritable uterus” and even “miscarriage” (and its even uglier associate, “spontaneous abortion.” And then for women with recurrent pregnancy losses we have the lovely, woman honoring term, “habitual aborter.” EXCUSE me?!). And then today, via The Unnecesarean, I read about a doctor inducing “labor” and then performing a cesarean on a non-pregnant woman.

Okay wow. So much could be said about that, but the kicker for me is that the woman was blamed—“The bottom line is the woman convinced everybody she was pregnant.” Huh?! So random surgery is totally acceptable if the person is “convincing” enough? What happened to diagnosing something first? Or, for taking responsibility for an inaccurate diagnosis?

The final thing that happened is that I got a completely unexpected refund check for over $400 today from my own local medical care system. While I’m not complaining about $400 that I thought I’d seen the last of, I had to shake my head in disbelief at the reason for the refund—“you overpaid”—excuse me, but I think the real reason is, “you overcharged me.” I checked back through my bills and I paid what I was billed (which, now that I think about, did seem like a heck of a lot for services NOT-rendered. If I had been in less of a state of grief and shock perhaps I would have questioned it more!), but now it has become “my fault” (in a sense) by switching the language to my overpaying vs. them overcharging.

What interesting dynamics these are…

Becoming an Informed Birth Consumer

Mar26

Though it may not often seem so, birth is a consumer issue. When speaking about their experiences with labor and birth, it is very common to hear women say, “they won’t let you do that here” (such as regarding active birth–moving during labor). They seem to have forgotten that they are customers receiving a service, hiring a service provider not a “boss.” If you went to a grocery store and were told at the entrance that you couldn’t bring your list in with you, that the expert shopping professional would choose your items for you, would you continue to shop in that store? No! If you hired a plumber to fix your toilet and he refused and said he was just going to work on your shower instead, would you pay him, or hire him to work for you again? No! In birth as in the rest of life, YOU are the expert on your own life. In this case, the expert on your body, your labor, your birth, and your baby. The rest are “paid consultants,” not experts whose opinions, ideas, and preferences override your own.

There are several helpful ways to become an informed birth consumer:

Read great books such as Henci Goer’s The Thinking Woman’s Guide to a Better Birth or Pushed by Jennifer Block.
Hire an Independent Childbirth Educator (someone who works independently and is hired by you, not by a hospital). Some organizations that certify childbirth educators are Childbirth and Postpartum Professionals Association (CAPPA), BirthWorks, Bradley, Birthing From Within, Lamaze, and Childbirth International. Regardless of the certifying organization, it is important to take classes from an independent educator who does not teach in a hospital. (I’m sure there are lots of great educators who work in hospitals, but in order to make sure you are not getting a “co-opted” class that is based on “hospital obedience training” rather than informed choice, an independent educator is a good bet.)
Consider hiring a doula—a doula is an experienced non-medical labor support provider who offers her continuous emotional and physical presence during your labor and birth. Organizations that train doulas include CAPPA, DONA, and Birth Arts.
Join birth organizations specifically for consumers such as Citizens for Midwifery or Birth Network National.
Talk to other women in your community. Ask them what they liked about their births and about their care providers. Ask them what they wish had been different.
Ask your provider questions. Ask lots of questions. Make sure your philosophies align. If it isn’t a match, switch care providers. This is not the time for misplaced loyalty. Your baby will only be born once, don’t dismiss concerns your may have over the care you receive or decide that you can make different choices “next time.”
Find a care provider that supports Lamaze’s Six Healthy Birth Practices and is willing to speak with you seriously about them:

Remember that birth is YOURS—it is not the exclusive territory of the doctor, the hospital, the nurse, the midwife, the doula, or the childbirth educator. These people are all paid consultants—hired by you to help you (and what helps you, helps your baby!).

New Post…

Mar20

I spent quite some time writing a new post yesterday and then it disappeared without a trace! I like to make a post here at least once a week, so I’m going to have to just link to the other post I wrote yesterday as part of the Women’s History Month blog carnival from Birth Activist. Birth Activist was the very first birth blog I ever started reading and the blog that sparked my own interest in blogging (a couple of years later).

In addition to teaching the Young Parents classes, which is a new venture for me, I also start teaching my second college class next week. This one is at a college branch about an hour from me, so I’m going to be doing a lot of driving in addition to all the preparation work. I think blogging is going to have to slip down my list of priorities for a while and so I may not be making new posts for a little while—I hope my readers don’t abandon me! Have no fear, I’ve managed to work birth activism into my class in a very appropriate way—I’m going to show them the Reducing Infant Mortality film and possibily The Doula Story as well, during my section of the class on teen pregnancy.