The Wonders of Breastfeeding

Week 2- on one hand it’s weird that two weeks have already flown by, and on the other hand I feel like it’s only been two weeks since WZW joined us?  He is starting off life Paleo/Primal since he’s exclusively breastfeeding.  Jimmy Kimmel, during his interview with actress Zooey Deschanel, brought up the question as to whether breastfeeding is vegan.  Her sister, who was also pregnant at the time of the interview, is vegan which is why Kimmel brought up the question- If the baby is to be raised vegan, can the baby breastfeed? It’s an animal product.

The topic comes up around the 2 minute mark:

In all seriousness, though, most of us know about the significant benefits of breastfeeding.  Otherwise I wouldn’t be dealing with the sore nipples and frequent late night feeds and such.  Mark Sisson, in his September 6 Mark’s Daily Apple post, had a link to this fascinating article about breastfeeding:

http://www.thestranger.com/features/feature/2015/08/26/22755273/the-more-i-learn-about-breast-milk-the-more-amazed-i-am

It talks about a lot of things I never knew before, like that there are tons of oligosaccharides (complex chains of sugars) that are unique to human breast milk, and are not digestible by the infant, but rather exist to support the microorganisms in the baby’s digestive system.  Also, breast milk changes constantly in response to the baby’s immune status via receptors in the mammary glands to baby’s saliva (baby spit backwash as they describe it).

Also, the foods that mom eats change the taste of the breast milk as well.  Apparently in the ’70s they did a study involving a “trained panel” of breast milk taste testers.  That must have been a very uh, interesting job to say the least.  But I’m happy to have that information.  It encourages me to eat a variety of foods, in hopes that WZW not only gets varied nutritional needs, but also develops a liking for a larger variety of flavors.

It’s interesting how now that I’m no longer pregnant, my aversions and inclinations have gone more or less back to normal.  Before pregnancy, I never liked carbonated drinks, but during the pregnancy we were purchasing sparkling water by the case at Costco.  It was a chore to drink water, even though I knew I was supposed to stay hydrated during the pregnancy.  After I delivered, I felt super thirsty and was drinking tons of regular water in the hospital without a problem.

During pretty much the entire pregnancy, I’d feel sick after eating, particularly if I ate too much.  It improved so that it was mild during the latter pregnancy, but was still there and annoying.  Now that the feeling has resolved, you’d think I’d go buck wild and gorge myself now.  Instead, I don’t know if I’ve just been too busy or what, but I’ve actually felt more satisfied eating healthier and don’t have as strong of an inclination to go for the sugar and junk.  During the pregnancy, I’d go out of my way to seek carbs and sugar.  Nowadays, I won’t turn down some ice cream that coincidentally shows up in my freezer after my husband’s grocery run.  But I am not as apt to seek it out.

My husband cooked a bunch of Paleo crock pot recipes to stock up in the freezer prior to WZW’s arrival, so we’ve had a good variety of healthy eats.  With that said, some of the food people have made/brought us hasn’t been completely Paleo, which is fine.  At this point, anything is appreciated.  I can see how with the sleep deprivation and lack of time that many people would tend to go for takeout and quick eats like pizza.  Thankfully, we planned ahead with the food in our freezer, and we have family/friends who have made or brought us real food.  Although I’m not going to eat perfectly healthy 100% of the time (particularly given the fatigue) I do have more of an inclination to do so knowing that I’m breastfeeding and that it will affect WZW.

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Week One

Can’t believe it’s already been one week since WZW joined us outside the uterus.  There’s so much I’ve experienced and learned in this short week.

It’s been great for me to go through the whole pregnancy, birth, and now parenting experience for myself since there’s a lot one learns from going through the process themselves as opposed to taking care of patients going through it.  For one, I anticipated that postpartum I’d have pain from my perineal sutures.  Patients generally complain of pain from the laceration repair, hemorrhoids, and/or uterine cramping.  And of course the C-section patients have their postoperative pain.  Some women get headaches, or have low back pain from the epidural site.

What I didn’t anticipate was that my whole pelvis would hurt.  My pubic symphysis hurt the last week of my pregnancy, and during my labor I felt pain there even in between contractions.  My pelvic bones were separating in preparation for the delivery.  What I didn’t realize was that I’d still have significant pain after, since I’ve never had patients complain about it.  For me, the pubic symphysis, as well as areas adjacent to my tailbone were sore after my delivery and I found it hard to find a comfortable position to sit.

I will also from now on always prescribe a stool softener for my patients as part of their hospital discharge medications.  Previously, I only ordered it if they were going to be taking iron or a narcotic medication for pain, since those tend to constipate.  Or if they had a 3rd or 4th degree perineal laceration (involving the anal sphincter), then I’d definitely order it for them.  What I learned the hard way is that even with a 2nd degree laceration and unfortunately hemorrhoids from the pushing during my delivery, a stool softener is very helpful in these early days, since everything hurts down there.  Since they didn’t order any of the Colace (docusate) for me postpartum, I bought some over-the-counter and was surprised that a package of 60 capsules was $28!  For most patients, if I prescribe it for them, their co-pay should be much cheaper than that.

We are experiencing the normal sleepless nights that all new parents do.   I think it helps a lot that after working countless overnight call shifts, I’m familiar with the feeling of being sleep-deprived.  Normally, it’s a challenge to feel so tired and still try to do my job as a physician (ie function at a high level not make any major mistakes).  So in comparison, being tired but having the primary job of breastfeeding is doable.  Granted, it’s like being on call every single night.

I knew breastfeeding wasn’t going to be easy, but now I’ve learned from personal experience.  Initially, my nipples were so sore from initiating the feedings and having them be so frequent.  It’s definitely tough to be feeding WZW constantly.  At his 3 day visit, they gave me a nipple shield to use, and that has helped tremendously so that it doesn’t hurt as much.  Also, I think my breasts are healing and getting used to it.  I’m very motivated to breastfeed given the benefits, but I can see how many women would throw in the towel.

The first couple nights at home were the toughest.  There would be times when WZW was fed, his diaper was dry, and we’d do all of the baby soothing techniques, and he’d still be crying and crying.  They tell us he was just getting used to life outside the uterus.  We try to take it in stride, knowing that sometimes no matter what we do, we can’t make him calm down.  We try to keep a sense of humor about it.  We took one video of him while he was raging- arms flailing as he was crying out of control, with the Outkast song ATLiens (“Throw your hands in the air, and wave them like you just don’t care.”) in the background.  We joke about how our little guy thinks of us as his servants- at his beck and call 24/7, scrambling to have his needs met as soon as he starts to fuss.  The episodes of uncontrollable crying are less frequent as we get used to things and he gets used to life outside the womb, but they still occur sometimes, like last night.  And sometimes I’m so tired that I can’t keep a sense of humor and just need to cry tears of frustration and fatigue.

Ultimately, though, we are enamored by our little guy and all of his expressions and actions.  Everything he does is the cutest.  What parent can resist a face like this?

Smiling

Welcome WZW!

Little Willie has now been upgraded to WZW, his actual initials.  He was born on Saturday, September 5 and weighed in at 7 lbs. 5 oz. (3320 grams).  So much for the “borderline growth restriction.”

WZW

My husband and I are so happy to have a healthy baby, and grateful that everything went well with the delivery.  In my line of work, most of the times are happy, but I’ve also seen such horrific outcomes such as stillbirths and maternal complications (including rarely death), so I don’t take any of this for granted.  We were a little superstitious and didn’t call our little guy by his actual first name until he arrived, and told very few people what his first name was going to be.

I had the best labor and delivery I could have hoped for, but even then it was tough!  Let me back up, though, and discuss some of my preparation going into the delivery.

One of my husband’s coworkers had given me a package of raspberry leaf tea that she had leftover from her pregnancy.  She said her doctor had recommended it to her.  I was a little surprised, since I myself am hesitant to overtly recommend things to my patients that aren’t evidence-based (even if I may do them myself).  A quick Medline search came up with one double-blind, randomized, placebo-controlled trial from a midwifery journal.  In that study, they used the tablet form rather than the drinking tea.  They found a shortening of the 2nd stage of labor (full dilation to delivery), but no difference in the first stage of labor (active labor to full dilation) which is what the herb is supposedly known to do.  There were no adverse effects for mother or baby.  Another study I found showed potential benefits, and no harm as well.  I figured the risk of harm was low, so I went ahead and drank the tea daily during the last month of my pregnancy.

I have mentioned before that following everything in the Gentle Birth Method book is nearly impossible, but there are some great tips that I did get from the book.  One is the perineal stretching which my husband and I did daily at the end of the pregnancy to try to prevent perineal lacerations during the delivery.

The book also recommends visualizations for the late pregnancy- imagining your cervix getting softer, thinning out, etc.  There is also a detailed script to help visualize how things would go during the day of delivery- the initial contractions feeling similar to Braxton-Hicks contractions, the real contractions visualized as pushing on the baby’s bottom, and causing the cervix to thin out and dilate.  The script goes into way more detail about visualizing everything that is happening with the uterus, pelvis and vagina as one is in labor.  It goes all the way through the delivery, including holding baby skin-to-skin and delivery of the placenta.  I did read through it, and found it helpful as a guide going into labor.

I woke up the morning of the delivery with a small gush of bloody fluid as I got up out of bed at 7:40.  I thankfully had a full night’s rest, which had been unusual during my late pregnancy.  It was more liquid than I’d expect for just bloody show, which is usually mucous.  But it wasn’t a ton of fluid, so I wasn’t quite sure if I’d ruptured my membranes.  I didn’t want to go in too early, for one if I hadn’t really ruptured.  Also, if I didn’t start to have contractions on my own, there’d be the tendency to start Pitocin (oxytocin) to induce contractions.  We do that because if the membranes are ruptured for many hours before delivery, there is a higher risk of infection (chorioamnionitis) since the barrier between the outside world and the contents of the uterus has been broken.

I figured it’d be easier to wait and see if I’d get more contractions on my own, or if I got more leakage of fluid to suggest I’d broken my water.  After a few hours, I’d had a couple more gushes that again were small, but more liquid than I’d expect for just bloody show.  I was having mild contractions every 10-15 minutes, but that was it.  I decided it would probably be best to get checked for rupture of membranes, so I called Labor & Delivery and they confirmed I should come in.

No joke- I’d told my husband that the Peet’s Mayan Mocha was back in season, so since I was still comfortable he wanted to stop by and pick one up.  While in downtown, we also picked up some food, since I knew they’d limit my food once I was on L&D.  So I had a samosa on the drive in.  I was still having mild contractions at 11 am when we were getting food.

By the time I arrived on L&D, it was probably 11:30 am.  At my hospital, midwives manage uncomplicated patients, and the doctors manage patients who have medical complications, are preterm, need an instrumented delivery (vacuum or forceps), need a C-section, etc.  Since I was uncomplicated, I’d always envisioned having a midwife manage my labor and deliver me if all went well.

The midwife checked for rupture of membranes by confirming the appearance of what we call ferning on a microscope slide of the fluid.  Since I wasn’t having consistent contractions yet, she deferred checking my cervix since we don’t want to increase risks of infection.  Around 12:30 pm as I was getting ready to be admitted was when I felt my first really painful contraction.  After that, the contractions started to really pick up.  They starting coming more regularly, every few minutes.  Interestingly to me, I didn’t feel them throughout my uterus like I’d imagined.  The pain was low, like menstrual cramps except WAY worse.

The Gentle Birth Method book recommends training in self-hypnosis during the pregnancy in preparation for labor.  I certainly wasn’t able to manage that.  Apparently some women are able to get themselves into a more pain-tolerant state, where they can imagine their contractions like crashing ocean waves.

As for me, my contractions were still painful as %*#$!  I had to just dig deep and breathe as best through my contractions as I could.  I did try to think about my cervix thinning and opening with my contractions.  In between contractions, I continued to breathe, and tried to relax as best as I could.  Even between contractions, I could feel pain of my pubic symphysis (pubic bone) area, so I wasn’t getting 100% relief from pain.  I basically had my eyes closed the majority of the time.

In the beginning, I tried walking, and tried different positions to see if they’d help.  In the end, I just sat up on my bed somewhat cross-legged.  I guess in hindsight it was sort of a meditative position for me.  I’ve seen some women hold their partner’s hand and squeeze hard with contractions, but for me I didn’t want to be touched.  So I pretty much was sitting there, eyes closed and my poor husband had to look on and watch me in pain.  He was great at being supportive as best as he could given the situation.

As it approached 3 pm, after 2 hours of these true labor pains, I asked to have the midwife check my cervix.  I didn’t think I could last much longer, and was open to getting an epidural.  Although I didn’t necessarily want an epidural ASAP, I’d always been open to getting one.  Well, when the midwife checked me, she said, “You’re not going to believe this- you’re rim.”  What she meant was that my cervix was almost fully dilated except for a little rim of cervix that was still left.  It was the equivalent of being 9.5 cm dilated (which is how she’d document numerically in my chart).  She said it was soft and easily reducible (meaning could be pushed back), so it would probably be gone shortly.

At that point, I decided to soldier on without an epidural.  My midwife suggested that I sit on the toilet, as that position can help relax my pelvis further and be a better position at this stage than sitting in bed.  She said as I developed the urge to push, then I’d return to the bed for pushing.  I wasn’t sure what to expect in terms of how that urge to push would feel.  Many times, women report an urge as if they want to have a bowel movement as the baby’s head fills the pelvis and they are ready to push.  But I’d felt some rectal pressure for quite some time.

Well, what I found was that as I transitioned into the second stage of labor (full cervical dilation to delivery), I would inadvertently start pushing a little with the contractions.  My midwife suggested that I could feel the baby’s head myself as I was on the toilet.  It’s weird after checking so many patients’ exams to now do my own.  I felt my baby’s wrinkly head (from the molding in the birth canal), which descended in the time I was on the toilet early on to when I started feeling the urges to push.

At that point, I went back to my bed.  Starting about 4:30 pm, I began to officially push.  I had read previously that side-lying can help prevent perineal lacerations, so I went with that position.  More importantly in that moment, it helped to be able to relax as best as I could between contractions in that position.

I’d always instructed patients to push like they’re constipated, since it’s the same muscles, and they feel rectal pressure from the baby’s head occupying that space.  So I figured that pushing would be a controlled, voluntary effort.  That is probably the case when one has an epidural.  What I found interesting is that when I started pushing voluntarily with a contraction, then it was like my body would take over and intensify it automatically.  My midwife described it like when you’re vomiting- the stomach contracts to expel its contents.  In a similar way, my uterine contractions were intensifying my pushing without my full control.  I could feel it, and also was getting feedback from my husband and nurses as they could see the head moving more.

At 5:15 pm, after 45 minutes of pushing, WZW delivered!  Luckily, his tracing had remained reassuring and there were no concerns, so we were able to put him immediately on me for skin-to-skin contact.  Given my emotions during my pregnancy (I cried watching The Little Mermaid), I thought I’d get emotional after the delivery.  Instead, I was just so relieved to have the contractions finally be over.

My midwife told me I had a small 2nd degree laceration.  Did the perineal stretching exercises help?  Who knows?  But I’m glad it wasn’t worse.  Based on my mother’s recollection, they might have cut an episiotomy when I delivered, and it sounds like it might have been a 3rd or 4th degree laceration because they wanted her to have a bowel movement before she went home.  And I weighed one ounce less than WZW did.  I always thought it must be really painful to have the laceration repair without an epidural based on how my patients flinch as I’m performing it.  But for me, the whole area just felt raw so it didn’t feel bad as my midwife injected the local anesthetic for the repair.

WZW was able to stay skin-to-skin on me and breastfeed early.  It was weird for me and my husband to finally meet him, and see what he looked like.  This little creature who had inhabited my uterus for so long was finally his own little person.

We feel very fortunate that everything went smoothly.  I still can’t quite believe how everything went so amazingly well with my labor and delivery.  I mean, I’d certainly hoped for it, but I knew from experience that on L&D, things rarely go as hoped.  I was able to manage no pain meds for a short labor, but I don’t know how women do it for many more hours.  Ultimately, no matter how things go, the goal is a healthy baby and mom, so hopefully women aren’t disappointed if their labors and deliveries don’t always go as anticipated.

It’s Almost Time!

Discovered the greatest Whole Foods hack- if you go in the morning when they have their breakfast items at the hot bar, you can get a bunch of bacon for cheap.  It’s perfect- you save the effort of frying it up, and since it’s light it doesn’t cost much if you can resist the other items at the hot bar.  I think I got like 9 pieces of bacon for $1.35.  If only everything else there didn’t cost so much.

I’m 39 weeks and 3 days today.  Several days ago, after having no Braxton-Hicks practice contractions whatsoever, I woke up at 2 am with them.  Though my whole uterus did get hard, I found it interesting that the pain was lower down, and felt like bad menstrual cramps.  They were coming 10-15 minutes apart, and I wasn’t able to go back to sleep for several hours.  They continued less frequently throughout the day.  After that, I haven’t really had them very often.

I have continued to have that occasional discomfort in my cervix- it must be his head pushing down into my cervix, because when my doc checked my cervix yesterday, I was already 3 cm dilated.  Between the contractions a few days ago and whatever the little guy’s been doing with his head, things are definitely progressing.

At each prenatal visit, we measure a fundal height, which is a measurement from the pubic bone to where we feel the top of the uterus (fundus of the uterus).  After 20 weeks, the measurement in cm is supposed to match how many weeks the fetus is, give or take a couple cm.  I’ve always measured on the smaller side by a couple cm, but today it was about 35 cm even though I’m 39 weeks, and it was 36 cm last week.  Although my doc figured he had just dropped lower in my pelvis, it is a significant discrepancy, so to be safe she had the high risk OB doc do an ultrasound.

He’s measuring 2880 grams, which is 6 lb 5 oz.  It’s in the 10th percentile for his gestational age, which technically is considered borderline growth restriction.  The high risk OB doc recommended that I be induced around my due date if I haven’t yet gone into labor on my own.  The good news is that Little Willie’s head is super low, which he was able to see on the ultrasound.  So that combined with my 3 cm dilated cervix hopefully means I won’t have to be induced.  And even if I were, my cervix would be favorable for induction compared to a long and closed cervix.

Intrauterine growth restriction (IUGR) is when the fetus in measuring in less than the 10th percentile.  With that said, many fetuses in that category are constitutionally small, which is a fancy term for growing appropriately small for its genetics.  If the mother is a smaller woman, it would be less concerning for the fetus to be growing <10th percentile compared to if she were 6 ft tall.  Though there are slightly higher risks of stillbirth for fetuses measuring less than 10th percentile, the risks of stillbirth as well as other issues after birth, are more significant for fetuses measuring in less than the 3rd or 5th percentiles, depending on the study.

Reasons that fetuses may develop growth restriction include maternal chronic conditions like diabetes, high blood pressure, and autoimmune diseases.  Also maternal substance use, teratogen exposure, and infection can contribute, as can fetal conditions/anomalies.

For fetuses that are growth restricted, there are two types: symmetric and asymmetric.  The latter is more common, and is also called head-sparing.  Four measurements are used to obtain the weight of the fetus- the diameter of the head, the head circumference, the abdominal circumference, and the femur length (thigh bone).  In asymmetric or head-sparing IUGR, the abdominal measurement is decreased relative to the head measurements.  It’s thought that the fetus is redistributing blood flow preferentially to the more vital organs.

On the converse, one of my attending physicians in my residency training who is a diabetes in pregnancy expert always said that if the abdominal circumference is relatively large in comparison to the head measurements, there’s a higher chance of a shoulder dystocia.  A shoulder dystocia is when the head comes out, but the shoulder gets stuck behind the pubic bone, preventing delivery.  This can be an obstetric emergency, since the cord at this point is compressed.  If the baby is not delivered quickly with the maneuvers that we use for this situation, then it can end up with permanent damage or death.  So these little football player fetuses, particularly if their moms have diabetes, can be at risk.

Turns out Little Willie’s abdominal circumference was lagging behind his other measurements.  With that said, 10th percentile is still borderline, and otherwise there is nothing to suggest any concern about his well-being.  Given my size, I wouldn’t exactly want to attempt to push out a 9 pounder.  So I’m not that worried, and hopefully I’ll just go into labor by my due date so I won’t even have to worry about the whole induction.

In my experience, the fetuses we worry about tend to be the ones who have mothers with chronic medical conditions, and perhaps have had growth concerns from earlier on.  The vast majority of my patients who have fetuses in the mild IUGR range have babies who are totally fine.