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Little Old Men… & Nursing in Public (Back by “PUBLIC” Demand)

Welcome to The Breastfeeding Cafe Carnival!
This post was written as part of The Breastfeeding Cafe’s Carnival. For more info on the Breastfeeding Cafe, go to www.breastfeedingcafe.wordpress.com. For more info on the Carnival or if you want to participate, contact Claire at clindstrom2 {at} gmail {dot} com. Today’s post is about nursing in public. Please read the other blogs in today’s carnival listed below and check back for more posts July 18th through the 31st!


My first baby was born in sunny Florida during a particularly hot stretch in May 1979.  Although I was an OB nurse, I knew very little about breastfeeding other than what my older co-workers had taught me—which was not all that correct or very helpful information. Luckily, I had a great friend who was nursing her 3 month old at the time my son was born. She really showed me the ropes. It just so happened that she was the one who took me home from the hospital. We had to stop at the store for a few items so we went in to a “Publix” supermarket with both babies in our arms.  My newborn son began fussing to nurse soon after we hit the air conditioning.

I said.. “I’m going to have to go back out to the car and nurse him.”

My friend says “Oh..You’ll do no such thing.. You’ll die in that heat.. Just hook him up and keep shopping so we can get finished and out of here!”

Me- “Nurse him in here?”

Friend- “Well if he’s hungry.. yeah!.. (after looking at my face) Oh stop worrying about it..go over to a deserted aisle, get him hooked on and put your receiving blanket up near his face… nobody will know!”

Me- timidly…above the louder howls.. “Alright, be right back..”

I found the most private place I could. I started cursing that complicated “wonderful nursing bra” I just had to have. (Remember..this is 30 years ago… this bra is now an antique!) My skills handling newborns allowed me some grace as I attempted to multitask by stooping down, prop my loudly crying baby on my partial lap, use 2 hands to fiddle with the damn nursing bra, then get him back up near my finally free boob and latched on.

Ahhhh~ quiet, happy, drinking baby!

Still stooped down, I peered slowly behind me — expecting that a large crowd must have assembled. Somewhat surprisingly, everybody was just going about their business and I happily realized that noone was looking at me! I stood up, made sure I wasn’t showing anything, and walked off with my happily nursing baby to find my friend.

It’s amazing how many people want to see a quiet baby as opposed to a screaming infant!

A sweet little old man stopped me first and asked me how old my baby was….”3 days”, I replied. He peeked in for a closer look and he actually didn’t get it right away.. “I can’t really see his face.”.. I said “Well- he’s feeding right now.”.. He just said..”OOPS….sorry about that! Well he’s a cute one!” then walked off.

The next person who stopped me was again.. a sweet little old man. He was very smiley and jolly. He asked all about the baby but didn’t lean over to look like the other man. I quickly said he’s nursing now and then answered all the small talk.  He never seemed uncomfortable about it at all! That probably gave me a lot more confidence. We parted ways and I finally found my friend. She gave me an approving thumbs up, asked me to hold a basket with my other hand and said we were almost done.

Another little old man stopped us by the register to ask about both babies. We gave him all the small talk answers and let him know my son was nursing. This guy was a real sweetie, commenting on how lucky kids were that moms were starting to “nurse their young” again and ‘good for you.”  He never tried to look in at my son. He didn’t seem embarrassed by the process at all. He was the coolest guy!

I left the Publix Supermarket on my way home to begin my life as a mommy…. with a little public education bonus.  Encountering those sweet little old men while feeding my baby and receiving their positive type feedback was the gentle support I needed. I went on to feel empowered to nurse in public for all three of my babies…  Those little old men were just so supportive! ~ When my baby was hungry, he needed to feed and it really didn’t matter where I was at the time.  Thank goodness for my friend’s wisdom and support to go for it!

I became a lactation professional while nursing my last baby. It was then, only after I really became more aware of issues surrounding nursing in public that I actually took any kind of public action to empower other moms.  I’ve done lots of different little things as the years have gone by. I want to mention one fun way that I thought I could help gently re-educate some of the “new” sweet little old men of this day and age.  Our local paper has a lot of little retired guys commenting back and forth on various local articles. I’m guessing their age and status by all the things they say. I took this opportunity to possibly educate some of these forum readers about breastfeeding rights in public.  Every once in a while, on the forum, I put out a little snippet on nursing in public… and sit back and watch what they have to say in reply! It’s quite fun!

Here’s an example I wrote on a long forum discussion a couple years ago on a breastfeeding article:

On another note, regarding a reader reaction in the forum, a skimpy bikini or the bathing-suit issue of a favorite sports magazine show more skin in a provocative, sexy way than any mom breast-feeding. Even the movie stars in their gowns with plunging necklines are showing almost the entire breast! Somehow, that is OK. It is sad that the public opinion of a baby breast-feeding (the most natural way for him to eat) is something that should be done in private … yet young girls are encouraged by media to bare more and more skin. Of course being discreet while feeding is important, but I can assure you, most girls in a tiny bikini are thinking more about “tacky exhibitionist behavior” than a mother breast-feeding her baby. August 1-7 is always World Breast Feeding Week. The theme this year is “Welcome Baby Softly,” focusing on the importance of the first hour or two after birth. Learn more about it. I would love to see the paper do an article on that.

This one provoked a few responses in both directions and sometimes there were a few people who actually thought out loud that …gosh maybe I was right… never thought about it that way…etc..

Here’s an example I wrote on a recent article about the appropriate % amount for tipping :

I have never left an establishment without tipping– however, I also tip according to service up to 20%. If there are unkind reactions to small children in a FAMILY establishment, they will be getting a bare minimal tip for sure!! I do my best to keep my children behaved with table manners AND respect other patrons… but fact remains, they are children! I cannot possibly be prepared for every behavior or an accidental spill. In addition, my breastfeeding baby may be hungry.. By PA law, I have the right to nurse my baby in a public place wherever he and I are allowed to be. I am discreet.. I am protected by law… I don’t need an unkind comment from servers. They do not get a 15-20% tip if nasty, unkind or disrespectful comments have been made about my children or my breastfeeding baby!

This provoked a foray of comments ranging from ‘good for you’ to ‘you should be in the back booth…controlling kids etc..’  Sometimes the opportunities to educate others come at unexpected times but produce amazing results!

On a few occasions, other readers were supporting my comments and

helping to educate those sweet little old guys with me!

😉


Here are more posts by the Breastfeeding Cafe Carnival participants! Check back because more will be added throughout the day.

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My Breast Pump and I didn’t get Along 

Can I Pump my MILK?  Should I? …

or  Not.  Even.  Bother.


My Own Struggles with Pumping and Working

and doing what worked for me

Welcome to September’s Carnival of Breastfeeding!!!

I have this post AND an additional post All about Pumping including choosing a pump and how to Practice Pumping before going back. After you read this, check out the other posts on this month’s theme of “Breastfeeding and Work” linked at the bottom of this post. All links will be added as I get them hopefully by the end of the day Monday, so be sure to check back for the full list!

breast pump

A little history

As far back as I can remember, the only breast pump we had around in nursing school or when I first started working on the maternity unit was this thing that looked like a bicycle horn. This picture above is for an old “Breast Reliever”. It is glass with a rubber bulb to squeeze for suction. This particular antique is from the earlier half of the 20th century. We actually had a similar type glass model in Nursing school and on my 1st OB unit in 1974.   Historical use of breast pumps shows the first patent was issued in the 1800’s and a patent for a mechanical version was issued in the 1920’s. Information was scarce then. Not too many nurses knew much about it.  Mother’s were instructed to use it if they got engorged. I can’t believe it would have been very helpful.

pump70sold horn pump

We got a newer plastic version of this pump in the 70’s but still didn’t have any clear instructions for use. I was never taught by instructors or fellow nurses, so all I could do for the patients in my care was review the instructions on the box with them! I don’t even remember what that said. Those old horn pumps were trouble. They were traumatizing to the breast and the rubber bulb was just a trap for bacteria.

I remember one mother in particular in 1975 had been readmitted with bleeding, gone to the OR for retained placental fragments at 2 weeks postpartum. She was breastfeeding and having trouble. I took care of her postop. She said “I can’t believe how much milk I have, what can I do?”  I promptly went for the only pump we had and went over the directions with her. She was saying it hurt but felt better at the same time because it did help to drain some of the milk.  I didn’t much know then about how the retained placenta can delay hormonal shifts and your milk coming in. She and I both thought at the time it was because of being separated from her baby!

ANYWAY

By the time I had my first baby in 1979, (YES- 30 years ago) I had become more familiar with pumps because I had a friend pumping and now I was very personally interested. I wanted to pump just like her! I want to store milk for my baby when I went back to work. Her baby was 3 months old and she had gone back to work. She pumped in front of me once to show me how easy it was. She used a cylinder style hand pump similar to this picture. She got 8 ounces of milk in about 10 min!

70s pumpIt had one chamber inside the other. To pump, you would place the cone over your breast and pull the outer chamber up and down. This was a very popular style pump at the time. Easy right? I promptly went and bought one! I can do this!

My son was born weighing 6 lbs 9 1/2 oz. Breastfeeding got off to a great start, there were no problems at all. I was very confident about that and had great support from my best friend. My son weighed 7lbs 2oz at 2 weeks and nearly 10 lbs by 6 weeks.

I had plenty of milk!

None of which hit the bottom of the chamber when I first tried to pump….  no matter what I did! I knew nothing about the technique of pumping. I worked and worked at it.  I could playfully squirt milk across the room. I had squirting contests with my sister. We cracked up laughing! I could not get any milk with the pump.

I had never practiced. I thought that once I was away from my baby, I would just pump… thought the milk would just come out like my friend. I went to work, let myself get a full feeling and tried. Nothing.  I woke him up when I got home and made him eat!  The next day… same thing.. Nothing.  Luckily I only worked 2 days a week so I nursed him all the rest of the time. I kept trying- week after week– I thought I just had to get used to it. I am sure I was very stressed each time, never using any of the tricks I teach moms today.  I still never thought to practice when I was home with the baby. The most I EVER got after 45 min of pumping was one ounce.  I gave up and only fed formula while at work. My body adjusted and I was happy doing what I was doing.

I wrote a guest post over at Breastfeeding Moms Unite on pumping including choosing a pump for you and practicing to pump. All moms are so different and many have no trouble at all expressing their milk. Others have  trouble releasing their milk to this plastic “thing” on them that doesn’t feel like their baby. It’s just not the same! In that post I say:

I have found it’s important for mothers to understand that pumping is a substitute for the real thing and that it takes practice for lots of moms. I always say to expect hardly anything the first time you try then whatever milk you may get is wonderful! One very important point to realize is that whatever you see come out with a pump or hand expression is NOT a reflection of how much a baby gets in a feeding when he is well latched and effectively feeding.  What you see come out with the pump is what your body released at that moment in time. Even women with a great supply and healthy growing babies can have trouble learning to pump. The baby is the master … you are merely trying to imitate him! The type of pump used and when you pump in relation to the age of the baby as well as the time of day, frequency etc. can have a big impact on your results.

My second baby was born in 1985 . Another 6 pounder at birth with rapid weight gain, a great milk supply for me.  I had some improved pumping results with him partly because of better pumps and mostly by sheer determination to help him heal through major surgery at  3 months. The Children’s Hospital had a hospital grade electric pump, a pumping room and directions on what to do. Because I was able to provide milk for him in the hospital, I had renewed faith in myself that I could pump once I went back to work.

pump 80s

There were different pumps, better pumps available. I tried my old pump and some piston style pump like above. I don’t remember the name of that either. I tried many…still waiting to pump again till I had eventually gone back to work. There were some battery/ AC adapter electric ones to buy. I had one, but don’t even remember the name.  I had to push a button to make the suction go on and off –>  otherwise there was constant suction on your breast and no control on the degree or amont of suction. Some people told me to keep the suction on till it started to flow then push that button on/off.

Well it didn’t flow, it hurt. I never released any substantial milk for any of these pumps. I wasn’t able to keep it up. I ended up doing the same as I had with my first son. I made a routine which worked for me of nursing all the time at home and formula when I was at work. We didn’t have any hospital grade mechanical pump until the 1990’s at my hospital, long after my third baby and after I became a Lactation Professional.

I had dealt with so many other issues after my third baby that pumping was never much of a thought in my head. I simply fell back into the routine that had worked for me with the first two babies. She is the baby that nursed the longest even after I went back to work!

Looking back, I think if I had access to the information I know now, and the availability of today’s high quality pumps…I might have, possibly would have had better success pumping. The most important point is that I still felt successful  and was happy with my breastfeeding relationship for all my children!

After all, I could squirt my milk the farthest!!

😉

More Carnival Posts:

A Formula Rep turned my Maternity Leave Injury into a new career as an IBCLC? Really?

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My contribution to this fabulous Carnival of Maternity Leave  , is a story of how during my maternity leave, an injury occurred leading to a career change specializing in Lactation… ! It starts with the birth of my third and last baby…… A  girl….. (after 2 boys) was also born by C-Section.. a first for me.

Well– first, let  me back up a few years… I’ve had a potpourri of maternity leaves. I have been a Maternity/L&D/Nursery since the mid 70’s.  I always worked full time and had never entertained thoughts of staying home with my children once they were born because the USA didn’t assist in providing any type of viable option for families who rely on two incomes or single moms with one income.  Prior to FMLA,  maternity leave was pretty much up to the employer as far as I understand it. The USA doesn’t offer any paid leave (unless offered by individual employer). For my first baby in 1979- I took 7 .5 weeks and went to a weekend 12 hr shift job which at least allowed me 5 days each week with him. 

 When my next baby was born in 1985, I worked at the same facility I am now. We were allowed to save up ALL Vacation, Holiday, and Sick time to be used collectively with your hospital allowed 12 weeks off.  I was able to have 5 1/2 months total, partially paid time to be with my new baby. Since he had to have surgery at 3 months, I needed that time and could have used more.. My leave was actually supposed to end on Christmas day (YUK).. however, they graciously allowed me to come back on the 26th… also his first day in Day Care. 😦

So back to my third baby in 1988~I had had a C/S — (that’s another story).  I had to be hospitalized for 10 days after the surgery with a whopping infection. A fresh incision and chills with a temp of 103.8 do not go well together! [Nurse Curse] Anyway, I made it thru–> healed and returned to life as a mother of three. The same type of collective accumulated paid hours were allowed withthe hospital’s offered 12 weeks. I didn’t have as many hours saved up as last time but was hoping for the best length of time.  One day in church, I held my little 2 month old baby girl on my shoulder with one hand, while using the other to hold the hand of my active 3 yr old boy as we made our way down the aisle. Suddenly, my boy squealed with delight and whipped over in a different direction. I held my daughter and did a sudden twist and reach for my son as he squirmed away. I immediately felt something “give” in my back.

It took a few days for me to feel the true extent of the injury. I thought it was just a little pulled muscle. After a 5 hour drive to my sister’s for a family visit, I ended up writhing on the floor with the unstoppable intractable “fire hot poker” pain of full blown sciatica…. all down my right side. I had to go to the hospital ER away from home, unfamiliar doctors, for help and drugs! Boy, I needed relief. As explained to me by the doctors… this was not the same as sciatica from many other causes. This was a swollen inflamed sciatic nerve… we didn’t know why yet.  The only thing helping at that point was medication and ice.. a lot of ice. I still insisted they give me meds I could take while breastfeeding, so they weren’t too strong.

I got home, went thru an MRI and diagnostic process, different doc’s, different opinions. I had a disc “blow-out” with”free extruded disc fragments” at L5-S1. Some felt surgery was needed immediately, others said to wait.  After careful consideration, we decided to wait and do some conservative type treatments with oral and epidural steroids. I still had to heal well enough to work, though. I spent many nights crying and wondering HOW I could work ??? How could I go and be on duty…running all over to keep up with the pace, helping people thrulabor and delivery…respond to emergencies…how?? I could barely care for my family! I called many friends while I was on periods of bed-rest and had various treatments during the time I had left of maternity leave. (I eventually did have to extend the leave a couple weeks for more recovery. I ended up witha 5 month leave altogether). I was searching for ideas.. visions of something less physically taxing which could combine my knowledge of labor/delivery/postpartum and neonatal care….. and allow me to continue working. I was, after all, the major bread-winner in our family!

Finally, a friend came up with an idea. He was actually a formula and drug rep for Ross labs.. TRUE!! But he was a friend, had heard I was hurt and stopped by the house to see how I was. He was a rep to many hospitals in the NorthEast and had exposure to what else was going on– what other hospitals were doing.  This was 1988, only a few years after the emergence of the Lactation Consultant profession. I had never heard of it. Sometimes word traveled slowly (by pony express) and things changed slowly in my little neck of the woods. He encouraged me to check it out and gave me phone numbers of LC’s at some of his other hospitals. I was really excited! I called a few and found out more about the lactation profession and the relatively new Board exam given every year in July to gain the credential of IBCLC.  I was actually naiveenough to think I could take the exam with my current knowledge base!  HA! (Unfortunately, this is what many nurses with a little experience think…we think we already know it all! Ha!) 

I called one of the LC’s at a hospital not too far from me. We talked a while and I had my eyes opened as to the extensive and vast knowledge base needed to become a lactation professional. I launched a quest for the best way to gain this knowledge. I joined LLL and went to meetings. I made home visits with the local LLL leader. I wrote many letters, made many phone calls searching for some type of education program. (remember– no Internet back then!)

Finally I found the perfect program for me. There was a correspondence course offered to be done all through the mail and phone calls designed to be an 18 month course.  It was a Lactation Consultant Course offered by BSC Breastfeeding Support Consultants! (the link shown is for their current course) Back then, you could be called a Certified Lactation Consultant after completing the clinical practicum and final exam. Because of continued back problems, I started this course in early 1989, had to take a few months leave from the course and completed it in early 1991. I then went on to continue studying and sat for the IBLCE exam in 1993 earning  my IBCLC status!

I have always continued to work as a staff nurse. I found a corset style back brace and found the best balance possible between family, back pain, work and more pain. I was able to get the pain subdued with steroids to carry on with life. In 1992, during a particularly gruesome relapse, I eventually consented to a myleogram… something I had previously NOT wanted. They also did a CT scan while the dye was in place. These tests showed my right Sciatic nerve had been pushed way up out of place by the disc material. I consented to surgery by a fabulous neurosurgeon the very next day. It turns out, the disc was actually adhered to my sciatic nerve!! He had to meticulously excise it off the nerve!!  My post-op pain was minimal compared to the pain I had before surgery. I was able to go back to full duty in 8 weeks!

Over 20 years later, I am still working as a staff nurse and am now a CLC… Certified Lactation Counselor.  Becoming a breastfeeding professional has enhanced and fortified my life! I am immensely happy I have gone down this road. To think it all came about as a suggestion from a Formula Rep!?!?!

Hope all had a great WBW 2009!!

Hope all had a great WBW 2009!!

WBW~ Breastfeeding in a Personal Disaster…. C.Michael’s Story

SendPicture14 August 2nd…..Today is my son’s 24th birthday. Yeah…I’m old 😉 This is not really the theme of WBW but I will take this opportunity to tell his breastfeeding story on his birthday.

In 1985, I gave birth to my second son. C. Michael. He was 37 weeks and behaved like many     near term babies… Breastfeeding got off to a slightly delayed start but then was awesome and without problems! Yay!

I wish C. Michael’s physical health was the same way.

C.M. was born with craniosynostosis.  Specifically, saggital craniosynostosis. Infants skull bones are purposely NOT fused together at the time of birth so the head can mold as baby makes his way down the birth canal and into the world. The different skull bones will overlap easily along the suture line so as to fit thru the pelvis. These bones then gradually reshape and the sutures eventually fuse.

My son’s saggital suture line was prematurely fused…causing a misshappen head. When there is a premature fusion, the growth can only occur parallel to the fusion. The saggital suture goes from the anterior fontanel along the top of the head to the posterior fontanel. Parallel growth would cause his head to be really oblong, or football shaped.

We took him to 5 doctors to decide if we would have corrective surgery… Yes that’s right…. it had to be OUR decision. Although this is a birth defect and causes a visual deformity, it does NOT affect healthy brain function UNLESS there is fusion of more than one suture and growth is impeded. So it is cosmetic surgery.

We decided to go ahead with the surgery at age 3 months and had everything arranged at CHOP (Children’s Hospital of Philadelphia). The craniofacial team was amazingly supportive. I was so very scared. My husband and I could not sleep. I hadn’t been able to sleep well since he was diagnosed. How many new mom’s tell you the baby is sleeping but they can’t sleep??? I’m not going to get into the whole surgical procedure… but the  main point of this story is how breastfeeding not only provided C.M. with the best nutrition and immune system protection, it also saved me thru my son’s ordeal.  My husband was able to pre-donate blood so we both felt like we were doing everything physically possible as his parents to help him tolerate and recover from this major surgery.

I was so pleased to be able to sleep right next to him in the hospital. We had to go in the night before and the he was not allowed anything after 4 am… he could nurse up to that point. I woke him to nurse around 3 am. It was very bittersweet. I was crying and he was happily nursing, not know what was coming next. It was difficult just to see the IV placed, let alone the actual surgery.  I was so grateful and happy they had done alot of pre-op procedures the night before when I could nurse him after each study. Now , when they wheeled him off to the OR, I was almost happy he had been slightly sedated because as hard as it was, I could never have handled him screaming at that point.

While he had the surgery, I headed first to the pumping room to try and get as much milk stored as possible. I had not been able to pump well before this so I had limited expectations. It was the first time I had used a hospital grade pump so I had much better volume than I expected. I stored a couple bottles and was feeling actively involved in his recovery already!

They called us to meet him outside of recovery a couple hours later. It was very difficult to see his head swollen and heavily bandaged. He had had a blood transfusion once already in the OR and they expected he would need more. Apparently the bone edges ooze when cut.  We took turns with him until he wasn’t groggy any more, then, once awake…. I rarely left him.  I was told he had to have a little bit of an electrolyte solution in a bottle first before I could nurse him, just to make sure he didn’t vomit.  He was ready to nurse in about another hour. They took him out of the crib, with his massive head bandage, black and blue eyes and 2 IV lines….place him in my arms and we gently rocked and nursed.SendPicture12

I felt completely lost, even as a nurse or especially as a nurse…. because seeing your child like that is very difficult. I kept thinking all the worst possible complications would happen to him. I wanted to keep him safe, protect him. I struggled with tremendous guilt, thinking I must have done something to cause this to happen… It must have been my fault.  Many parents go thru that, I’m sure. Breastfeeding him thru the hospitalization, two more blood transfusions and recovery period helped me feel like I was actively healing him. My husband felt similar thoughts because they used his blood for the first 2 transfusions. It was an empowering feeling.

I’ll close by saying that finally being finished with the decision process, the surgery completed (sucessfully I’m happy to say) and on the recovery road also cured my sleeplessness.

The night nurses at CHOP laughed at me! There I was, sleeping right next to my precious brave 3 month old post-op son…and they had to wake me up to tell me he was crying to feed in the night.  😉

What a handsome guy now!

What a handsome guy now!

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OB Docs and Nurses Scoff at Homebirth

My community hospital’s views have never been in favor of any type of home-birth… whether it’s with a skilled professional  practitioner or a skilled lay midwife. There could have been some free unassisted births going on but we were not aware….  As I grew-up in this profession, I learned first from my experienced counterparts…then I began to educate myself and learned a lot from mothers and babies.  The doctors and nurses I worked with were all stagnant in their knowledge in my early years. They were satisfied with how things were.  I was young, I had an open-minded philosophy and an eager quest for knowledge.

In the later 70’s, just when we began to have mothers speak out and request a more natural childbirth, I had a few friends who enlisted the aid of some lay midwife in the region and arranged for homebirths. They all had a really nice birth experience without a single complication. Perhaps that was why I was open to the idea even though I was not personally involved. Besides some of the truly prepared couples who came in and had incredibly beautiful births….. that had been my first exposure as an alternative option to the knock’em out–pull’em out births I had been working with on the job. I knew my friends were very low-risk and had done their homework. 

   However, the hospital’s exposure to a homebirth in those days was only if the homebirth went awry for some reason or another and they came in our doors seeking help…  here’s what the docs and nurses would say to one another :

  • “Can you believe she planned to deliver at home???”
  • “How could she take take a chance like that with her baby?”
  • “The reason people started coming to hospitals to give birth was because mothers and babies were dieing at home….she must be crazy or totally insane!!”

   We’ve had planned homebirths come in for various reasons, as I am sure other facilities did…. (keep in mind that in my area, the usual birth attendant was a lay midwife). The situations bringing the mother to the hospital were often scary and upsetting for her. The most common were:

  • Fetal heart rate decels with or without meconium stained fluid 
  • Lack of progress with pushing mostly after many hours..
  • Higher than normal bloody show or bleeding–possibly abrupting
  • Breech, brow or face presentation
  • Retained placenta

Often the OB’s didn’t handle themselves well.. certainly not professionally. We had this one OB who would call for the OR to be opened before he even examined the patient or evaluated the situation…..regardless of why they came in.  And he often actually yelled at the mother, in the middle of her scary situation.

“Your baby will die if we don’t do an emergency C/S right now, why did you let this happen!”

Most often the backlash was directed at the midwife who cowered in the hallway- uninvited by the staff, left alone detached from her patient. She never left the unit though until she was afforded the opportunity to visit and speak to her patient. 

The two significant situations I remember which would fall in to statistical data for morbidity were:

  1.  An abruption which resulted in a crash C/S upon admission and a neonatal resuscitation with good response….(final apgars 3@one min then 7@ five min) positive overall outcome, no long term sequelae.
  2. A birth where the father (a chiropractor) was the birth attendant for his wife, a multip, encountered a shoulder dystocia and the baby ended up with a displaced fractured left humerus. That baby was in a crib with traction to realign the bone. The child went on to be an honor student at a local university after homeschool.

I feel that instead of the midwife or mother receiving hostility (or even the mother being wisked away to the OR without a trial of something if the baby was deemed stable..)~ the staff should have behaved in a compassionate professional manner, acting on any urgent situation with consideration that this mother is now experiencing not only labor but fear and grief over the loss of her beautiful planned birth.

Despite all the negativity from the staff, we never had a seriously bad outcome from attempted homebirths arriving on our doorstep.  We still have attitude problems, probably always will~ just as we do with breastfeeding.  I wish they could  look at it from my perspective. Those who choose homebirth today have better information to hopefully make an educated informed decision about their birth options and choose wisely. I really like Ricki Lake’s “The Business of being Born” among other’s. I hope those choosing homebirth are truly investigating all these options, deciding what is best for them and not making any decisions out of “anger at the system” or any sort of revolutionary zeal.  

  There is so much out there for medical professionals to be aware of other than what goes on in their tiny little realm, their little part of the world. My co-workers and doctors need to be better informed.  

Any one bad outcome (which most certainly happens in the hospital)  does not mean that every homebirth is a bad idea.

Cesarean Delivery of the Second Twin… Why? 

029I was talking to one of my on-line Twitter friends @onefinebreeder about twin delivery. I was telling her about how things used to be.. how vertex-nonvertex twin gestation’s were always delivered vaginally ….. and she commented on how it was sad that some of the old OB skills have been totally lost to surgery… So Very True!

I got to thinking about the first combination Twin delivery I had witnessed back in the very early 80’s. This was actually one of our own (hospital employee) nurses .  She was a multip…. around 37-38 weeks and healthy…no complications during pregnancy. Twin A delivered spontaneously, vaginally with a generous episiotomy as they often performed at that time… The baby , a girl, was about 6 pounds, vigorous and had no problems. We were all marveling at the first baby, checked fetal hearts on the second twin and started waiting for him to get in position.  Still before consistent ultrasound, we were not worried. However, we had a newer doctor who was attending this birth. He began to get concerned after 5- 10 min when contractions slowed and he was worried that if this baby was breech, he would have difficulty with the “after-coming” head. Up to this point, all I had learned was this can be a real concern if the smaller feet or buttocks present through a cervix which is not fully dilated. Much research was done later on but at the time, I did not know about it. He began to ask us to call the OR for a C/S. This was unheard of in my limited experience at the time…. my 70’s world. I thought.. how can they do a C/S now when one baby was already born??? I tried to be an advocate… (my early days… )”We have Piper forceps…”  I said meekly… “Have you tried to grab a large part and help bring the baby down… ?” This was my limited knowledge… all I knew to suggest. I kept wishing one of the other doctors was on duty that day.. or maybe we could call them???

In front of the mother, he said to me “I’m not going to have a bad outcome here!” By now it was 20 minutes or so. There was no cord prolapse, no drop in fetal hearts, no evidence of immediate trouble… the baby was seeming to work itself into breech position…. To the mother he said “Your baby is in serious danger and the best thing to save him is to take you for a Cesarean now!” “I’ll sew your episiotomy together while we are in the OR.”

I was in shock. She signed, scared to death of course. So we prepped her for the OR. She went up for a C/S of her second twin and repair of her generous episiotomy. Her second baby was delivered frank breech…  a beautiful boy about the same size and was also vigorous and healthy. I remember I felt as though she was almost assaulted. I remember feeling that this was a true rare event if it every happened before. There was no immediate access to information like today.

Luckily mom and babies did fairly well in the postpartum period even though healing from both the episiotomy and the C/S was difficult for her.

"How can I get out if I'm not head 1st ??"

" Psst-- How can I get out if I'm not head 1st ??"

I wanted to see how much research I could find on this topic. I had gone to the green journal (OB & GYN) website but then it locked me out. (You can only look at abstracts anyway unless you want to purchase the article. You are on your own for that.) I had some luck with the abstracts at PubMed so I have put a few here.

I decided to take a look across time…….

This first one is from 1981. . Quoted abstract from the PubMed site:

Cesarean Section for Delivery of the Second Twin

Evrard,JohnR.; Gold, Edwin M.
Obstetrics & Gynecology. 57(5):581-583, May 1981.

Four cases of combined vaginal-abdominal delivery of twins are presented, and an additional 5 cases from the recent literature are discussed. Malposition, malpresentation, and contracted cervix were the main indications for cesarean section for the birth of twin B. In the 9 cases presented, there were 2 perinatal deaths.

Interesting that this research was done during the same time frame as my experience above. I’d like to know more about those poor outcomes 😦

The next interesting article I found was researched over a 10 yr period, somewhat close to here in a larger facility, published 1997. THIS study examines the delivery of the second twin by utilizing external version vs breech extraction . 😉 The results are showing in favor of breech delivery vs version (those meeting exclusionary criteria ).. Versions were associated with higher a incidence of Cesarean and fetal distress. Neonatal outcomes no different and are stated below:

Method of delivery of the nonvertex second twin: a community hospital experience.

 Smith SJ, Zebrowitz J, Latta RA.   J Matern Fetal Med. 1997 May-Jun;6(3):146-50

Abington Memorial Hospital, Pennsylvania, USA.

The purpose of this study is to examine the incidence of cesarean section and fetal distress complicating the delivery of the second twin in vertex-nonvertex twin gestations in which the second twin underwent either breech extraction or external version. The intrapartum courses of 510 twin gestations delivered at a community hospital over a 10-year period were retrospectively analyzed. All vertex-nonvertex twin gestations were identified in which the second twin underwent attempted breech extraction or external version. Exclusion criteria included birthweight < or = 1,500 g, fetal anomaly, intrauterine demise, and monoamniotic twins. Of the 76 twin sets that met inclusion criteria, 33 underwent external version and 43 underwent primary breech extraction. The two groups had similar demographic characteristics. External version compared to breech extraction was associated with a significantly greater incidence of cesarean section (8/33 vs. 1/43, P = .008) and fetal distress (8/33 vs. 1/43, P = .008). There was no difference between groups in neonatal outcome for the second twin as measured by length of stay, 5-minute Apgar < 7, intensive care unit admissions, hyaline membrane disease, intraventricular hemorrhage, and traumatic birth injury. In conclusion, the increased incidence of cesarean section and fetal distress in patients undergoing attempted external version suggests that breech extraction may be the preferable route of delivery for the nonvertex second twin weighing more than 1,500 g

The next study was published a little later in 2001 and covered a 20 year span of time… during the 80’s and 90’s at a larger center in Nova Scotia, Canada. They noted an increase in their combination vaginal/cesarean twin births and documented some statistical data, looked at reasons for an operative second twin birth. I wish to read this study further some day to see if there is mention pertaining to mother/baby outcomes other than statistics outlined (even though that wasn’t their objective) in this abstract:

Combined Vaginal-Cesarean Delivery of Twin Pregnancies

Obstetrics & Gynecology . 98(6):1032-1037, December 2001.

Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.

OBJECTIVE: To estimate the incidence and factors associated with combined vaginal-cesarean delivery in twin pregnancies. METHODS: We studied all twin births weighing 500 g or more during a 20-year period (1980-1999) at a tertiary care center. Major anomalies, monoamniotic and conjoined twins, and antepartum fetal deaths were excluded.

RESULTS: During this 20-year period, 105,987 women delivered, of whom 1565 (1.5%) had twins. Of these, 1151 twin sets fulfilled the study criteria. The mode of delivery was vaginal in 653 (56.8%), cesarean in 448 (38.9%), and vaginal-cesarean in 50 (4.3%). During the 20 years there was a statistically significant increase in combined vaginal-cesarean and elective cesarean deliveries, with a decrease in vaginal deliveries. Parity, gestational age, and birth weight discordance (>25%) were not associated with combined delivery. Compared with vaginal delivery, the nonvertex second twin was associated with a twofold higher risk of cesarean delivery (relative risk [RR] 2.3; 95% confidence interval [CI] 1.3, 3.8; P =.002); and an interdelivery interval of over 60 minutes with an eightfold higher risk (RR 8.2; CI 4.6,14.6; P <.001). Vaginal-cesarean delivery had a 22-fold higher use of general anesthesia compared with vaginal delivery (RR 21.8; CI 5.4, 88.5; P <.001). CONCLUSION: There has been a significant increase in combined vaginal-cesarean and elective cesarean deliveries among twin gestations, with a decrease in vaginal births. Vaginal-cesarean delivery is associated with nonvertex second twin and a prolonged interdelivery interval.

Now we come to 2008!  There is a study here from Texas. This study looked a twins born by C/S after labor and twins who had cesarean birth of the second twin. they campared outcomes to see if the twin of a combined delivery had more problems. The most important pieces of information I gather from this abstract of results…. (again, having NOT read the entire study):

“Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.”  Hmmm 

Cesarean Delivery for the Second Twin

Alexander, James M.; Leveno, Kenneth J.; ….et al:for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU)   Obstetrics & Gynecology . 112(4):748-752, October 2008.

Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75235-9032, USA. james.alexander@utsouthwestern.edu

OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.

I gather from these studies that a combined delivery route leads to more problems.. however…there are probably more problems than breech presentation alone to lead the provider to make that choice. I believe that many newer providers of obstetrics in a hospital setting are more apt to do a scheduled C/S for any vertex-nonvertex twins they encounter. That is what is done in my facility today. The same for all breech presentation singleton gestation.

Where is that old-fashioned nurse when you need her?? How ’bout the old fashoined doc??? 😉

I am very interested in anyone’s story or experience either in healthcare or your personal birth. Please let me know if you know anything about this!

Thanks for reading!

Our HOSPITAL’S First Planned VBAC

I say our hospital’s first planned VBAC (Vaginal Birth After Cesarean)….. however a prelude is necessary because the actual first VBAC I can remember…. totally freaked everyone out. Here are the stories:

Sometime in the mid 70’s -circa 1976, a mom came in to L/D for a labor check. She was near term with some regular contractions, a little bit of bloody show. The nurse calmly wrote her name down in the notebook…. [Yes– a notebook, that’s the only way we kept track of labor checks back in those days. No medical record, no registration, just a name in a book and the day they were here and checked]… She was getting ready to gather more information when the mom said she had a history of a prior C/S.
Suddenly all the nurses were scrambling—“Quick, call the doctor!” “Quick, shave her belly,” “Get the Fetal Hearts” “Call the OR and tell them we have a STAT C/S”…We were all busy quickly getting her ready for the OR.
This little baby, however, definitely had other ideas. The mom told them she had to go to the bathroom…
Someone said: “Not now honey, we’re going to get you to the operating room to have your baby.”
The Mom: “But—I have to go….. AUGHHHH” (loudly grunting)
One of the seasoned nurses threw the sheets back and low and behold, that little baby was crowning!! “Doctor W– No time for the OR– This baby is coming!”
She did deliver vaginally, quickly, and everyone was in a state of shock!
I was thinking– I didn’t think that was possible–they told me once a cesarean always a cesarean—they told me the uterus would rupture–that the mother would hemorrhage. She and her baby were just fine. I realized once again that I had a lot to learn!

Fast forward now to 1984.

I was sent a nicely written post on the VBAC Pendulum by Dr Shelley Binkley which discusses the rise and fall of VBAC’s in the US and makes for very interesting reading. There’s been tremendous controversy surrounding this topic.

VBAC’s were widely discussed in the literature at early to mid 80’s and many women were interested…the doctors???– not quite so sold on the idea.  However, in the late 70’s early 80’s, we had one very progressive young doctor (Dr.B)  in the main OB practice.  He was responsible for many of the advances we had in a more natural approach to childbirth.  He was willing and eager to give this a try. 

I am not sure what he may have discussed in the office with his patients or how he may have selected his first patient who could try for a VBAC.  Knowing him, he may have brought it up to mom’s instead of the mom bringing it up to him. Anyway– sometime in the summer of 1984 we heard we would be having our first VBAC! She was due in December with her second child. Her first baby had been delivered at our hospital by Dr. B via C/S because of some fetal distress.  He knew her history and had full access to her records to know exactly what type or uterine incision she had.  She was young, healthy and continued her pregnancy to term without any complications. She was very excited. 

The hospital staff was a nervous wreck.

Where oh where were we going to labor her so that should ANY complication arise, we could do the fastest C/S possible??? We didn’t do C/S’s on our unit. The OR was down a floor and in another wing!!! Such a dilemma.  They finally decided to use the tiny windowless isolation room of the Recovery Room right outside the OR.  They decided to bring all the equipment from L/D down to that room to see how it all fit. We had a regular bed,overbed table, the fetal monitor, some other IV equipment/meds/ supplies etc.. a chair for dad, stool and sm desk for nurse…all crammed in the room. (OK- we scrapped the desk..that was rediculous) We were literally practicing like when they do separation surgery for conjoined twins!!  Quite the production. 

Ready or not, here she comes…….arriving in labor almost a week late at 40 5/7 weeks.  She was in very early labor much to the relief of everyone involved. OF COURSE I was on duty! OF COURSE I was elected to be her nurse! I was after all, the most prepared (say all my co-workers).  So while other’s got the room ready downstairs, I admitted her. There were no special consents at the time.  My orders were continuous fetal monitoring,  start an IV right away, AND insert a Foley catheter so we would keep the bladder drained, avoid any excess pressure on the uterine scar and keep her from needing to get up.  I also had to do a big shave prep in case of an emergent C/S. We took her down to that tiny closet of a room when it was ready, around noon. She was still in early labor.  The plan was to do a double set-up in the OR for delivery. That meant a whole set-up for a vaginal birth and a whole set-up open for a C/S complete with the entire OR team. They would call them in when she was in active labor. She had progressed to 7 or 8 cm with her first baby before needing a section so the thought was she’d go fast this time. 

Early labor continued into the late afternoon. All the managers involved kept stopping in repeatedly with all the same questions:….. “Is everything alright??”….. “Any problems??” …..”Any sharp pain in the lower abdomen?”….. “Any blood in the urine?”…….. “How about any excess vaginal bleeding?” ……..They were making me crazy.  We didn’t do any Pitocin augmentation. This poor mom was just in bed the whole time, in the closet with the single bright light, moving around when I suggested changing positions. Finally she headed into active labor and then did progress quickly to transition.  The membranes ruptured spontaneosly and the fluid was clear. The baby was great on the monitor!  The mom was a trooper, never complained, always smiling in between contractions, agreeable to whatever we said.  They asked me to stay and I stayed…. long past my shift.  

They called in the OR teams. I wasn’t nervous anymore. Get me alone with my patient– away from the nervous Nellies and we can connect and work together through labor. It helped that I had seen that unplanned VBAC so many years before and that I had tremendous trust in and respect for Dr. B.. He was there past his shift also. I had already helped her through so many contractions. She didn’t have the slightest symptom of problems. I had her pretty relaxed, she went thru transition and headed into the second stage in good shape.  At this point, they wanted to move her to the OR for pushing. I think back and feel so bad for her… She was however, still excited and still very agreeable.  She pushed on the hard delivery table in the OR in front of the assembled teams. Talk about performance anxiety.  She sure had a lot of coaches!!

She delivered and 8lb 14oz boy named Michael later that evening!!! He was 20 1/2 inches long, his apgars were 8 and 8, just needing some blow-by oxygen in the OR.

There were no complications. This mom came back and had a few more VBAC’s ending up with 5 children overall. I don’t remeber how many VBAC’s we labored in that rediculous closet of a room before we would keep them in L&D. 

I admire this mom for her strength and courage. I thank her for all she taught me…taught us..

Michael will be 25 years old this December!

If you like this story or have any interest in how any specific childbirth element was first seen or has evolved, Please comment or contact me! Thanks

Medical Science vs Natural Childbirth 

I sat here to write the story of our first planned VBAC and realized as I scanned my other posts that I had to tell just a little more history to help explain the attitudes of the times.

During the mid 70’s early 80’s… our country was changing in many ways. In the medical world, Obstetrical medicine was becoming more specialized with the development of many subspecialties including  “Perinatology” and “Neonatology”.  Perinatology by definition is the study of the unborn fetus and recently born infant during the first several weeks of life. It was the changing concern of obstetricians from a sole focus on the mother’s health to one which is balanced between the mother’s health and the unborn or newborn. ACOG started to offer a specialty certification exam for perinatology  in 1974, and in 1977, the Society of Perinatal Obstetricians (now called the Society for Maternal-Fetal Medicine) was formed.  The term used to describe a Perinatologist today is a Maternal-Fetal Medicine Specialist.  This specialty is the management of high-risk pregnancies and the assessment and treatment of the fetus. Neonatology (established 1975 by the AAP) is the study of a highly specialized care of the newly born infant especially the ill or premature newborn infant usually hospital based in NICU’s.

Young women were becoming more and more interested in a natural approach to childbirth. People all over the country were driving maternity services to offer the availability of birth options for these moms. The ICEA [International Childbirth Education Association] came to our town in the late 70’s and a local chapter was born. “Freedom of choice based on knowledge of alternatives” in childbirth was a motto on their pamphlet information. There were some individuals in the community going for the new certification of childbirth educators. They were educating some new mom’s about birth options…… that we, the staff hadn’t learned about let alone developed as an option for our patients. Many on the staff scorned this movement. It seemed to me that these changes were all happening at the same time. We were learning about advances in observing and monitoring the well-being of both the laboring mother and her unborn fetus, preventing complications etc…. arising from the research studies done from the emerging sub-specialties. We had one fetal monitor and purchased another. As soon as the specialists found that continuous fetal monitoring was advantageous to picking up potential problems in advance, to possibly avoid or prepare for complications, there was a natural childbirth revolt against the constant recumbent positioning that EFM (electronic fetal monitoring) seemed to require. There were more examples as with IV fluids or access and other routine procedures. The nurses didn’t understand. They were just trying to do what science and our doctors were telling them…[though not always willingly as some were afraid of the newer technology.] To them, this group pushing a natural childbirth movement was the same population that had just wanted to be given drugs, put to sleep and “wake me when it’s over” crowd.  

I realize that although these advances in science and the movement of young people seeking natural childbirth options seemed to happen so close to the same time in my world, it probably didn’t happen this way for all of the country. Here, I really think it probably greatly contributed to the attitudes of nurses and doctors I worked with at the time. Those professionals who just couldn’t relinquish control. They were learning more about the science of birth, of monitoring and couldn’t quite allow or see how the “natural” component could fit in. Those individuals often were guilty of the abuse of professional power, the use of misinformation and the blindness and arrogance to maintain control of the birth process… taking it away from the mother.  Those professionals who should have known better.  They did not know of the rights of childbearing Women, or of general patient rights for that matter. Unfortunately– there are some who still have these control issues.

That’s another story….