Waiting for Agnes

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Not in the zone October 5, 2010

I’m feeling very gloomy this evening. A bit short and snappish, preoccupied with the unfolding of events at work over the past two days. Usually it’s other people’s inadequacies and crappy decision making which send me home fuming, but tonight I’m just gloomy about my own.

I cannot count the number of times I have heard other maternity care professionals justify their decisions/refusals/interventions with the phrase “I’m just not comfortable with ______________” (insert any of the following: waiting for you to go in to labour on your own/allowing you to birth on the floor/you using the bath during labour/not giving you antibiotics/not doing this test/not giving this drug/letting you go home yet…). The list is endless and the language is always saturated with notions of permission-giving and implications of women being naughty, rule-breaking girls who don’t give a fig for their babies’ welfare. This notion of practitioner comfort as a guide for practice irks me as much as the statement “If it was my wife ____________ (having a breech baby/questioning the necessity of a test/being female and pregnant and conveniently oppressed by archaic obstetric care) I would advise her to _____________ (just do what I say even if it’s based on nothing but fear or financial incentive/not question me/just shut up already). Midwifery and obstetrics and having babies are not meant to be about being comfortable, not for anyone. As an aside, there is never a dumber question asked of a labouring woman than “Are you comfortable?”. This job of caring for women as they step into motherhood should be about understanding the normal and knowing the evidence for intervening in the abnormal. It should be about providing the information and honouring the woman’s ability to make decisions for herself and her baby. Should should shmould.

So, what have I done? I have run smack bang into the invisible wall of my very own comfort zone. Let me set the scene:

On Sunday evening, around seven o’clock, a woman gave birth to her first baby. I was not there, but I know she had a spontaneous, vaginal birth, using only nitrous oxide (the gas) for pain relief. She did not bleed excessively and is otherwise well. At birth, her baby was handed straight into her arms and lay, skin to skin, on her chest. She wants to breastfeed but her baby is not interested. Sensibly, she keeps her baby skin to skin with her, allowing him plenty of opportunity to breastfeed. Over night, the midwives help her to try and express some colostrum, but report that they are unable to express even a drop. By eleven o’clock the next morning her baby still has not been able to breastfeed. He has attached on and off a few times but hasn’t attempted to suck. He is settled and remains skin to skin on her chest. He has had a poo, but no-one is sure if he has had a wee (disposable nappies can be tricksy for detecting the teensy wee of a newborn). The woman’s husband is with her, anxiously attentive, lovingly stroking her and the baby. Her mother in law is sitting by the bedside, tutting and tsking as hard as she can, muttering about starvation and formula and glaring hard at everyone. The unit lactation consultant is off for a training day. All very helpful. The midwife looking after her asks me for help. I whip out my breastfeeding cure-all and show the woman how to position herself and her baby to feed lying down (really, it is a very useful skill). Baby has a go at attaching but still isn’t swallowing. He is starting to cry and is no longer easy to console. Together, we have another go at expressing some colostrum. Three glistening drops appear. I suck them up painstakingly with a 1ml syringe. It is twelve o’clock and has now been seventeen hours since birth. Conferring with my fellow midwife, we decide to finger feed the baby these three precious drops of colostrum mixed with 1/2 a ml of sterile water. Gently sliding a finger into his mouth and dripping the liquid in slowly, I hope fervently that this will trigger the switch in his brain – that he will start to connect sucking with swallowing with feeling something in his belly. As he starts to suck my heart sinks a little. His mouth is dry and he is so very uncoordinated, not sealing his mouth around my finger, not bringing his tongue forward but instead using it to push against my finger. But afterwards he turns back towards his mother’s chest and settles again, so we don’t give up hope. I step out of the room and back to into the relentless pace of another October day.

A few hours later, just before we morning midwives finish our shift, I check back with this woman and her baby. No change. It is now twenty hours since birth and he is starting to look truly hungry, crying and crossly pushing at her breasts. She is tearful, her husband more anxious. On the upside, her mother in law has tutted herself to sleep in the bedside chair. I step out again, seeking out the midwife who will care for her next. Hating the words coming out of my mouth, I suggest that while the woman should continue to keep her baby skin to skin and keep expressing, the baby may need a supplementary feed of formula. Then I go home.

Today, I’m back on the ward, every room full. Our lactation consultant is back on deck. She is frantically busy and she is furious – furious that this woman’s baby has been given formula with no medical indication. On paper this is true. The baby is not lethargic, jittery, under 1.5kg, admitted to the nursery, septic, hypothermic or hypoglycaemic (that we know of – no blood sugar measurement was done). His mother is not sick or absent. I feel horrible. I have great respect for our LC and we usually work well together. Usually she respects my professional judgement. Now, buffeted by the wave of her anger, I suddenly find myself questioning my decision. Should I have been more trusting? Should I have waited longer? How long? I ask this and the answer is firm – no medical indication, no formula. But really, how long? Until a medical indication arises. How do I feel? Uncomfortable.

And there it is. Discomfort. Have I really interfered unnecessarily because I wasn’t comfortable? I come home and haul all my breastfeeding textbooks off the shelf. Am I trying to justify my decision? Or can I find something to stretch the boundaries of my comfort zone a little? There are answers, sort of. Although the authors vary in how many feeds they feel should occur in the first 24 hours post-birth, they concur on one point: if a baby has not latched on and fed by 18-24 hours of age, the mother should be assisted to express colostrum and feed it to the baby by finger, cup or spoon. But none of these texts suggest what to do if there is no colostrum. In a perfect world, this woman would have a sister/cousin/friend who was breastfeeding, someone who could donate some breastmilk to tide her baby over until her own milk comes in. Or we could access donor milk from a breastmilk bank. But this world is far from perfect. This woman’s only family in Australia are her husband and tutting mother in law. And if they were here, the idea of sharing breastmilk amongst family and friends is disappointingly taboo. We will have a breastmilk bank up and running in Victoria soon, but even then it may not have enough to provide milk for babies not under nursery care. So what is the answer? How long can a baby wait?

 

After the horse September 27, 2010

Filed under: Breastfeeding — titchandboofer @ 2:00 am
Tags: , , , ,

Breastfeeding has been getting a lot of exposure in the past couple of weeks. Dr Jennifer James sparked a a slew of newspaper articles, television news stories and current affairs program stories with her proposal that infant formula should be available on prescription only. At the same time there have been a few articles and television stories popping up here and there, debating whether or not women should or shouldn’t have to, or want to, cover their babies and their boobs while breastfeeding in public. Usually I’d be thrilled that a topic so dear to me is getting this much airtime, but at the moment I’m in an ambivalent kind of fug. In fact, it’s not so much ambivalence as a quiet sense of hopelessness. If only the media was buzzing about the value of breastfeeding, the value of mothers, about increasing support for women to initiate and sustain breastfeeding, and about helping women mould their lives around their need to breastfeed instead of the other way round. Then I would be delighted. But it’s not. To me the focus seems so negatively skewed. There’s a prevailing defeatist attitude that while women might want to breastfeed, most of them will be failed by their inadequate bodies or their sick babies, so they might as well opt out from the beginning.

This is absolute crap. Yes, there is a tiny percentage of women (<10%) who physically cannot breastfeed because they just don’t have sufficient breast tissue, or they don’t have their breasts anymore, or they’re being treated with the very rare medications that are not safe during breastfeeding (note to all: commonly used antibiotics do not fall into this category). The rest of them are not failed by their bodies or their babies. They’re failed by our peculiar society, with its distrust of the unpredictable rhythms of the human body and its voracious, conspicuous need to consume and control. Articles like Breast is best, but don’t ditch the back-up are just a literary and, in this case, actual advertisement for artificial feeding – the original article had an active Google advertisement for Nutricia smack bang in the centre. I could go on and on about the enormous infant formula companies and their ability to profit from fear-mongering. But really it is as simple as this – there is no money to be made from breastfeeding women. Except possibly for the people who make these (Oh Hathor, thank you. On days when I really feel the whole world is mad, I visit your blog and am instantly cheered up.). So, it doesn’t matter that breastfeeding is the biological default – I would say it’s the normal thing to do, but statistically that is a doubtful statement these days – it will still be advertised as too difficult, inconvenient and easily and safely replaced with powdered, modified cow’s milk. Is there another mammalian species on earth that fails so comprehensively at feeding its young that it chooses the milk of another species instead? Somewhere in me is a lengthy opinion about shared breastfeeding and community and donor milk, but that’s for another day.

Sometimes it’s just exhausting to care what choices we make as a society. So what if breastfeeding is the default setting? So is spontaneous, unmedicated vaginal birth. So is boys having a foreskin on their penis. Who cares if it’s the best choice, with long term health consequences for mothers, babies and society? So what if women are encouraged to opt out of doing something because they might not succeed, or it might hurt, or their partner won’t be able to bond with the baby, or they won’t be able to have a drink, or they might want to go to a wedding, or they won’t be able to buy enough stuff to sustain the local baby emporium? Why even bother trying to stop the juggernaut? Let people opt out. We can opt out of every other potentially uncomfortable thing in life. Why should this be any different? Even goddamn Pass the Parcel at children’s birthday parties has a prize in every layer these days, so kids don’t have to feel the discomfort of not winning. If that’s life when you’re four, why should adulthood be any different? And isn’t that the beauty of choice? So that people can make choices for themselves and their children even if the consequences are negative and irreversible.

That’s how I feel when I read the news these days. If people don’t value breastfeeding, if they’re not taught and supported to do it, if they’re misinformed, if they’re hindered, if they’re shamed for doing it in public, if they’re harassed for doing it for more than six months, if they suffer through difficulties over and again with no help, or if they just don’t want to do it, making infant formula more difficult to access won’t change that. But if we can fix everything else? Then absolutely…I’m on board!