My baby would have died!

How many times have you heard this one? I needed interventions, if I hadn't been in hospital my baby would have died. This is such a difficult thing for me to hear. Because in almost every case it is just not true. Think about it! If you were a midwife, at what point would you choose to call in the Doctors? Only when the baby is certainly going to die otherwise? Maybe what it has a 50:50 chance of survival without medical intervention. 1 in 10? 1 in 100? 1 in 1000? What level of risk could you tolerate when its you are professionally responsible for the possible outcomes? I'm guessing its towards the 1 in 1000 end of the scale. Am I right? This is the reality of the situation. Yes, there are very rare circumstances which present a real medical emergency -- a sudden turn of events which puts baby in immediate danger -- but these are not the norm. More usually midwives are aware that labour is putting a strain on the baby. They monitor the situation over a period of time. It is a gradually evolving situation. Their evaluation of the risk evolves over time too. Risk to the baby, and to themselves professionally.

But sadly the situation is not always communicated clearly to labouring women. What language do professionals use in the delivery room? "OK, the baby is distressed now." "We need that baby out now", "I think we need to just give the baby a helping hand". Its natural woman who hears these things is likely to come away with the impression that their baby was saved from certain death, but in the vast majority of cases its just not true.  To add to the confusion, professionals are often keen to justify the choices made during labour after the fact, for their own sakes as well as for the parents. "Its a good job you had a c-section, look at the size of his head." These comments are no doubt well meant, and may provide some comfort in the short term, but in the long term they perpetuate the myth that birthing is horrendously dangerous, especially outside of a hospital setting.

A recent study in the UK found that for the majority of pregnancies, those were there is not pre-existing medical concern. Giving birth outside hospital, in a midwife lead unit was just as safe for babies, but with a lower rate of interventions, and a higher level of maternal satisfaction. And for second time mothers with no risk factors, giving birth at home was equally safe. This news may have shocked the nation, but it did not shock our midwives. They already knew that while there are some risks to giving birth out of hospital, there are also risks associated to giving birth in hospital. Every little intervention can affect the natural course of child birth, which is at its essence an intimate bodily function, fuelled by a cocktail of hormones, notable the "shy" hormone of love Oxytocin, and involving the woman opening her bottom to a level she has never experiences before. Its no wonder that some women find they were labouring well at home, but everything cools off at they bump down the highway and into a brightly light busy hospital. It is possible that simple going to hospital could put your at a higher risk for prolonged labour, which is probably the most common cause of interventions.

But there are other factors at play here too. At home, there isn't the back-up of medical support. This might sound like a dangerous situation, but when you consider that all interventions also come with some level of risk to mother and baby, it might be advantageous to put a bit more space between yourself and the surgery.

You see, I was one of those mothers who had a prolonged labour. 28 hrs in total, and because the baby was wrapped in the chord he became distressed as I pushed him out. I won't lie to you, that was a horrendous birth. Painful, long and difficult. And towards the end, everyone in the room felt some fear as they listened to my babies heart beat drop lower and lower with each contraction. I am quite convinced that had I been in hospital I would have had an assisted birth.... if I even made it that far. I may have hit the "failure to progress" criteria and had my labour augmented by synthetic Oxytocin, which may have put my son under even more pressure. I may have even ended up with a c-section. But I wasn't in hospital, I was in my bedroom with two highly qualified midwifes. I was too far from hospital to "save him" in the last few minutes of birth. They started uttering the phrases about... as polity yet urgently as they could, and they waited and encouraged my to push out my baby.... and I did. As soon as his head was out, he cried and by the time I figured out how to turn from all fours to lie on the bed, shaking like a leaf he was as rosy as a baby can be. 

It was certainly a tough labour which left my with little energy for appreciating my baby before I passed out from shear exhaustion, but at least I came away with the knowledge that my body CAN do the job it was designed for, and with my womb intact ready to carry and birth another baby without the additional risk of a scar. At least I was there in my bed, with my baby and my husband. Ultimately this tough experience, which I would not wish on anyone opened the way to the gloriously triumphant birth of my second son three years later. A wonderfully fun and loving birth which gave us a easy start as a family of four.

Should I breastfeed or bottle feed?

I enjoyed breastfeeding my two boys. Breastfeeding can be all-consuming at the start while you and your baby are learning together, but once you get the hang of things it seems easier than bottle feeding to me.

First there is the practical side of things. You don't have to sterilize anything, take bottles with you, think about how long you will be away from home etc. As long as you are there, baby has everything they need to eat and drink. This was very important to me because I've always been somewhat impulsive, and not a great planner. Plus you can feed your baby the moment you want to... no waiting around for bottles to cool while baby cries. And do I even need to mention the cost of formula? 

I also like the way that breastfeeding encourages you to trust your baby. Its hard to do at first as you are learning to read the way your baby communicates, but since you are not measuring you HAVE to go by how your baby seems and the signals that they are giving you. And best of all (for me) you don't have to follow a particular routine, or analyse what your baby needs next, because the breast meets almost all their needs. Hungry, thirsty, tired: it doesn't really matter. You give them the breast and they either perk up or fall asleep. And if they only drink three sips, nothing is wasted.

At the end of the day, babies LOVE to breastfeed and the breast is such a powerful tool for parenting. I have a huge respect for all those mums (not to mention the dads) who care for their babies without it, whether out of choice or necessity! Please don't call your choices selfish!

Are there any downsides of breastfeeding? Well you do tend to be glued to your baby, which is both a blessing and a curse. There is still plenty of chance for your partner and family to be involved, but if your baby doesn't take a bottle you may not feel able to leave your baby completely for more than an hour or two at a time. Of course many mums don't want to anyway, regardless of how they feed. 

Some women feel uncomfortable about breastfeeding in public. It certainly takes a bit of getting used to, but it is much easier is you make friends with other mums, so that you can stick together the first few times.

You might think that you would get more sleep bottle feeding, but studies show that breastfeeding and bottle feeding mums are equally well rested (or should I say poorly rested!). Although breastfeed babies wake more often, they fall asleep again more quickly because they don't have to get up to make bottles and because breastfeeding releases hormones which make baby AND MUM sleepy. Breastfeeding mums who choose to cosleep get the most sleep of all, because they can feed lying down and even fall asleep during the feed. (And the evidence now suggests that sharing a bed can be safe for most babies with a few precautions.)

Breastfeeding hormones seem to have some effect on me, beyond making milk, which could be seen as a positive or negative: they seemed to make me a bit more patient and confident and content... more "motherly" I guess(?), but I also have less get up and go. Breastfeeding can also affect your libido -- giving birth and caring for a newborn tends to anyway, but if you are breastfeeding this might continue for longer. It seems to vary a lot from woman to woman. On the positive side it can suppress your monthly cycle for months, or even years, and can even be a pretty good contraceptive. Do your homework on this if your interested, I don't want to be held responsible for any surprise siblings!!!

If you decide to breastfeed, its a good idea to get informed beforehand and find out where to get local support after your baby is born to improve your chances of breastfeeding successfully. In the UK, look out for Baby Cafes and La Leche League groups 

Reflections on our sleep training

DS (2 yrs 10 months) is now sleeping in his own bed, voluntarily! We listen in on the monitor, and he know he can call if he needs me. He also reminds me that if I needs him, I can call for him. I posted the following in response to a lady struggling with sleep deprivation due to nursing two children at night, I am copying it here as a record of our experiences.

You asked how tough it was teaching your son to sleep independently. I can only say that for me, at the time, it was less tough than the alternative of nursing a 2.5yr at regular intervals throughout the night during early pregnancy. This was not so much about embarking on a mission, setting hard rules and sticking to them etc. as most main-stream parents would claim is necessary. It was more about being honest and open about my needs -- although a largely unbroken nights sleep was certainly a goal that motivated me, my actions at any time were driven by my instinct at the time. It was also very much about testing the water and seeing how far we could progress. In all honesty I may not have had the conviction to night wean DS at this point if it hadn't been for pregnancy hormones. I felt so strongly repelled from nursing during the first few months of pregnancy that I can really relate to the current thread on D-Mer. However, when I said that night weaning was tough, I guess that I meant that it was very hard work. All in all I look back on it as a positive experience. We shared lots of lovely times together in the night, not always happy times, and often very tired times, but very loving and very special none the less.

There was one exception when I very determined/stubborn and that left a very bad feeling for me. On this occasion I decided not to nurse DS to sleep at the beginning of the night and told him plainly that I could not do this.... I was exhausted and really felt that I couldn't. He understandably put up a big protest but I was feeling so determined that I decided to drive him around in the car (the only other way that he would fall asleep at the time) rather than give in, which worked, but unfortunately I woke him transferring him to bed and then then sat through 1.5 hrs of crying before he finally fell asleep. I honestly though at this point that after 2.5 yrs of patience we would were reduced to cry-it-out, but this was not the case, I made an effort to be more flexible from then onwards, and as it turned out cutting out the midnight feeds was far less stressful than the bedtime feed... which we have continued to this day.

Typically, when DS woke in the night I would remind him that we don't do milk in the night, then there would be a protest. I would calmly tell him that I love him very much but that I was tired and sore and needed to sleep. This would generally result in further protest and/or attempts to climb into my night-clothes. Then I would lie him down and either caress him (rubbing the sole of his foot was a favorite), or start telling a story, or suggest that we listen to all the night-time sounds. Basically anything to distract him. Any suggestion of such distractions would be resisted but once I actually started he normally got drawn in. Most of the time he only cried/complained very briefly (1-2 minutes perhaps) until distracted, but then sometimes it took a while to help him fall asleep again. All of this was tiring, but it never felt emotionally draining the way that it had when I had set my mind on not feeding him to sleep and stuck to my guns. It was actually quite rewarding to watch DS do things that had until that point seemed impossible. It felt to me like our relationship changed, but in a positive way. DS learned to respect my needs and I gained a great deal of respect for DS too.

You said that it is the younger of the two that keeps you awake the most. For our DS 18 months seemed to be too early for night weaning, it was just taking too long for him to adjust. But every child is different, and even though we didn't make much permanent progress I don't look back on trying as a mistake. Again I learned so much from the experience, for instance that DS was able to fall asleep in the gap between our pillows by pretending that he was in his car seat! I was quite amazed when that suggestion worked! We also established a verbal cue for falling asleep at this time. I would just say "sssh, night night." as he was falling asleep, and this cue has helped to resettle DS ever since. Also, the experience that DS gained falling asleep without milk, or when I detached him before he was fully asleep did seem to have some impact on how often he bothered me at night, as least temporally, so it did help us get through tougher phases.

I don't think that teaching a toddler to sleep independently needs to be an all or nothing situation. Each time that they fall asleep without the boob in the mouth they are learning something. In my experience once a baby, toddler or child has learned to resettle themselves without milk they do sleep much better, almost without exception. This has certainly been the case among my friends who sleep trained at various times.

I can understand your dilemma and your issue with not treating your two the same. I guess this could be tricky. However, I guess there are many things that your older child can do that your youngest cannot, and he has probably already noticed that your daughter wants/needs to nurse more often than he does because she is so much younger. Maybe he might be ready to accept that big boys do things a bit differently? I am often stunned by the level of understanding that my DS can show sometimes. A while back when DS was still nursing a lot more than now we were talking casually about when the new baby arrives and how much mummy milk it will need because it won't be able to eat real food and in a very low key way I expressed some concern about how I would cope with feeding the two of them. I was amazed when a week or so later he cheerfully announced that "baby will have mummy milk, and me not have any... and me do KIND things for baby!"

Our night weaning experience

We co-sleep and DS has fed to sleep every night, and several times during the night until now, so teaching him to sleep in other ways has been our main challenge. We are really making progress now. DS gets his milk to go to sleep in the evening, but we don't do milk in the middle of the night any more. I choose when is it nearly morning and he is allowed some again. When he wakes, I tell stories, or do the "in the night garden" thing, sometimes continuing to make up a whole in the night garden episode (generally not the most challenging of plots).

To start with, things were tough, and I was happy to give in at 3 or 4 in the morning, but then one day I woke at 5 and realized he had gone without milk until then. After just a few weeks we are down to nursing at bed time and in the early morning, and sometimes to help him get off for a nap. Slowly he is asking for milk less often in the night, and sometimes when I do let him nurse he will let go when I ask him too -- handy seeing as he has developed a vice-like grip. I find his generosity humbling. I tell him that I am tired and sore and he takes this on and (sometimes) he can accommodate my needs. Sometimes I let him nurse at "disallowed" times, usually when I am very tired, and he is very needy. I really dislike the advice that you hear from everywhere about consistency with these issues. Yes, you need to keep working towards your goal, but surely there can still room for give and take?

I also went some way down the night weaning road at 18 months, and at this point I found he responded best to songs and physical stimulation: back rubs, leg massage (no oil, but otherwise as taught in baby massage class), and an action song that we learnt when he was little about how a leopard has spots and a tiger has stripes. I think we could have successfully night weaned at this stage, but I decided that the old way was so much easier all around and let it drop. This time is different though: although it has not been easy for any of us, weaning feels natural. Nursing hurts, I feel tired and delicate and I don't want to be touched. Supporting him though his disappointment and providing comfort in our ways seems the more attractive option. In July I watched two great big lamb twins nursing, their tails were wagging with excitement as they drank, just like the day they were born -- but mum soon shook them off. I bet she felt just like I do now.

I love the idea of letting the child decide when to stop bfing, but I feel that for my ds this would not be for many years, and I am not happy with that thought. Even though he is still so attached to nursing, I am no longer convinced that he *needs* it. He needs comfort, he needs security, he needs to feel loved, but I hope that we are gradually learning other ways to fulfill his needs. When I started I was unsure whether I would be successful, or whether ds's need to nurse would be stronger than my need not to feed him. It is only now that I have gone down this road and seen him cry for milk but then, reluctantly, but calmly, accept alternatives that I feel optimistic.

Now we are reaping the rewards. Last week I went out, and for the first time in over 2 yrs dh was able to resettle ds when he woke. This Saturday was my brother-in-laws' wedding. I though I might have to leave early to put ds to bed, but my mum took him to a quiet corner and cuddled and told stories, and lay on the floor with him until he fell asleep. Now he is talking about going to stay the night with granny and grandad! These things make me very proud.

How much alcohol passes to your baby when you breastfeed?

If you drink when you are breastfeeding, how much alcohol passes to the baby? A simple question, but I have not seen the answer published anywhere in the public domain. In every statement on the safety of breastfeeding and drinking, this basic fact is omitted. Once again we are given plenty of statements advising us on how to behave, but not the basic information that would help us to make an informed decision for ourselves!

I have done some research and come up with this answer: your baby should not get more than 1% of what you drink. So if, for example, you drink a 175ml glass of wine and continue to breastfeed as normal, your baby might consume, at most, the equivalent of 1.7ml of wine. If on the other hand you drink a whole bottle of wine (750ml), your baby could get the amount of alcohol in 7.5ml of wine (that's one and a half teaspoons). It is not my aim to condemn,condone or otherwise advise, but simply to inform you.

In the rest of this post, I will try to convince you that this answer is right, or at least in the right ball park. First I will use a very simple argument, which I will then follow with a more detailed analysis based on blood alcohol data which is widely published. This analysis will also show that this estimate is quite conservative, and in most cases, if you only drink 1 or two drinks, your baby will be getting significantly smaller doses of alcohol than the 1% maximum.

First, we need some background
Alcohol that you consume enters your blood stream and is distributed around your entire body, including your milk. In fact alcohol passes so quickly into mother's milk that the concentration in your milk is essentially the same as that in your blood. However, what goes in, can also come out. As you sober up, the amount of alcohol in your blood falls, and the amount in your milk falls simultaneously.

In order to calculate the amount of alcohol consumed by the baby we will need to have an idea of how much milk the baby will drink. Of course you never know how much breast milk your baby takes, but we can hazard that it might be similar to a bottle fed baby, so your baby is not likely to drink more than say 250ml (1/4l). It is believed that an average baby will consume 570-900ml of milk per day (see Kellymom), and this is pretty much constant as the baby gets older until significant quantities of solids are consumed. The quantity of milk remains pretty much constant while the consistency and quality of the milk adjusts over the months to meet your child's changing needs.

A simple (and not very accurate) argument
When you have a drink, be it large or small, the alcohol you consume enters your blood stream and circulates around you entire body. I weigh 55 kg, and this equates to approximately 55l of meat, bone, gristle and blood. If we assume that the alcohol is uniformly dispersed throughout the body, including mother's milk, then each litre of my body contains 1/55th (or 1.8%) of the alcohol I consumed. When my baby drinks 1/4l of milk, he will be getting 1/(55*4) =0.5% of the alcohol that I drank.

Further analysis
In the simple argument above, there are a number of assumptions which may not be accurate:

1. My body's density may not be 1 kg/l, so although it is true that I weight 55kg, this might not be exactly 55l.
   
2. Alcohol may not disperse to all body parts equally.
3. If you only have one drink, then probably 250ml is a safe upper limit on how much your baby might consume while you are under the influence. However, this might not be true if you drink several drinks.
   
4. Your milk alcohol content might not be at its highest when you feed your baby.
   

The first two limitations of my argument can be addressed by remembering that milk alcohol content (MAC) is the same as blood alcohol content (BAC), and using widely published data which relates number of drinks consumed to blood alcohol content. For instance, the table at:

http://www.statemaster.com/encyclopedia/Blood-alcohol-content/

Using this table we can see that after consuming a "standard drink" containing 18ml of alcohol, a woman weighing 55kg will have a peak blood alcohol content of 0.04%, or 0.4 ml alcohol /litre of milk. So, our 250ml feed would contain approximately 0.1ml of alcohol. This is 0.1/18= 0.6% of the alcohol that I consumed. So, very close to the original figure I suggested of 0.5%. (Note also, that the blood content increases linearly with the number of drinks consumed, which means that our argument applies equally well to one or many drinks).

Now, so far all these calculations have been based on my body mass, but if you are smaller, then the concentration of alcohol in your blood and therefore in your milk will be a little higher. For a 40kg (6 st 6 lb ) lady the 0.6% becomes 0.7%.

Addressing points 3 and 4 is more tricky since there are many possible drinking and feeding patterns that we could consider. I will discuss this further in a later post. For now you should note that the results stated here are assuming that you drink all your drinks in a short space of time, then feeding your baby when you blood alcohol content is at its highest, but also assumes that you will only feed a maximum of 250ml to your baby while you are under the influence and that you will be sober before any further feeds. I expect that the figures given above will be fairly relevant to more realistic drinking patterns, but as a precaution I have simply rounded the figure up to give the 1%, as quoted at the beginning of this post.

Other considerations

There are many things to consider when deciding whether you will drink alcohol while breastfeeding. These include underdeveloped liver in very young/small babies, dehydration of the mother, effect on the let down response, and the fact that babies tend not to drink as much when you have been drinking. These factors are outside the scope of this post, but most are covered at Kellymom: http://www.kellymom.com/health/lifestyle/alcohol.html

Weaning

When, at about 5 months, C started to show an interest in trying to eat real food, we let him try. No purees or specially prepared food, but he was able to take some of the food we were eating ourselves and suck or chew at it. Soft cooked courgette was a particular favorite in these early stages.

As the months went by we were keen to let C set the pace and let him eat as little or as much as he wanted. We ignored books telling us to introduce foods one at a time, giving several days to watch for allergies, and pressure from others to progress rapidly through the food groups. We knew that in some parts of the world babies are exclusively breastfed for a full year, and felt secure in the knowledge that breast milk would supply the bulk of C's nutritional requirement. We simply started cooking without salt, and offered him a wide range of our own food.

But, as time went on, I started to be curious. How much milk does a baby drink? How much food would a baby need to eat to fulfill his requirements? When is the best time to wean? How much salt is too much? Is sugar really "bad"? Here are some partial answers to these burning questions.

How much food a baby would need to fulfill his requirements? Breast milk becomes richer with every month that you breast feed but, as a rough guide, it provides 22 kcals per oz. If we assume that a breast fed baby takes on roughly the same amount of milk as a bottle fed baby, lets say 5 8oz feeds, that's approximately 750kcal per day. Of course, calories are only one measure of nutrition, but an interesting baseline, which can give us a rough idea of how much food would be required to completely substitute for mum's milk.

When is the best time to wean? The La Leche League argue that milk should be the primary source of nutrition in the first year. It is after all specially designed for your baby. The age at which humans wean seems to vary hugely from culture to culture, but the natural, or biologically optimal age appears to be somewhere around 2-5 years. Chimpanzees nurse their young for approximately 4 years, and some of the more relaxed of the remaining non-industrial human populations follow suit. The !Kung San of Namibia, for example, are reported to allow their children to become tired of the breast. Following their babies' lead, breastfeeding reduces gradually until by the age of 3 it is a rare activity reserved for times when extra comfort is required. Mothers who have breastfed their children for just a few months often look aghast at the thought of breastfeeding for so long, but I can assure you that feeding past 6 months is really not a big imposition. Yes, feeding a new-born is a huge commitment, but by 6 months, feeds are really quick and easy, and the look of adoration on you child's face really makes it feel worth while. I'm still not decided on when I will wean C, but he is already nearly 2 years old and still going strong.

How much salt is too much? I found the advice handed out by health visitors on salt very confusing. First we are told not to add any salt to our cooking, but then told that feeding bread, cheese, Weetabix, even Marmite, to our children is fine! The only more specific advice I have received on salt levels is that children under two should not eat take more than 1g. This might sound a lot, but start adding up how much is in a slice of bread (~0.5g) or a tablespoon of shop bought tomato sauce (~0.25g) and you start to realise that you really need to watch out. In the first few days of breast-feeding the salt content of the milk is quite high, presumably to meet some peculiar need of the newborn. But after a few days the salt content stabilise at about 1/4g per ltr. The average baby will drink approximately 1L of milk a day, so daily salt intake before solids are introduced will be about 1/4g per day.

Is sugar really bad? When C started eating solid foods, we wanted to start him on the right track with lots of nutritious foods, so we didn't want to encourage him to load up on sugary foods. However, sugar is not all bad. Fruits and vegetables can be high in sugar, but also provide a great all round package of nutrition. We decided fairly early on not to worry about sugar too much, but we tried to opt for foods close to their natural state, and limited the amount of refined sugar C ate to occasional desserts or chocolates, until he was better established on solids.

Dry at night?

At 21 months C is well on the way to being potty trained. I'm so proud! Right now, all the ups and downs on ECing seem so worth while. Now I am starting to think about ending night time nappys. We are not ready yet, partly because I am too tired/lazy for night EC, and partly because C still makes several visits to the milk bar each night, and what goes in must come out! But, I have been reading the nappy and potty training section on netmums, and this has really got me thinking.

How old will your child be before they are dry at night? Many parents find that they are still using nappys at night long after their child is reliably dry during the day. Sometimes many years later. Why would a child who understands the need to stay dry at day, choose to sit in their own waste at night? Lets look at things from the child's perspective.

As a young child, you probably don't have a choice in the matter. If you are left in your room for 11 or 12 hours a night, the chances are that you are going to nee to pee at some point. You are not yet independent enough to get undressed and go to the bathroom on your own, and maybe you are imprisoned in a cot, or zipped into a sleeping bag. Having been successfully trained to "sleep through" the night, you understand that mum and dad simply don't want to be disturbed during the night. Maybe you used to cry out when you woke with a full bladder, but it has been made quite plain that when this happens you should pee in your nappy and get back to sleep.

At some point as you get older you start to realize that you are expected to stay dry at night. Probably by now you can take yourself to the bathroom and undress yourself, but after years of the convenience of using your nappy, getting out of bed must seem such an effort. You're night time toileting needs have been ignored forover 2 years, first by your carers, then slowly by you too. Now maybe you don't even wake up fully to pee. Even if when your parents are brave enough to put you to bed without a nappy the wet bedclothes are still warmed by your skin and in your sleepy state you might this might not be enough incentive to change your habits.

Now, if you slept in the same room as your parents, as the vast majority of children have over the history of our human civilization, they would probably notice your stiring or wriggling and be able to help you to the toilet when you needed to go. Alone, in your room, the best they can offer is a preemptive "lifting" before they go to bed, then you are on your own. No wonder it takes some children years!

Is there a solution to this problem? I can think of only one and that is to sleep close enough to you child to be able to help them with their toileting needs until they gain the independence to do this alone. If you start early, then hopefully they will not ever learn to pee while asleep, but even if you start later, you will be probably soon be able to figure out when in the night they need a trip to the toilet. Hopefully they would then get used to waking and getting out of bed to pee. The only real alternative is to accept nappy use until their bladder can last all night, or they learn to recognize the signs on their own and take themselves to the toilet. For some children this happens quite soon after day time toilet training, for others you may have to wait until they are 5 or 6 years old.