Pregnancy, Prematurity and Pumping

First up — I was invited to do a guest post on the “Breastfeeding with Comfort and Joy” blog on my experience with pumping breastmilk for someone else’s baby. The post was inspired by this video, entitled “Prescription Milk,” which focuses primarily on the importance of babies — particularly premature babies — getting human milk for their nutrition.

It was so touching that the mother featured in the trailer chose to celebrate and memorialize her daughter’s brief life, by continuing to pump milk even after her own baby died, so that other babies might live.

My personal experience was that I had over-supply issues, so being able to pump extra was a blessing, instead of having to try to minimize my production. Some mothers may not be able to pump enough milk to feed their babies, but there isn’t enough donated milk to supply all the babies who need it. If you are currently pregnant or breastfeeding, or know someone who is, please look into becoming a milk donor through the Human Milk Banking Association of North America, your local hospital, some other organization, or (like I did) just giving a friend bottles or bags of milk. You have to be screened to make sure you aren’t carrying any diseases that may be transmissible through breastmilk, so get started on the process as soon as you can.

Pregnancy is the perfect time to start preparing yourself for breastfeeding. The best way to do that is to talk to women who have successfully breastfed, and watch women breastfeed. I emphasize, “successfully breastfed,” because so many women tell horror stories of how awful breastfeeding was, and how they ended up with sore, cracked, even bleeding nipples, or how they “tried to breastfeed, but I never could make enough milk,” or some other unsuccessful breastfeeding experience. You wouldn’t ask a poor man how to become a millionaire; you wouldn’t ask a teenager for tips on a successful marriage; and you definitely wouldn’t ask me for tips on how to run fast or throw a baseball. 😉 You would instead seek out someone who had been successful in whatever it is you were wanting to succeed. Likewise, don’t ask someone who had a horrible time breastfeeding for breastfeeding tips (even if the lactation person she saw at the hospital said she was doing everything right, or she is otherwise sure she did what she was supposed to do). Or if you do, don’t be surprised if you, too, have a horrible time breastfeeding! Instead, seek out those who had an easy time, who were successful, who had no pain, who nursed as long as they wanted to (and/or longer than they expected). If you don’t know anyone that fits that description, or feel awkward asking to watch them as they nurse their babies, don’t despair! There is a book filled with beautiful and intimate breastfeeding images, along with clear and simple text, to help you see what a good latch really looks like and how to achieve that.

Get the book now, while you’re still pregnant, read the text, study the pictures, take it with you to the hospital (or just keep it at your bed-side table if you’re having a home birth), and start breastfeeding off not just correctly but confidently. As World Breastfeeding Week draws to a close, let’s not just celebrate breastfeeding, but help support women as they breastfeed, and remove hindrances that would keep them from success.

~*~

Update — I just noticed that WP has added a “like” feature to posts — that’s cool! 🙂

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Kangaroo Mother Care Saves Lives

Read the full article here — premature babies on their mothers’ chests have better outcomes than those placed in incubators. This is particularly important in low-income countries who simply don’t have the resources to have all the “bells and whistles” that can help preemies survive and thrive.

Well now I’ve heard everything!

The “Little Blue Pill” saved a premature baby’s life! When Baby Lewis, born at 24 weeks gestation, was having trouble with getting enough oxygen due to his premature heart and lung capabilities, even after surgery, doctors gave him Viagra, which saved his life, by allowing his tiny lung arteries to expand. Now that’s an off-label use of medication. And one I can agree with!

When you think of it, though, it’s not really that odd — if you know a bit of the history of Viagra, anyway. Sildenafil Citrate was being tested as a new and improved blood pressure or heart medicine, when the test group (which would typically be older men, since they are usually past the age of fathering children) started reporting an, um, increased benefit in their… “abilities.” So, Pfizer started researching it simply for its sexual benefit, which is why they were able to sell it for five bucks a pop. And also why people who take Viagra are warned not to take certain other medications for heart or blood pressure — it could cause disastrously low blood pressure if accidentally used in combination.

I’m struggling with not telling all the Viagra jokes I know, but I’ll instead tell a funny story that actually happened:

A lady came into our pharmacy soon after Viagra was released, and said she wanted to buy some. She said she was going to put it on her tomato plants… so she wouldn’t have to stake ’em.

There’s your smile for the day! 🙂

Oh, wow!!

A premature baby declared dead by doctors was found to be alive hours later when he was taken home for a funeral wake.

* + * + * + *
Also, Rebirth Nurse has her “Why I Chose Midwifery” blog carnival up, so go check out all the posts.

Let’s get something straight, shall we?

In the wake of Dr. George Tiller’s murder in Kansas, I’ve been in some conversations, read other blogs without joining in, and was apprised of conversations other people had had, that discussed the nature of the abortions he performed. One man said that “6,000 women will die every year” because Tiller won’t be able to perform “life-saving abortions” on them. Many other people apparently think that most if not all of post-viability and/or third-trimester abortions Tiller performed were to save the life of the mother. This is not true.

Here is the link to the Kansas Department of Health and Environment’s abortion reports, from 1998-2008. I’ve only looked at a few of them, and as far as I know they don’t mention Tiller by name, but I believe he was the only person in Kansas who regularly performed abortions after fetal viability. The Data Summaries appear to be pretty standard, and starting around page 10 have tables showing abortions performed at 22 weeks or more — where the women were from (Kansas or another state), before or after fetal viability, the reason for the abortion, etc. I looked at the 2001 document (just picked that one at random) and was surprised at several things, which may be of interest to you, regardless of where you fall on the pro-choice/pro-life spectrum.

Let me insert here, that it is a “spectrum”, as polarizing as this debate can get. Few people who call themselves “pro-choice” will literally agree that women should have the right to have an abortion at 39 weeks 6 days for any reason; and few people who call themselves “pro-life” believe that there should be no abortion ever, not even to save the life of the mother in the case of a pre-viable fetus. (I have read a few comments or seen a few polls that way, which is either not consistent with a pro-life stance [sacrificing two lives when one could be saved], or they define “abortion” in such a way that they don’t consider that removing a tubal pregnancy is an actual abortion, because the purpose of the surgery is not to kill the baby, but rather to save the mother’s life, and the death of the baby is an unfortunate and unavoidable end result of saving the mother’s life, since the baby is pre-viable.) Most people are in-between, with lots of shades of variation.

So, there is a wide spectrum, but the abortions I think of when I think of Dr. Tiller are the post-viability and/or third-trimester abortions.  “Viability” is the point after which the fetus could live outside the mother’s womb, and this varies depending on the technology of the country and the particular hospital. In America, it’s generally agreed to be about 24 weeks, which is when 50% of all babies survive, albeit with many babies suffering from defects (including things like cerebral palsy, blindness, mental retardation, etc.) due to being born too soon. [Those of you who work with L&D or the NICU or know first-hand statistics can fill in some of the gaps, or correct any mistakes.] The rate of survival goes up and the risk of defects goes down the longer the baby stays in, so delaying birth if possible is always a good thing from that standpoint; and by the beginning of the third trimester, the baby has a good hope of survival with much lower risk of long-term negative side effects. Obviously, the likelihood the baby will survive if born prior to 24 weeks is low, but the youngest surviving baby I’ve heard of is Amillia Taylor, who was born at 21 weeks 6 days of gestation; she turned two last fall, and is starting to walk and talk. Considering that she had less than half the typical womb-time of most babies, this is miraculous; and adding in the nearly 5 months she ought to have gotten before being born, she would be about 18-19 months old, so not even totally off the developmental charts for a baby born at a normal gestational age.

So, back to the 2001 report, dealing with abortions at 22 weeks or greater (on the edge of viability, or beyond) — 1) 585 abortions were performed on out-of-state women, with only 50 done on Kansas women. 2) 385 post-viability women were from out of state. This makes me wonder just how dangerous the woman’s condition was that she could go off to another state for health care, rather than going to her nearest hospital. To those of you who work L&D and particularly antepartum, trying to keep pregnant women safe and alive who are suffering certain health complications — does it sound even remotely safe for you to pack up these women and transport them from all over the country to Kansas for an out-patient procedure, under the “medical care” of the woman’s family or friends? I’ve read numerous blog posts from you, in which you detail working with patients on magnesium drips — how you have to watch them carefully, taking reflexes every hour, among other things, to make sure that they are being treated properly. Does it sound right to you to send off sick women for an out-patient procedure without medical care? Or does it give you the heebie-jeebies? 3) There were no abortions performed to save the woman’s life; all post-viability abortions were done to “prevent substantial and irreversible impairment of a major bodily function” should the pregnancy continue. In fact, I just looked at all the data summaries, and not one case was done to save the woman’s life. But in many cases, these babies are viable, meaning they have a reasonable chance of living outside the womb, if they were allowed to be born alive by induction or C-section, if the pregnancy did indeed need to be terminated for maternal health reasons. (Since there is no break-down of abortion data, we can’t say from here how many abortions were down at 24 weeks, and how many were done at 30 weeks [when there is at least a 90% viability rate, with a low rate of long-term complications due to prematurity] or beyond. 4) There were no “emergency” abortions — which is a good thing, because the abortion procedure Tiller employed took 3 days to complete, usually starting with an injection of digoxin into the baby’s heart to stop it from beating and thus kill him or her, and inserting laminaria into the woman’s cervix to slowly dilate it, before administering some drug (perhaps Cytotec) to induce labor and the woman would give birth to the dead baby. This blog goes more in depth into the data summaries, adding up all the reasons of all the years.

All pregnancies are terminated at some point. The majority of them end somewhere between 37-42 weeks with the birth of a live baby, either by C-section or vaginal birth. There is no doubt that some pregnancies should be terminated early, but whether this ends in the birth of a dead or live baby is where the point of contention lies. What is the reason to ensure that the baby will not be born alive (which is the point of a post-viability abortion, and the only difference between an abortion and a preterm induction)? Except for having limited medical attention over the course of the dilation, and giving the baby a lethal injection prior to birth, Tiller’s procedure is basically an induction — the mother gives birth vaginally to the baby at whatever stage of gestation she is, whether 22, 24, 27, 30, or 36 weeks. If she can give birth vaginally to the baby at that stage (which she obviously can without damaging her “health” or “major bodily function”… since that is exactly what she did), why kill it first?

I will also take another side-track to define “health” and “major bodily function” the way either the United States or the Kansas Supreme Courts do, and that is to include “mental health” as a “major bodily function” and “finances” as an aspect of her “health.” Of course, most people who use the terms “major bodily function” and “health” do not think that finances are an aspect of health, nor that “mental health” is a “major bodily function.” I have to tread lightly here, because I don’t want to seem like a jerk about mental health. I’m not; but I have a major problem with the way the courts have defined it, and more importantly with the way elective abortions have been shoehorned through that loophole. If you want an actual psychiatrist’s take on Tiller’s “diagnoses” of these women, click here to watch an interview with Dr. McHugh, who reviewed the redacted medical records and noted a paucity of actual clinical diagnostic information, and said, “he had mostly social reasons for thinking that the late term abortions were suitable. That the children … would not thrive. That the woman would have her future re-directed. That they wouldn’t get a good education after they had a child. That they would be always guilty in some way about having that child. That they had been abused already and that this — to have the baby would be another form of abuse. These … are not psychiatric ideas… These were social ideas. …. There was nothing to back these things up in a substantial way.”

In response to one hard-headed abortion advocate I was discussing this issue with, I emailed a group of pro-life Maternal-Fetal Medicine specialists with the following letter:

I’m currently in the middle of a debate on a pro-life blog with an abortion proponent who is insisting that the sort of late-term abortions the late Dr. Tiller did were medically justifiable, although he can come up with no such medical reason, and a L&D nurse I know said she could think of none — saying if the mother’s life or health is in danger, they induce or C-section the mom, thus saving both. I’ve asked if he could give evidence of any OB doing what Tiller did (i.e., kill a baby who could be born alive, particularly leave a woman who supposedly needed an abortion to preserve her life or health in a hotel for 3 days with her friends), rather than at least keep the mom in a hospital. He claims that Tiller’s way must be okay since, “you can’t point to even a single case of his way being condemned by any authority.” So, I guess I’m asking for authoritative voices who have condemned Tiller’s method of terminating the pregnancy in such a way as to kill the baby, rather than preserve his or her life. If you could particularly point me towards sources that authoritatively declare that the proper way to end a pregnancy if a woman’s life or health is on the line does not include out-patient procedures, nor injecting digoxin into the fetal heart, but in trying to preserve both mother and baby.

To which they responded:

Kathy,

1)       Dr. George Tiller was a family practice doctor. He had NO training in high risk pregnancies, fetal or maternal problems.

2)       There is no need after 23-24 weeks to ever perform an abortion in the way that Dr. Tiller did, to save or protect maternal life or health in any way. If life or health is threatened all trained obstetricians and maternal-fetal medicine physicians can and would simply deliver the baby and place the baby in a neonatal intensive care unit. It happens every day, many times, all over the United States .

3)       Sometimes before 23-24 weeks (rarely) a pregnancy has to be delivered because the mother’s life is clearly in danger. In this case, the labor can be induced, the baby delivered and the baby will not survive because of the early gestational age, but this can be done without intent of killing the baby.

4)       The only reason abortions were done by Dr. Tiller was because the mother did not want a LIVING baby born. He induced their labor and delivered the baby, almost always killing the baby first, before inducing the labor, to achieve the real purpose for which woman came to him: they did not want to deliver a living baby.

5)       If a mother’s life or health was really at risk from her pregnancy it would at least border on malpractice, if not be frank malpractice, for a family practice doctor without any special training in high risk obstetrics to induce the labor in such a woman in the outpatient setting. This alone should make it clear to anyone familiar with medical practice that none of the abortions he did were MEDICALLY necessary, at least not with the need to kill the baby before delivery.

You won’t find any “authoritative” voice that will say exactly what you are looking for. It would be like looking for an authoritative source that says if you jump out of an airplane and want to survive you need a parachute. In other words, it is so obvious, and there is no other way it is normally done, that you don’t need an authoritative source to state this in so many words. Any one in medicine who works in obstetrics would have to admit this.

On the other hand, every single text book on obstetrics or maternal-fetal medicine can be scoured and you will not find any description stating that killing a fetus before delivery is necessary to save the life or health of the mother, in any circumstance. This should be evidence enough. . …

Nathan Hoeldtke, MD for the Pro-Life Maternal-Fetal Medicine Group.

For those of you who may still have reservations, thinking there must be some reason for late abortions to be necessary sometimes to save a woman’s life or health, or that ACOG would have some position statement either endorsing or censuring it, let me direct your attention to something. The American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG) wrote a brief one-paragraph statement about how ACOG arrived at its stance on partial-birth abortion (which is not precisely what was under consideration in the majority of this post — PBA was outlawed in Kansas at some time during Tiller’s career, so he switched from that to digoxin-induction as his method of abortion; but I think it has bearing on the topic). Basically, a select panel met to formulate a policy statement, came to the conclusion that there were no circumstances in which PBA was necessary to save the life or health of the woman… and then the ACOG board unilaterally added the statement that it “may be the best or most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman. . .” The AAPLOG response to the actual ACOG position statement is here, in which they blast the leadership for issuing such a position without any evidence, saying it “lacks scientific credibility.” If you’re surprised that ACOG would take such a position without evidence… remember their stance on elective C-sections, as well as on home birth.

So if you’re in a conversation about late-term abortion and somebody says that they’re necessary to save a woman’s life or health, or that Dr. Tiller in particular saved women’s lives by performing late-term abortions nobody else would do, ask them, “Where’s the evidence for that?”

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Two Great Posts in One

Kangaroo Care (snuggling a premature infant skin-to-skin 24/7) has been a topic I’ve meant to research and write about. But this post has an article which sums it up nicely. Why reinvent the wheel? — just go and read it.

Also on that post (the first half of it), it talks about another topic related to premature infants that I’d never thought of before: additives, including alcohol, dyes and sweeteners, being given to premature infants at amounts much higher than they should receive for their weight. The article urges that medicines given to premies be manufactured in forms that are free from unnecessary additives. I guess I assumed that most medications would be given through an IV; but it makes sense that if a premature infant needs a medication that is available in oral form, that it would be given it. Unfortunately, a lot of these medicines contain too much of bad things, including alcohol, red dye and aspartame. Can anyone explain why a medication given to a child of, say, less than a year old need to include dye? The purpose of the dye is to make it look tasty and palatable, and I don’t think infants really care that much; even if older infants do, premies likely never even see the medicine coming, so certainly don’t need for it to look pretty. Sweetness is an acquired taste, to a certain degree. While the human tongue is attuned to sweetness, medicines don’t have to be sweet (a spoonful of sugar, à la Mary Poppins) to make it go down — especially babies too tiny to fight nasty-flavored medicines going into their mouths. May not be pleasant for the wee babes, but they really can’t struggle too much, the way a child of even six months can. Besides, things are overly sweetened these days — and I say that as someone with a very developed sweet tooth! (I’ve recently given up sugar, and am surprised at how sickeningly sweet my kids’ jam is on their PB&J; I never used to notice it.) Even if these babies can taste well, and should be given stuff that is palatable, it doesn’t have to be as sweet as it is made in order for them not to dislike it. And don’t even get me started on alcohol for infants! Here we have pregnant women who risk society’s wrath if they ever take so much as a sip of an alcoholic beverage while pregnant, yet these babies (who should still be gestating but were born too early) are getting alcohol straight from their medicine, not even diluted via the mother’s blood-alcohol content. Kinda makes ya think, hmm?

So, if you are pregnant now, or know someone who is, or are planning on having more children in the future, go read this article, because there is always the possibility that you will have a premature baby (even if you think you won’t because you’re so healthy or you’ve never had a problem before, you could be involved in a car wreck and have the placenta dislodged — rare possibility, but still there — so still read it). Many hospitals may be unfamiliar with kangaroo care, and tell you instead that the babies need to be left alone so that they reduce the risk of infection. That is a consideration, but one to counterbalance against all the benefits of kangaroo care laid out in the article. At least read the article and discuss it with your care-givers. And nurses may also not even think about all the additives they are giving your baby along with the medication. You can help educate them, and perhaps save your baby from some negative effects of, say, alcohol poisoning.

Elective C-sections and the Risk to the Baby

Many women have a C-section for no medical reason, which is considered an “elective” C-section. Some of these include the “too posh to push” women; those who are afraid of labor and birth; those who want to schedule a “no-muss, no-fuss” C-section rather than go through the unpredictable and sometimes messy labor (which, by the way, I gotta question why these women even get pregnant in the first place — are not babies by their very natures unpredictable and sometimes messy? Perhaps the unpredictability and mess associated with labor somehow helps these women come to grips with the reality of life with a new baby, but I digress…); women who are not allowed to have a VBAC, women whose first birth was a C-section so go with what they know rather than attempt a vaginal birth, etc.

My husband’s cousin was sort of in this last group — her first baby was born preterm by C-section due to some health issue (I think pre-eclampsia, but can’t remember for sure right now), and her doctor told her she could have a VBAC IF she got all her work done and IF she could find something suitable to wear. No, wait a second, that was Cinderella’s wicked stepmother. No, her OB required that she go into labor naturally after she reached term but before the date of her already-scheduled C-section, which was at 38 weeks. Oh, yeah, just conjure up labor sometime in that week, and you’re good to go; if not, we’ll slice you open! Is it any wonder so many Cinderellas out there end up in rags instead of going to the ball?

But, a recent study (hopefully I’ll be able to find the article somewhere, but until then, I’ll make do with this) has looked at elective C-sections — that is, surgery for no medical reason — and found that babies who are born by C-section prior to 39 weeks have a much higher risk of complications, including respiratory distress, low blood sugar, infection or need for a respirator or intensive care. It also found that a full 36% of these elective C-sections were performed prior to 39 full weeks of gestation, which is the minimum age or cut-off point recommended by ACOG.

While “term” is considered to begin at 37 weeks, ostensibly, babies who are born after that time by C-section should not have any more problems than those born vaginally. However, in speaking of the difference between babies born at 37 weeks after the spontaneous onset of labor and those born at the same time with no labor but by elective C-section, one of the authors of this study says,

“We would not worry about a 37 1/2-week baby born vaginally with the onset of labor,” Thorp says. In that case, “there is some signal from a baby to his mother that says, ‘I’m ready …’ “

Hmm, maybe a baby should still be considered “premature” until the onset of labor. After all, while the exact mechanism may be unknown, it is accepted that, normally, the baby sends a “readiness” signal to his mother signifying to her body that he is ready to be born — he is mature enough to leave the womb and survive on the outside without the need of respirators and all the other gadgets I’m so glad exist to save the lives of premies.

Those born at 37 weeks were twice as likely

and those born at 38 weeks 50% more likely

to have a problem than those at 39 [weeks].

Wow, so nature knows best, huh? Who’d’a thunk it?

h/t to Dr. Jen for bringing the article to my attention