Writing a "Birth Plan"

At some point near the end of your pregnancy, you will likely come upon the term "birth plan" or "birth preferences." Typically, it's a good idea to spend some time thinking through your ideal birth scenario and how you might react to various unexpected complications or changes during your labor and birth. Knowing in advance what your preferences are regarding pain relief, birthing position, birth location, various other medical procedures, monitoring, breastfeeding plans, and surgical interventions is helpful for you, your partner, any other labor coach who might be present (a doula, another family member, a friend), and your care provider, as well as anyone else who might be in attendance (a hospital labor and delivery nurse, for example). Many women choose to have a written document prepared and handed out to anyone who is present during the labor and birth process, while others simply like to have in mind answers to some of the questions that might come up throughout the process.

I don't like to talk about a birth "plan" so much, because birth often does not go according to anyone's plan, even if it all goes smoothly and you are satisfied with the outcome. I believe it's important to have two ideas in mind: (1) What is your ideal birth scenario? and (2) What are your preferences regarding certain questions in the event that something doesn't go according to your ideal? Instead of calling it a birth plan, I like calling it birth "preferences," as in, this is what I'd like to see happen, and here's what I've thought about in case this happens instead.

These are the major areas you'll want to think about when coming up with your birth preferences:

• Where will you give birth? (hospital, home, birth center)
• Who will attend the birth? (care provider, partner, nurse(s), doula, friend, relative)
• How will you give birth? (vaginal or surgical)
• What kind of pain relief do you expect to use? (epidural, narcotics, breathing techniques, birthing classes, birthing methods)
• How do you feel about the use of certain routine interventions? (fetal monitoring, IV, Pitocin, antibiotics, vacuum, forceps, episiotomy)
• Do you want the option to be mobile? (walking around, birthing ball, shower/bath, changing positions)
• What do you want to happen as soon as the baby is delivered? (immediate skin-to-skin, immediate breastfeeding, use of Pitcoin to deliver placenta/contract uterus, who will cut the cord, timing of cord cutting (delayed, immediate), preservation of placenta (for encapsulation or burying, for example), baby bath, vitamin K injection, protective antibiotics for newborn's eyes, weighing and measuring)
• Do you want to breastfeed? (immediate (within first hour) latch-on, rooming-in versus nursery, skin-to-skin)

Once you've figured out some of the basic direction you'd like to go, be sure to run these preferences by your care provider to make sure these desires are compatible with his/her policies, hospital policies (if applicable), and are realistic in your specific case.

You'll also want to come up with alternative preferences. For example, your desire may be for a spontaneous, vaginal birth without any medical intervention, but what if a complication arises during labor, such as fetal heart decelerations, maternal blood pressure spikes, or infection? You'll need to know what might happen and have a plan in place in case a surgical birth is warranted, for example. You don't have to write up a separate plan for every potential complication or question, but you should have a general idea of a what-if scenario.

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As an example of what you might want to think about, here are my birth preferences for my upcoming birth. You don't need to follow a specific chart or guideline or layout; you don't have to have an answer for every question. This is not a legal or official document. Simply talking with your care provider may be enough, or you may feel the need to put it all in writing, for yourself and for the others in attendance.

Location of Birth: [Local] Hospital.

Who will attend? My primary OB (if available), or other on-call doctor from the same practice; my husband; L&D nurse

Mode of birth: Vaginal birth (3rd VBAC)

Pain relief and other interventions: I prefer to avoid the use of any Pitocin during labor, as I have reacted poorly to it in the past (PP hemorrhage). I intend to avoid the use of any pain medications, including epidural or naroctics. I prefer to have an IV of saline placed for hydration and in case there is a need for additional IV meds (i.e., to prevent postpartum hemorrhage, of which I do have a history). I prefer to have assistance with breathing and relaxation techniques. I prefer not to be coached during pushing but to follow my body's cues. I prefer to use intermittent fetal monitoring if possible, and telemetry monitoring (wireless fetal monitoring) if available. I would like my waters to rupture spontaneously; I decline to have the amniotic sac artificially ruptured.

Mobility, pushing position: I would like the option to move around during labor, including walking, standing, sitting, squatting, depending on how I feel. I would like the option to use the shower. I would like to push in a "non-traditional" position, probably squatting, to open my pelvis, as my babies tend to have large heads. I prefer to avoid an episiotomy; if the care provider believes an episiotomy will be necessary, I prefer to be consulted first.

Upon delivery: I desire immediate skin-to-skin; please do not remove my baby from my person for any procedures, including weighing and measuring, until after the first breastfeeding has been accomplished. Please wipe him off with a towel but do not bathe, dress, or swaddle him (except a diaper) before he is put to my chest. All procedures, including Apgar scoring, vitamin K injection, etc., should be performed while I hold him. I prefer to delay cutting the umbilical cord. The doctor may cut the cord, unless my husband elects to. We have no plans to save the cord blood. If the doctor believes Pitocin is necessary after delivery for my safety and to prevent hemorrhage, I am open to this. Please use a local anesthetic when stitching up any tears or episiotomy. I do not wish to see or save the placenta; please dispose of it as usual.

Additional preferences: I decline to have the hepatitis B vaccination administered in the hospital. I decline to have him circumcised in the hospital. I insist on rooming-in to facilitate bonding and breastfeeding. I insist on delaying his bath until at least 12, preferably 24 hours of life.

Basically, my goal is a spontaneous, vaginal birth with little to no intervention. Because of my personal history of both pregnancy-induced hypertension and postpartum hemorrhage, I am aware that certain procedures or interventions may be desirable or necessary for my own safety. One of the decisions my husband and I have made in this regard is that I will always give birth in a hospital. Another is to allow an IV to be placed, as well as the use of Pitocin after delivery to help my uterus clamp down and slow the bleeding, if necessary. I am also aware (having given birth three times already) of both my capabilities and my limitations.

I have thought about possible complications. For most of these, I believe I and my husband are educated enough to make well-informed decisions if a situation should arise that is contrary to my stated preferences.

Surgical birth preferences: The most obvious less-preferable scenario would be a need for a cesarean section, either due to the baby's position or an emergency situation for me or the baby. The biggest concern if an emergency c-section is needed is that because I will most likely refuse an epidural in labor, a true emergency would require general anesthesia. If, however, it is possible to take the time to administer a spinal block, I would, of course, prefer to remain conscious during the surgery. I would then request immediate skin-to-skin and breastfeeding upon delivery of the baby, assuming baby is otherwise healthy once delivered. The rest of the surgery can be performed with the baby on my chest. I would want my husband in the OR with me.

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Did you write up birth preferences? How closely did your actual labor and delivery follow the "plan" you had in mind? Did you change your mind during labor about any of these preferences? Did you have a plan for any alternative scenarios? How open was your care provider to your birth preferences?

36 Weeks/9 Months!

Well folks, this is it, the final countdown, the home stretch, bottom of the 9th, um...I'm out of sports metaphors...I'm 36 weeks pregnant today, with about a month until my due date, which makes me officially nine months pregnant.

Over the next few weeks, I expect the baby to "drop" farther into my pelvis (which may, at least, relieve some of this relentless heartburn/reflux), more and stronger contractions as a preamble to labor, more discomfort, and plenty of impatience. And you, my fans, friends, and readers, will be anxiously awaiting that update, that notice, that announcement that the baby is on his way.

But when will that happen? Will he pop out on his due date or surprise me early? Will he be the first to throw me a curveball (ah, another sports metaphor) and hang on for a few extra days? Is he excited to come out and meet his brothers, or is he cozy and comfy in there with no desire to see the world? I surely don't know!

So, a fun little game, while we wait.

In the comments here or on the Facebook page, make your prediction! I'm taking guesses for birth date and birth weight.

Some vital stats, to help you make your prediction:
I'm measuring average/right on track for fundal height.
I have not gained excessive weight, but I'm far from tiny.
My first baby was born 2 days after his due date; my second was induced two weeks ahead of schedule (due to high blood pressure); my third was born 2 days before his due date.
This one's due date is October 22, according to LMP, or October 25 according to ultrasound. Take your pick.
My first baby was 9lbs., 1oz.; my second was 7lbs., 6oz.; my third was 8lbs.; 3oz.

Have at it! Let's hear what you think!

Childbirth Choices Series Part IV: What Will Happen at My Prenatal Appointments?

This is the fourth in my Childbirth Choices Series, geared toward newly pregnant or planning-to-be pregnant couples with the goal of educating women and their partners about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

More articles in this series:

Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part V: It's almost Time to Have a Baby!
Part VI: Labor and Delivery

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Now that you've chosen a care provider and a birth venue and started to learn more about the birth process, you'll settle into a routine of regular prenatal visits. In this article, we'll discuss what a typical prenatal appointment will look like, and the schedule of appointments you can expect as your pregnancy progresses. We'll also talk about some of the tests and procedures your provider may suggest or prescribe.

During your first and second trimesters, your provider will probably want to see you approximately every four weeks. Once you reach the third trimester, from about 30 weeks until 36 weeks, you'll be seen every two weeks, and then every week until you deliver. Often, they'll suggest that you schedule these appointments well in advance, as the coveted time slots fill up fast. (Please note that some of this will only apply in a clinical or office setting. Home birth midwives may follow a slightly different procedure, although the exam and visit will cover the same bases.)

A Routine Prenatal Appointment

A typical routine prenatal appointment (except the first one, which we talked about in Part II) will look something like this:

You'll be asked to provide a urine sample*, which will be tested for glucose and protein using a special paper strip dipped in the cup of urine, which will then be disposed of. If the results are negative, you don't have to worry about anything. If there are any concerns, the nurse or assistant will notify the provider so that they can follow up.

*Some tips for peeing in a cup, for the uninitiated. I should say that by the end of your pregnancy, you'll be a peeing-in-a-cup pro. I usually try to drink a glass of water just before I leave for my appointment. This way, I'll be sure to need to pee when I arrive. Especially in the later months, peeing on demand is typically not a problem. Take the cup they provide and keep it near the toilet. Sit down on the toilet and hold the cup under your vulva, but not touching, and allow your stream to start. You may find you need to hold the cup a little farther back than you might expect. And, yes, you may find that you do pee on your hand once or twice until you get the hang of it. Fill the cup about halfway - you don't have to impress them with volume; they just need enough for the quick dip test - and finish up in the toilet. I like to wipe the outside of the cup with some toilet paper in case I dripped on the outside at all. Put it down wherever you can and finish up your bathrooming as usual. They'll tell you what to do with the cup afterwards. 

You'll then be weighed. Your provider will want to monitor your weight gain to make sure you're not gaining too little or too much. There's a wide range of "normal" when it comes to pregnancy weight gain, but if you're not gaining weight at all, this may indicate a problem and could be dangerous for the baby. Conversely, if you're gaining weight very rapidly, this could signal a different set of problems that may need to be investigated, such as gestational diabetes or a thyroid issue that can be managed.

Your blood pressure will be taken. It's important to monitor blood pressure, as a rapid rise in blood pressure, or sustained high blood pressure, can indicate a serious, even life-threatening, disease called preeclampsia. The only "cure" for preeclampsia is delivery of the baby, although often the high blood pressure can be managed if it is too early in the pregnancy to safely deliver the baby. Preeclampsia can cause serious problems, including stroke, in the mother and low birth weight for the baby, so it's important to keep an eye out for. The cause of preeclampsia is unknown.

You'll then be seen by your provider. He or she will use either a stethoscope or a special monitor called a Doppler to listen to the baby's heart beat and record the heart rate. A fetal heart rate ranging from the 120s through the 140s is normal. The provider will then measure your "fundal height," which is the distance from the top of your pubic bone to the top of your uterus (the fundus). Typically, the fundal height in centimeters should approximately match the number of weeks of your pregnancy. This is a noninvasive way to make sure the baby is growing normally. Assuming there are no concerns with your urine, weight, or blood pressure, which, for the majority of women, there likely will not be, that's all you'll need to do at most of your appointments.

The exam part of the visit is usually quite short, and then your provider should give you an opportunity to bring up any concerns or ask any questions you may have. I find that often by the time I'm actually in the exam room, I've forgotten all the questions I've thought of over the past few weeks between appointments. It may be a good idea to write down some of your concerns so you can raise them at the appointment. You may have concerns about discomfort you are experiencing, pain you're not sure is normal, unexpected symptoms, or questions about your lifestyle or diet. Don't be embarrassed or timid about raising any concerns you may have. Usually, your provider will be able to reassure you that what you're experiencing is normal and may have suggestions for relieving or reducing discomfort or pain. It may also be that one of your symptoms is the result of a disease or disorder that can be treated, from a yeast infection to a urinary tract infection (both quite common in pregnancy), to something more serious. Don't write off anything as "just because you're pregnant." If you feel your provider doesn't take your concerns seriously, you may want to seriously consider changing providers or seeking a second opinion.

At some appointments, your provider will likely order certain blood tests. Usually, these tests look at iron levels, thyroid function, platelet counts, and other useful information to help assess your health and the health of your pregnancy. 

Glucose Tolerance Test

Around 25 weeks, you'll be asked to have the glucose tolerance test, which determines how well your body is processing glucose. If this test comes back outside of normal range, you may need to be assessed for gestational diabetes.

The glucose tolerance test is reasonably simple. There are several versions of the test. The most common first test is the one-hour test. You'll be given a bottle of a cold, sweet drink that tastes roughly like flat orange Fanta. Some women find this quite unpalatable, while others don't mind it. This drink has a specific amount of glucose in it and is used only for this type of test. You must finish drinking the whole bottle within five minutes, and you'll be asked to note the exact time you finish drinking it. Exactly one hour after that, your blood will be drawn, and they will test your blood sugar levels. You cannot eat or drink anything during that hour, because anything you eat or drink (except water) will affect your glucose levels. Usually you'll simply wait at the lab, so bring a book or something!

Some providers will order instead a two-hour glucose tolerance test, which is essentially the same thing except will require you to wait two hours until having your blood drawn.

If this initial test is within normal limits, you're fine. If it's not, you may be asked to do a three-hour test. Most women "pass" this three-hour test and have no further concerns. If you do not, you'll probably be assessed for gestational diabetes (GD). Gestational diabetes can often be managed by diet alone and will resolve once the baby is born. Women diagnosed with GD may be at increased risk of developing Type II diabetes in the future, as well as at risk of unhealthy weight gain during pregnancy and other complications.

Do I need to do the GD screening?

Of course, as I've mentioned before, you don't need to do any of the tests or exams your provider recommends. However, the GD screen is relatively simple, mostly noninvasive and very low-risk, and merely takes a some of your time. Identifying GD is important, and ruling it out gives both you and your provider peace of mind. If you are stalling or hesitant due to the amount of time involved, you may be able to discuss other options with your provider for GD screening. There is a test which allows you to eat a very specific breakfast and simply have your blood drawn at a specified time after eating, as the glucose level of the foods will be known. There are also other ways of monitoring your blood sugars on your own to determine if your body is properly processing glucose, which you may find preferable to the standard tests described above. Discuss these alternatives with your provider if you're not sure about your ability to do the more standard tests.

Anatomical Ultrasound

Between 16 and 20 weeks, typically, your provider will order the complete anatomical ultrasound. For the ultrasound machine to get an accurate and clear picture of your uterus and it's precious contents, you'll need to have a full bladder. You'll receive instructions on how to achieve this. Generally, you need to drink about 32 ounces of water in the 60 to 90 minutes before the test. Your full bladder will help push the uterus up and out of the pelvis as well as providing fluid for the sound waves to travel through. Having such a full bladder may be uncomfortable. At my ultrasound in my third pregnancy, the technician actually had me go to the bathroom and pee out a limited amount (she gave me a 16-ounce cup to fill) because my bladder was too full. What a relief that was! However, if your bladder is not sufficiently full, the ultrasound may have to be rescheduled, as a clear and accurate picture is necessary.

This is the ultrasound at which you can usually determine the gender of the baby. But that is not the primary purpose of this test. The ultrasound technician will examine your baby from, literally, head to toe, measuring the bones of the skull, looking at the brain, the structures of the face and neck, the spinal cord, the heart, lungs, kidneys, and other internal organs, the arms and legs, hands and feet, fingers and toes. It's really quite fascinating. I enjoyed my ultrasound very much, especially because the tech was very friendly and open about showing me everything she was looking at. They'll also look at the placement of the placenta (to make sure it's not in danger of blocking the cervix), the structure of the umbilical cord, and the length of the cervix. It's very comprehensive. The tech should ask you if you want to know the baby's gender and will take a peek between the baby's legs if you say yes. Remember that the technician can't diagnose anything or identify problems. The technician merely takes the pictures. Interpreting the ultrasound is the job of the radiologist who reviews the ultrasound report. If the radiologist finds any problems or concerns, he or she will notify your provider, who will contact you to discuss the next steps.

Do I need the anatomical ultrasound?

Again, usually, you don't need any of the tests your provider will suggest. These tests help assess your health and the health of your baby and may identify conditions in mother or baby that can be managed or treated. In some cases, they may reveal irreversible genetic or congenital disorders in the baby, or structural problems in the uterus, placenta, or cervix that may affect the birth.

While routine ultrasounds have been performed for about 30 years now without any major risks being identified, they have also not been shown to necessarily improve outcomes, either. For this reason, some women feel that it is not necessary to have the 20-week anatomical ultrasound, as they do not wish subject their bodies or their babies to any unnecessary interventions or tests that do not have a proven benefit. You are always within your rights as a patient to refuse any tests your provider orders, for whatever reason, including financial. If you are paying for your prenatal care or birth out of pocket, for instance, the ultrasound may be an expense you choose not to undertake.

Other Tests

If your pregnancy is progressing normally and no problems are detected, those blood tests and the ultrasound will probably be all that your provider will order. However, if any of these routine tests turn up a possible problem, there are other tests you may be asked to undergo. These range from additional blood tests to additional ultrasounds to more invasive testing such as amniocentesis. If your provider recommends any of this additional testing, don't be afraid to ask questions, investigate risks to you and the baby, and decide for yourself what is necessary and what is alarmist. There's far too much to get into here, as this series is meant to cover the course of a normal pregnancy, but I wanted to mention that there may be more depending on your personal risk factors.

Cervical Checks

In the last few weeks of your pregnancy, your provider may want to check your cervix. Some providers and women like to know if there has been any dilation (opening of the cervix) or effacement (thinning of the cervix), which may indicate whether your body has started preparing for labor and delivery. Routine cervical checks prior to labor are controversial and generally not useful or necessary. Often, the cervix will show little-to-no dilation or effacement before labor begins, and even if you are dilating and beginning to efface, that does not mean you'll go into labor tomorrow. Some women walk around at 4cm of dilation for weeks before active labor begins, while others are at 1cm at their 40-week prenatal appointment and end up in labor that same day. In other words, you and your provider may want to know if anything's "happening," but whether anything's happening may not actually have any bearing on when you'll actually give birth. Checking the cervix will, of course, involve undressing from the waist down and allowing your provider to insert two fingers into your vagina to measure the cervix. Some women are sensitive to these types of exams and may experience discomfort or spotting after a cervical check. If you are uncomfortable with the idea, you may tell your provider that you prefer not to have any cervical checks.

GBS Testing

Between 35 and 37 weeks, your provider will likely want to perform a Group B Strep test. For this, you will need to undress from the waist down, and your provider will swab your vagina and anus. This sample will be tested for a specific type of bacteria called Group B Strep (GBS). The presence of GBS is not harmful to you, but it can cause infection in the baby at birth, requiring the use of antibiotics and possibly other interventions such as a brief NICU stay. Women who test positive for GBS will likely need to receive IV antibiotics during labor to reduce the risk of the bacteria infecting the baby as he passes through the birth canal. You can discuss the procedures for giving birth when GBS+ with your provider if you do end up testing positive.

Non-Stress Test

If you are experiencing any complications such as high blood pressure, or if you go beyond your estimated due date, your provider may order a non-stress test (NST). An NST will help determine if the baby is reacting normally to his own movements. An NST is noninvasive and requires only the use of fetal monitors, which are strapped to your belly and measure the baby's heartrate and the contractions of your uterus. You will relax for 20 to 40 minutes, preferably after eating and emptying your bladder. The baby's heartrate will be recorded. The expectation is that the baby's heartrate will increase when he moves. The nurse conducting the test will watch for at least two instances of the baby's movements and confirm that the baby's heartrate increased by a certain amount during those movements. If the baby is reluctant to move, you may be asked to drink a glass of orange juice or very cold water. This will usually encourage the baby to kick. They may also use a buzzer to startle the baby to get him to move. 

While you are there, they may also conduct an ultrasound to determine your levels of amniotic fluid and to view the placenta. 

Assuming the baby reacts as expected and there are no other concerns, you can feel comfortable continuing on as you are and wait for labor to being naturally.

Weight or Size Estimate Ultrasound

Some providers may want to use an ultrasound toward the end of the pregnancy to estimate the size or weight of the baby. While it may be fun for you to "see" the baby again, please note that ultrasounds are a notoriously unreliable way to estimate the size of a baby in utero. Be aware that the ultrasound estimate may be off by as much as one and a half to two pounds in either direction. In other words, if your provider estimates that your baby will be 8 pounds, that means your baby could be anywhere from a petite 6 pounds to a robust 10! Or, just because the estimate says 10 pounds doesn't mean your baby will actually be unusually large. He may come out a healthy 8 or 8.5 pounds. Also be aware that the size of the baby generally does not have much effect on whether you will be able to give birth vaginally, if that is your desire. Listen to your provider's suggestions, but be armed with your own research on the subject as well, and  be ready ask questions if your provider recommends inducing before 40 weeks because of "macrosomic" (large-bodied) baby. We'll discuss induction, c-section, and interventions in a later article.

Membrane Stripping and Breaking of Waters

At 39 or 40 weeks, or if you go beyond 40 weeks, your provider may offer to "strip your membranes." It is thought that doing so may jump-start labor in a woman who is on the brink. Stripping the membranes involves the provider inserting his or her finger into the vagina and sweeping the cervix, separating the membrane that connects the amniotic sac to the wall of the uterus. This is typically an uncomfortable procedure, though relatively quick, and may cause cramping and contractions in the hours following. If successful, you will find yourself in labor not long after your appointment. However, it may not work if your body or your baby are not quite ready to go into labor, and you may experience a fair amount of discomfort to no effect. When it was looking like I was getting close to going into labor toward the end of my third pregnancy, my midwife stripped my membranes. For about an hour (in Toys R Us with my kids, no less), I was certain I was about to go into labor. I felt horrible. And then it all stopped and I went into labor spontaneously two weeks later.

A more extreme way to attempt to induce labor without drugs is to manually break the amniotic sac. If your cervix is dilated at all, your provider can use a tool to poke a hole in the sac, releasing the waters. This may trigger labor. However, once the amniotic sac is broken, your uterus and baby are vulnerable to infection, and if labor doesn't begin on its own within about 24 to 48 hours, your provider will recommend you go to the hospital immediately to be induced with Pitocin or to have a c-section. Please note that once your water is broken, whether spontaneously or manually, you should not put anything into your vagina, to reduce the risk of introducing infectious agents into the uterus.

I mention these various procedures so that you'll know what your provider is talking about when the time comes. This gives you the opportunity to do your own research on the various topics as they become relevant so that you can ask educated questions and make an informed decision when presented with the option. 

Please remember that the average first pregnancy goes beyond the 40-week estimated due date, and even on to 41 weeks. If your pregnancy is otherwise healthy and there are no concerns, you do not have to feel pressured to attempt to induce labor by any means (natural, manual, or using medication). Have an honest discussion with your care provider about the risks and benefits of allowing your body to progress to spontaneous labor.

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More articles in this series:
Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part V: It's almost Time to Have a Baby!
Part VI: Labor and Delivery

Choices, Choices, Too Many Choices!

I was listening to the radio today in the car. Just the regular radio. One of the local stations. Actually, six of the local stations - I flipped from preset to preset as commercials came on or songs I didn't like were playing. I enjoyed it immensely. I loved the surprise of what song might come next. I liked hearing songs I've heard often and songs I haven't heard in a long time. I liked cranking up the volume on the ones I especially love, and disliked having to turn it back down when one of my kids had something to say. This is all totally normal and ordinary behavior, of course, but I haven't engaged in this particular activity in a while, because we got 90 days free of Sirius-XM satellite radio when we bought the minivan, and that 90 days just ran out last week. I haven't listened to regular-old live radio in a long time (before that, it tended to be a single CD on repeat to please the little-'uns).

Similarly, we subscribed to some basic cable channels when we moved, after quite a while without having any live TV to watch. There's a certain joy in sitting back on the couch with the TV remote in hand, flipping channels until you find something interesting, browsing during commercials. We've had Netflix for so long, and have relied upon them exclusively, that I'd forgotten how relaxing it can be to simply watch what's on.

It occurred to me today, while flipping back and forth among the six radio stations in my presets, that there's a lesson here for us as parents. Sometimes there can be too much choice. Sure, it's pretty awesome when you can choose from 60,000 TV episodes and movies from all over the world through your various streaming TV options. It's amazing to have hundreds of commercial-free radio stations to browse through on your satellite radio. But I felt so much more relaxed simply letting the radio choose for me, to be totally reliant on whatever the DJ and the radio producers felt should come next.

We are inclined, in this day and age, to offer our kids choices. What do you want to wear? What do you want to eat? Where do you want to go? We feel like we should give them some control over their lives where we can, because we control so much of what they do every day.

But kids can become overwhelmed by the infinite choices of those open-ended questions. What if kids' lives were more like live TV and less like Netflix? What if we could give them the option to watch "Wild Kratts" or "Dora the Explorer" but not include every other PBS and Nickelodeon show ever made? They could then only watch whichever episode of "Wild Kratts" is on, without having to choose from dozens of them. I've found my kids tend to watch the same few over and over again, possibly because choosing from the myriads of options is just too much. It's too hard. It's too complicated.

And, there's the problem when giving open-ended choices backfires on you. "What do you want to eat?" might end in a choice that isn't available. And then you have to deal with disappointment and let-down when they ask for spaghetti with tomato sauce and you don't have any. And then they don't want whatever you do offer, because you asked what they wanted and then denied them that option! (Case in point, when Netflix's contract with Nickelodeon ended a couple months ago and Dora and Diego disappeared from the list of options, my toddler was devastated! And there wasn't anything I could do about it...until we signed up for Amazon Prime. Sigh.)

I'm usually in favor of the "Do you want this or this?" style of offering options. Do you want to wear the giraffe shirt or the cow shirt? Do you want to eat macaroni and cheese or chow mein? This, at least, brings the options down to what's actually available, and it allows you to still direct what they do while giving them the illusion of control.

But this can backfire, too. What if they don't want either of those options and they refuse to choose? What if they expect to be given a choice when you have no intention of giving one? What if they have to wear the blue track pants because everything else is dirty and you haven't done the laundry yet? What if the only thing you have in the house for dinner is hamburgers?

I'm often happy to simply hand over control to someone else. "Where do you want to go for brunch?" "I don't care, you pick" is akin to "Let's just listen to the radio" rather than starting up your iPod playlist. I think kids are that way as well. I don't think "I don't know" as an answer to "What do you want to eat?" is necessarily them being intentionally unhelpful. I think sometimes it's genuinely choice burnout. They really, honestly, don't know, because trying to think of every food they've ever eaten and pick which of those foods they want right now is just too overwhelming. Do I want to watch "West Wing" or "Star Trek" or "30 Rock" or "Frasier" or a movie? Do I want a comedy or a drama or a cartoon? Do I want to start at the beginning or choose from one of the 250 episodes available? I don't care anymore! You pick!

Choice becomes noise after a while. It becomes stressful to have to decide. Let's bring the choices down to a few things that don't matter so much. Let's eliminate some of the clutter in our own minds and streamline the process. And let's enjoy the fact that sometimes there isn't a choice, rather than let that get us down. Hopefully our kids can learn to see the positive in that, too.

Fasting During Pregnancy and Breastfeeding

Yom Kippur is this Saturday. Jews customarily fast for 25 hours during this holiest of days in order to distance ourselves from worldly needs and focus on prayer and repentance. When we're pregnant or nursing, however, our babies cannot be totally out of mind, since we still have to meet their needs even while denying ourselves our own.

There are five minor fast days on the Jewish calendar (a minor fast is from sunup to sundown only, while a major fast - of which there are two - is from sundown to sundown). Typically, pregnant and nursing mothers are exempt from minor fasts, because they need to stay hydrated and nourished for their health and the health of their babies. In Islam, too, as I understand it, pregnancy and breastfeeding are considered health exemptions from fasting.

Yom Kippur, however, is different. If you have a health problem that would make it dangerous for you to fast, you can talk to your doctor and rabbi about whether you should attempt a fast or not. For example, a diabetic who needs to maintain blood sugars probably cannot (and should not) fast. However, pregnancy and breastfeeding, assuming the mother and child are otherwise healthy, are not automatically grounds for exemption from the Yom Kippur fast.

I, personally, have fasted several times now while pregnant or breastfeeding. All of my kids were fall babies, so I have been either heavily pregnant or nursing a young baby during Yom Kippur for many years. While it is not easy to fast even when you have only yourself to worry about, it is safe to fast for one day even while nourishing a growing baby.

By fasting, I mean refraining from all food and drink, including water. This means that you need to make sure you are well hydrated before the fast begins. Dehydration can reduce your milk supply when nursing, and it can cause contractions, swelling, and discomfort when pregnant. Some women who are near their due date at Yom Kippur do go into labor on or shortly after the fast day due to the stress fasting places on their bodies. If you are concerned about this happening to you, please consult with your care provider and a rabbi. Being sure that you are well hydrated in advance of the fast will reduce the negative effects of refraining from water for one day.

Many of us walk around chronically slightly dehydrated. It's hard to make sure we're drinking enough water. This is the single most important element in a successful and relatively easy fast, so make sure you plan for it. In the two or three days leading up to the fast, drink considerably more water than you usually do. Keep a bottle or glass of water nearby and constantly refill it. If you're starting out from a slightly dehydrated state, like me, you need to not only get what you need for the day, but you need to make up for the deficit you already have. Drink until your pee runs clear, and then keep up that level of hydration throughout the days leading up to the fast.

On the day before the fast, especially at the last meal before the fast begins, make sure you eat a meal with plenty of protein and complex carbohydrates. Don't make your meal too salty or sugary, as these will dehydrate you, and simple sugars will give you a short burst of energy that will wear off quickly and leave you feeling hungrier. You need something that will give you a slow burn. I usually have chicken and brown rice before a fast. Do have that last glass of water, too. Every drop helps. This advice applies to anyone planning to fast, not just pregnant or breastfeeding women.

If you're nursing, continue to nurse on demand. You may find your supply decreases temporarily toward the end of the day, and your baby will probably nurse more frequently in the days following the fast in order to bring back your milk supply. As long as you rehydrate and eat well once the fast ends, your supply should recover easily. If your baby is also eating solids, you may find that it helps you to offer more solid foods during the fast to reduce the load on your body. Make sure you return to your regular nursing routine following the fast so that you do not permanently harm your supply.

If you're pregnant, pay close attention to your body and the movements of your baby. Make sure your baby is moving around. If you notice any strong contractions, keep track of how powerful they are and how often they occur. If you have more than four or five strong contractions in an hour, lie down and rest. If they do not subside, talk to your rabbi about possibly breaking the fast and drinking some water to calm the contractions, especially if you are still a while from your due date. Typically, one day of fasting will not put you into labor if your baby is not ready, but you don't want to risk your health or the health of your baby. If you have any concerns prior to Yom Kippur or other fast day, please talk to a rabbi. It can help to know in advance what guidelines you should follow if you develop any problems during the fast.

I am 34 weeks pregnant and will be fasting this Saturday. I fasted last year while nursing a toddler, and the year before that while nursing a newborn. The year before that, I was nursing a toddler, and the year before that, I was nursing a nine-month-old. And the year before that, I was pregnant. I successfully fasted every time. I think what's harder than the fast itself is caring for your kids while you fast. They still need to eat, they need your attention, they need to be entertained. If you have access to babysitting or a non-fasting helper on that day, take advantage of it! Most synagogues do offer a children's program for the High Holidays. Be sure to rest when you can, and sit down if you need to. You can also explain to your older children that it is harder for you to be patient and energetic today because you are very hungry. Hopefully, they'll cut you some slack.

May you have an easy fast, and g'mar hatimah tovah!

Video: Breastfeeding in Public

My latest YouTube video is live. We're talking about nursing in public, which I've touched on here on the blog before. What are your thoughts on breastfeeding in a public place? Appropriate? Inappropriate? With or without a cover? Whenever and wherever? Has your opinion changed over time? Do you nurse in public? Why or why not?




Check out the video, and subscribe to the Jessica On Babies YouTube channel!

(You can ask a question for an Ask-Me Monday video by liking "Jessica on Babies" on Facebook and send a private message or comment on an Ask-Me Monday thread.

Formula "Goody" Bags

I've written before about doctors and hospitals giving out bags supplied by formula manufacturers, specifically here and here. It is a common marketing technique for formula companies - especially Enfamil, Similac, and Nestle/Gerber - to provide "gift bags," samples, and coupons to OB offices, pediatricians, and hospitals to be given out to expectant and new parents. In exchange for the doctors' and hospitals' assistance with marketing their formula, the company supplies free formula to these providers. Their idea is that if you send a new mom home with some free formula and some nice "gifts," she will be more likely to choose your brand if she decides to use formula, and she will be more likely to try using formula if she has some on hand already.

Samples may be anything from a small can of powdered formula, to a few ready-to-feed bottles, to coupons for free or discounted formula at the store. Often, the company will take things one step further and give out diaper bags, insulated bags, ice packs, and other useful items, along with booklets of information about infant feeding.

Research has shown that new parents who have formula samples at home, especially those that they received from their doctor or hospital, are more likely to supplement unnecessarily and are less likely to be exclusively breastfeeding at six weeks than those who do not have formula readily available. Formula samples directly sabotage breastfeeding. (See the above-linked posts for why and how this happens.)

In all honesty, in all three of my previous pregnancies, I did not receive formula "freebies" from my OB or pediatrician. Since my first baby was receiving formula from day one anyway, I did receive samples from the hospital and pediatrician, and I don't know what I would have gotten had I been breastfeeding. With my second and third, formula samples were not offered, and I was exclusively breastfeeding. I did receive some samples and coupons in the mail from joining mailing lists, but I did not receive any from any of my medical providers.

Today, though, I had my third visit with my new OB. After the appointment, I spoke with the billing office about what our financial obligations would be, based on my insurance coverage. After signing the payment contract, I was handed two gifts, one with Similac branding and one from Enfamil. I was excited, because never having received formula goody bags before, I didn't really know what they might be like. Also, it was entirely possible some of the stuff might be useful (ice packs are ice packs, after all), and I was curious to see what I was given. The Similac bag was a nice shoulder bag, while the Enfamil packaging was not in and of itself useful.

I know I personally won't be swayed by the formula marketing, since I have successfully exclusively breastfed two kids already and am extremely confident about breastfeeding this next little guy. I'm not worried that having some formula samples in my house will cause me any problems. I have a purely academic interest in what these bags contain and how their contents might be perceived by a mother less gung-ho than I am about breastfeeding.

I was not disappointed.

I'll start with the Enfamil package. It was a small, cloth bag fastened with Velcro. The label said it is a "birthing and beyond kit" and informed me that it contained ready-to-use formula. Inside were four "Nursette" bottles - two Newborn and two Gentlease - and one bottle nipple. Also included were a booklet on caring for my newborn, a book of coupons for various Enfamil products, informational cards about each type of included formula, and a postcard telling me that I could download the American Academy of Pediatrics' New Mother's Breastfeeding Essentials ebook from Enfamil's website.

The booklet, called "Your new baby - a detailed guide to your newborn's nutrition and well-being" contains a selection of generic advice regarding newborn care, milestones, and development, including a section on breastfeeding. This section is brief, not detailed, and is not complete enough to truly be helpful. They also find ways to advertise other Enfamil products such as their Vitamin D supplement, with a page on why supplementing with Vitamin D is important. The breastfeeding section is immediately followed by a section entitled "supplementing & formula-feeding," with the headline on the first page, "Going back to work - or just ready for a change." They then briefly discuss reasons why a mother might choose to supplement with formula, none of which are situations in which supplementation with formula is medically necessary: "milk was delayed coming in," "going back to work," "didn't feel like baby was getting enough," "mom or baby got sick," "baby had trouble latching or sucking," "pumping was too uncomfortable or inconvenient." This is followed by tips for bottle-feeding and preparing formula. The booklet also directs you to an 800 number or the Enfamil website for "live help."

I'll discuss all of this after we look at Similac's bag.

First of all, Similac's gifts were much more impressive. It starts with a quilted, messenger-sized shoulder bag which could be used for just about anything. It is simply black, with no Similac branding except for the large, removable label hanging from the strap. The bag is called a "Breastfeeding Supplementation Kit". In the bag were a sample-sized can of Similac powdered formula, a black cooler bag sized just about right for two bottles, with two Similac-branded ice packs inside, a Similac-branded booklet called "The Art of Feeding", a chart for how long breastmilk can be stored and instructions for use of the cooler bag, and a pile of coupons for everything from diapers to Disney movies. Surprisingly, none of the coupons were for Similac itself.

The "Art of Feeding" booklet starts out by recommending that mothers take Similac's prenatal vitamin during their pregnancy to aid their babies' development. It then discusses the nutrients a baby needs in its first few days and weeks of life and gives a quick overview of a sample diet for a breastfeeding mother. Next is a several-page guide to breastfeeding, including rough descriptions of the four most popular breastfeeding positions, tips for latching, an overview of newborn feeding habits, and what to look for when it comes to baby's diapers and weight gain. There is a brief FAQ, and then they recommend contacting their "feeding experts" at a toll-free number if you have further questions. The rest of the booklet contains advice about how to wean to formula, how to choose which type of formula to use (of course, Similac offers a wide range of options), how to choose a bottle and nipple (Similac has those products, too!), how to prepare, store, and use formula, and an overview of all of Similac's products.

The first thing I want to draw your attention to is the absurdity of a formula company - any formula company - offering advice on breastfeeding. Take any of this advice with a grain of salt. While none of what they say in either booklet is precisely "wrong," it's also not the kind of detailed help a struggling new mother might need, and some of it is misleading or incomplete. By including this information, these companies are trying to look like they're being breastfeeding-friendly, while simultaneously giving new parents the "permission" they need to supplement or switch to formula rather than try to solve any breastfeeding problems they encounter. By "allowing" a mother to use formula in addition to (or instead of) breastmilk, they are presenting her with a guilt-free "get out of breastfeeding" card. And they offer no real advice about how to know when you actually need to supplement, how to avoid the need to supplement, or how to realistically combine formula and breastfeeding in a way that will not further harm your breastmilk supply. They also do a fine job of explaining why their products are "almost as good as," or "the next best thing to" mom's own milk, and they show a range of products to meet any baby's needs.

Why does all this matter?

Well, let's look at where I got these bags. Who gave them to me? My doctor. By giving me these bags, my doctor is implicitly endorsing my use of formula. She has not given me any information on breastfeeding, has not discussed my choice of feeding method, and has not asked if I need any help making such a decision. I'm seven weeks from my due date. Maybe I'm still on the fence about how I want to feed my new baby. Maybe I haven't even really given it much thought. Maybe I'm being bombarded from all sides by the internet, my family, and my friends about how I "should" do this or I "can't" do that. Maybe I don't trust my breasts and my body. Maybe I don't really "get" how breastfeeding works. Maybe I think it's "gross." Or maybe I have body issues due to psychological problems or sexual abuse and the thought of anyone touching my breasts, even a baby, is nauseating or panic-inducing. I now have a ready-made solution: my doctor gave me formula samples. If I have any doubts about breastfeeding, I now know that my doctor thinks giving me some formula "in advance," "just in case," is a good idea. And if my doctor thinks it's a good idea, who am I to question?

Now, granted, this is my fourth baby, and I've made it pretty darn clear with my doctor, in the short time we've known each other, that I know exactly what I'm talking about and that I have a very clear idea of what I'm going to be doing. So it may be that she sensed I don't need her advice. I don't know how she might be with a first-time mother, or even a second- or third-time mother who is considering breastfeeding for the first time. I may actually ask her at our next appointment if they do provide any prenatal breastfeeding support or advice. One thing I am comforted by is that I got two different brands' bags, so the office is not endorsing one over the other, and they just sort of threw them at me with a, "Oh, yeah, you can have these if you want" attitude. But I wasn't exactly discouraged from taking them, either. And the way it's presented, "Oh, and we have some goody bags for you, too!" makes it sound so exciting and exclusive! Of course I'd want a goody bag!

I'm very interested to see what, if anything, I get from the hospital, if this is what I got from the OB!

Breastfeeding simply can't compete with the formula marketing scheme. Sure, I could get a bag from Medela or Hygeia or Avent or Lansinoh with various breastfeeding accessories such as breast pads, lanolin, and freezer packs. But these companies simply don't have the market share that the formula companies do, and they don't have as vested an interest in gaining you as a customer. You'll never, ever spend as much money on breastfeeding as you would if you buy formula. You just won't. It's not worth it for their bottom line to give out freebies like it is for the formula companies. That leaves doctors and hospitals and midwives and bloggers and lactation consultants to do the leg work of educating the public about breastfeeding.

What it comes down to for me, with this blog and in my life, is this: I don't have any say in what you choose to do, how you choose to give birth, how you choose to feed your baby, or any other of the myriad choices you'll be making as a parent. But, I do care that you make those decisions based on good, solid, evidenced-based information, which is what I try to provide you with here on my blog and if you ask me advice in person or through my social media outlets. There is no disputing the fact that formula is inferior to breastfeeding. There is a time and a place for the use of formula, and I can even give you advice on how and when to use it in a way that won't sabotage your breastfeeding relationship, if you need such help. I hope - I really, really hope - that you won't turn to Similac or Enfamil or Nestle to tell you how to "successfully" supplement your breastfed baby with formula and think that the information they give you is truly accurate.

I know that these formula samples can be genuinely helpful in certain cases when short-term supplementation is necessary. But I also think there are ways to provide such samples to the mothers that need them, without essentially spamming every pregnant mother with something she probably won't need.

As for me, I'm going to keep my bags to use as an educational tool when I finally start teaching my own breastfeeding classes. Raising awareness of exactly what you're getting when your doctor hands you a "goody bag" is a necessary step toward improving breastfeeding rates and successes.

Did you receive formula goody bags from your OB, hospital, or pediatrician? What types of products did you get? How did you feel about receiving these freebies? Did you use any of the products?