How Does Milk Production Work in the Early Days Postpartum?

The first few days and weeks after your baby is born can be confusing. You have so much to learn and so many things to worry about. It's stressful and scary. You want to be sure you're doing the best you can for your baby, and that includes making sure he's getting enough to eat. When you're breastfeeding, it can be hard to tell how much your baby is taking in and whether it's as much as he needs or wants.

So let's talk about how milk production works in those early days, so that you can be more confident that your baby is satisfied.

You start producing the early milk, called colostrum, between 10 and 14 weeks of pregnancy. Colostrum is milk, but it's not the mature milk you'll see a few days after your baby is born. Rather, it's a highly concentrated, thick, golden liquid consisting mostly of protein, beta carotene, and antibodies. Colostrum is sometimes called "liquid gold" because it is so valuable to a newborn baby to help protect his tender new gut, support his undeveloped immune system, and prepare him for life outside the womb.

10mL (2 tsp) of colostrum pumped on my baby's second night of life.

The presence of the placenta and the progesterone it produces keeps your milk volume low, so you won't produce mature milk until after your baby is born and the placenta is expelled. Your levels of prolactin - the hormone that tells your breasts to produce milk - are very high at the birth of your baby, but it's just floating around in your blood stream with no way to send the message until you start actually nursing a baby. The action of the baby suckling at your breast (or of a breast pump or hand expression) creates "prolactin receptors," places for the prolactin to attach within the breast so that the message to produce milk can be sent. The takeaway from this is simple: The more you nurse your baby in the first 3 days of life, the better your milk supply will be even months down the line.

Now, once the baby is born and the placenta detaches, your levels of progesterone, the hormone produced by the placenta that supports the pregnancy, drop, and you've started establishing prolactin receptors. This paves the way for the prolactin to do its job, and your body will begin producing more milk - and that milk will be the mature, watery, white substance we think of when we think of "milk."

It takes about 48 to 72 hours for your milk volume to increase. In the first two to three days of your baby's life, he does not need to eat much. Remember that he was being constantly fed by the umbilical cord while inside you, and his intestines are full of meconium - a greenish-black, tarry substance that coats the intestines. There isn't room for much food until the meconium is cleared out. Colostrum, along with all of its other amazing properties, acts as a laxative to help clear out that meconium. Your baby's stomach is very tiny at first and cannot hold more than about a teaspoon (5mL) of milk anyway, so it doesn't take much for him to feel full. Remember, in the last few weeks of your pregnancy, he was packing on fat stores to help him survive these first few days of life where he suddenly isn't eating much.

Though your baby isn't super hungry at birth, he will have a high need to suck. This high need to suck serves a few purposes. First, when the baby suckles at the breast, it stimulates the release of oxytocin, which helps the mother's uterus shrink back down and slows her postpartum bleeding. Second, as mentioned before, it helps set up receptors for the milk-production hormone called prolactin. Third, the sucking stimulates the baby's intestines to start moving out the meconium to make room for the milk. Finally, newborns find sucking comforting. Babies even suck on their hands inside the womb!

Remember that breastfeeding takes practice. The best thing to do in these first few days postpartum is to bring the baby to breast absolutely as often as possible, at least 12 times in 24 hours, or as often as the baby asks. The quickest and easiest way to learn your baby's hunger signals is to start out by offering the breast every time your baby fusses. You'll begin to recognize certain movements of his head and mouth that indicate that he wants to nurse. You'll learn the different types of cries that mean he's hungry or tired or uncomfortable. By offering the breast every time your baby seems fussy, you'll give yourself and the baby every opportunity to practice nursing and to establish those prolactin receptors and build your milk supply!

By about 72 hours after the birth, you should notice that your breasts feel fuller and are now producing something that looks a great deal more like "milk" than the colostrum did. Some women find they become extremely engorged literally overnight, while others notice a more gradual increase in volume. If your milk hasn't increased in volume by about 72 hours after birth, you may need to speak with a lactation consultant and/or your baby's pediatrician about providing supplemental donor milk or formula until you have a greater volume of milk available. It is important that your baby start eating so that he can grow.

Once the milk supply does increase, you'll want to know that your baby is getting enough to eat. You can monitor how much the baby is getting by counting diapers - what goes in must come out! A 3-day-old baby should have three wet diapers and three poops per day. A 4-day-old should have 4 and 4. A 5-day-old should have 5 and 5, and after that, there should be at least 6 pees per day and anywhere from about 3 to 6 or more poops. In order to be sure that your baby is really producing at least that many wet diapers, you need to check your baby's diaper at least that many times per day. If you're not sure how to tell if the diaper is wet, or you are concerned that your baby isn't wetting as often as he should, you can place a piece of tissue in a clean diaper. When you check the diaper, if the tissue is wet, then your baby has peed.

Another way to reassure yourself that your baby is getting enough to eat is to watch his growth. Your pediatrician will want to see your baby several times in the first two months of life. Your baby should be gaining at least half an ounce a day, if not more, and should be back up to his birth weight by the time he's 10 to 14 days old. Even if you don't get to weigh your baby often, you'll notice as he starts outgrowing his clothing and diapers, becomes heavier for you to hold, and starts to fill out.

If you're concerned that he's not taking in milk, you can do what's called a "weighted feed," where you weigh the baby hungry, then feed him, then weigh him again on the same scale with the same amount of clothing. This requires a sensitive baby scale that can measure in small increments. Many baby boutiques and lactation consultants will have scales like this available to do weighted feeds and to check your baby's growth. Typically, a newborn baby will take in about 2oz. of milk in a feeding, which you can see because he'll be 2 oz. heavier after feeding!

Finally, you can tell if a baby is getting enough by making sure he's not dehydrated. His eyes and mouth should be moist, skin should be smooth and not have dry patches, and the fontanel (the soft spot on top of the head) should not be sunken. He should not be lethargic or floppy, should have periods where he's awake and alert, and should wake on his own to eat. If you see orange urine crystals in his diaper or he has fewer than six pees in 24 hours after day 5 of life, call your pediatrician immediately. Dehydration in a baby can be very serious but is also very treatable.

If you have any reason to be concerned about your baby, don't hesitate to call your pediatrician. Trust your gut. If your baby is not himself, it doesn't hurt to have him looked at. Often the nurse can listen to your concerns on the phone and help you determine if the doctor needs to see the baby.

Remember that a newborn typically eats 12 or more times in a 24-hour period, but that doesn't necessarily mean he's eating exactly every two hours. He might eat three times in three hours, then sleep for three hours, then eat twice more in the next four hours, then sleep for two hours, etc. Watch the baby, not the clock, for when you should feed him next, and follow his cues.

The best way to ensure that your milk supply is healthy and your baby is well-fed is to simply nurse, nurse, nurse. Avoid artificial nipples such as pacifiers and bottles until at least three to four weeks of age, when breastfeeding should be well established. Have your baby's latch evaluated if you have any pain while nursing. Sometimes it may look like your baby is nursing well but he's actually not transferring milk efficiently. Listen for the sounds of swallowing and for a suck-swallow-breathe pattern. If your baby is sucking but not pausing to swallow or breathe, he may not actually be getting any milk, or not enough to trigger the swallow reflex.

Check out my videos on newborn nursing to see what it looks like (and sounds like!) when a tiny baby nurses!

About Those Formula Freebies and Mayor Bloomberg...

By now, just about every breastfeeding blog I read has made some kind of commentary or another on New York City Mayor Bloomberg's new program for breastfeeding promotion in NYC hospitals. Part of the Latch-On NYC initiative, this voluntary program requires that participating hospitals lock up formula, not routinely give out formula samples and formula-branded paraphernalia to new parents, prohibit the display of formula promotional materials in the hospital, and conform to the New York State hospital regulation that exclusively breastfed babies not be given formula supplementation unless medically indicated. The program is expected to raise breastfeeding rates in participating hospitals because research shows that women who are given formula samples by their doctors or in the hospital are 3.5 times more likely to be supplementing with formula by two weeks of age. If formula is kept under wraps, and new mothers receive education about breastfeeding before their babies are given any formula, the thinking goes, breastfeeding rates will rise and the overall health of the population will improve. Hand-in-hand with this is news of an AAP resolution that pediatricians should not routinely hand out free formula samples to patients, for the same reasons.

I have been reading every blog post I've been linked to, taking in almost every comment on all the major breastfeeding and parenting blogs I frequent, and I still don't quite know how I feel about this initiative. It sounds like they're basically trying to get NYC hospitals to conform to the Baby Friendly Hospital Initiative standards without going through the BFHI certification process. I gave birth to GI in a Baby-Friendly hospital, and I felt that the breastfeeding support there was excellent. Of course, I went in intending to breastfeed. If I had gone in less certain, uneducated, or sure I wanted to use formula, I'm not sure how I would have felt. I didn't need or want to ask for formula, so I don't know what kind of "lecture" or "education" I would have gotten had I made the request. I didn't have any problem nursing or producing milk, so I don't know how I would have been treated had I genuinely felt my baby was starving and needed formula supplementation. Because I've been lucky enough to be able to nurse with relatively few problems, and because I'm extremely pro-breastfeeding, well educated about breastfeeding (I literally wrote a book on it), and because I wasn't going to let anything or anyone stand in my way of breastfeeding, I didn't need to think about "the other side."

I often wonder whether I would have been able to breastfeed NJ had I given birth to him in a hospital like the one where I had SB and GI. Rather than jumping straight to formula when there was the slightest hint of a problem, if they had been more supportive of breastfeeding and, more importantly, had been more supportive specifically of me in my situation, would I have left the hospital breastfeeding instead of with an extra case of formula? It's very hard to say. My husband and I were discussing this last night (in the context of the above-mentioned controversy). His perspective and memories of those early days are different from mine, but we both remember that the lactation consultants who visited me were quite unhelpful. While it may have been true that many women who experience postpartum hemorrhage have difficulty with their milk supply, and while it may have been true that pumping often would help bring in my milk, what I really needed was to spend lots of time skin-to-skin with NJ, nurse him on demand, and be forced to care for him. Yes, I was weak. Yes, I had lost a lot of blood. Yes, I was in pain. But NJ was healthy and strong, had a great latch, and, with a little help, I probably could have initiated breastfeeding while in the hospital and breastfed him several times a day during that four-day stay rather than allowing the nursery nurses, my husband, my mom, and my visitors to feed him for me. It's probable that he would have needed a few bottles (or to be fed via syringe, perhaps?) on the first day when I was fairly down-and-out from blood loss, but on the second day? The third? Through the night? I do remember some good practices, such as telling me to save whatever I did pump and that they could give him that in a bottle instead of formula. They did provide me with a pump and show me how to use it. They did have lactation consultants come every day. But I constantly feel, looking back, that the advice the LCs gave me was, while not necessarily wrong, unhelpful or misleading. If you straight out tell a woman she won't have enough milk, why should she even bother to try? And if you don't tell her or her husband that formula is not, in fact, equal to breastmilk, then why shouldn't she just go straight to formula to begin with?

What's missing in all of this, to me, is that education prenatally is vitally important. The decision to breastfeed can't necessarily be made in the postpartum haze. The desire to stick with it is lowest when in the throes of newborn nursing, and the temptation to use that free formula is highest at the most critical period in the breastfeeding relationship. I know this. I've lived it. You need to walk into that hospital determined to breastfeed. You need a supportive hospital staff, from the OB or midwife to the delivery nurse to the postpartum nurses. You need lactation consultants on hand 24/7 (not just during business hours!). You need good, solid breastfeeding information. And you need to know that you are going to be respected for whatever choices you make.

The loudest complaints against this program seem to be from two basic viewpoints. One is the women who never wanted to breastfeed and don't liked feeling "shamed" or "guilted" by the hospital for their choice. The other is the women who desperately wanted to breastfeed but, for whatever reason, needed to supplement with formula in the early days and struggled long and hard with the decision. Both feel that formula samples are helpful, especially those that only needed a can or two of supplements before being able to go on to exclusively breastfeed. Both feel that being lectured or educated by hospital staff before someone will go get them a bottle for their starving babies is shaming and unfair.

The thing is, I agree with them, too. If my baby is starving because I can't produce enough colostrum or milk to satisfy him (please note that this is rare), then I need to be able to give him something else. If the hospital staff balk at giving me a bottle of formula to feed him, and I have to sign a form or justify my request every time my baby gets hungry, it's going to make me feel even worse and more inadequate. Support doesn't mean just patting a woman on the back and telling her she's doing a good job breastfeeding. Support means sitting down with a woman and figuring out what she wants, what her goals are, and then helping her get there. A good IBCLC knows this, and a good IBCLC will know when formula supplementation is necessary and how best to introduce, use, and wean off of those supplements, if possible. Having a nurse who's had a little bit of lactation training come in and tell you once again that formula isn't as good as breastmilk, and maybe you should have another go at feeding from the breast before you give a bottle, is only going to make a frustrated mother more flustered and upset. We need a balance.

I'm in favor of locking up the formula, but I'm also in favor of giving it to any mother who asks for it. I'm in favor of banning the gift bags and the formula-branded handouts, but I'm also in favor of giving unbranded formula to mothers who need it (in the hospital). I'm in favor of good breastfeeding support and information, but I'm also in favor of education in the proper preparation and use of formula, if a mother chooses to use it. I'm in favor of pediatricians having formula samples on hand to help out mothers who need it, but I'm also in favor of pediatric offices having lactation consultants on staff to help mothers who are struggling. Balance.

We need a more comprehensive solution. While restricting access to free formula will increase breastfeeding rates among those who are on the fence (that's been proven), it will not help those women who truly need it or who adamantly refuse to breastfeed. We need information and education throughout women's lives, and especially during pregnancy, to help them learn about breastfeeding before there's a squalling baby in their arms. We need postpartum support, especially for those women who are going back to work. We need support for pumping in the workplace. We need better, longer maternity leave. We need a cultural shift.

If there is one thing I know, unquestionably, it's that the more babies who are breastfed, the better. Banning formula freebies in hospitals and pediatric offices is a step in the right direction, but it's not the only step.

Breastfeeding a Newborn

I'm back in the "breastfeeding a newborn" phase of life. Actually, the new baby has been amazingly good to me. I've written about how my second son was a snacker, eating every hour. This new guy, he eats very enthusiastically, sometimes only for 10 minutes, other times for 20, but he cluster feeds for a bit, then takes a nice long nap, sometimes close to two hours. (Not that I can make any definite statements about his habits at 17 days old, but this is sorta how it's been so far.) It's kind of amazing. I was prepared for another every-hour eater, so this is pleasant.

Before my milk came in, his latch was horrible, it was hot as heck here (no A/C), and he would not let go of my nipple without screaming. I dreaded latching him on, I cried, thinking I couldn't possibly handle a baby like this, I despaired. And then my milk came in, and he became the most content, easy-going guy. I'm very lucky.

I read a very good article yesterday - which I wish I'd read two weeks ago! - about how positioning is more important than how the latch looks, and how the latch feels is more important than it looking like they describe in the books, and suddenly he's latching better, with just a few simple tips. Hold the baby tummy-to-tummy with you, so his ears, shoulders, AND HIPS are in one line. Bring the baby to your breast, with the nipple in line with his NOSE, and let your breast brush his CHIN. This will stimulate him to open his mouth, and then you can drop the nipple in. If it doesn't hurt, you're fine. Also, it helps keep him latched comfortably if you recline a bit. This is called biological nurturing, or laid-back nursing, and it helps keep the baby from flinging his head backward and coming off the nipple in a rather painful way.

I would like to brag a little at this point. Baby was born 8lbs., 3.5oz. By day three he had lost about 6 ounces, and was down to 7lbs., 12oz. The very next day, day four, he was up to 7lbs., 15.5oz. (yes, he gained 3.5 ounces in one day, once my milk came in). Today, he had his two-week appointment, and at 17 days old, he's 9lbs., 14oz. Yes, folks, he gained over two pounds in two weeks. He's a good eater, that one!

Anyway, I have mastitis. I've preached up and down, here and in my book, about getting rid of plugged ducts and avoiding mastitis, and here I wake up yesterday morning with a horribly engorged right breast, chills, achy joints, and a hard, sore spot on the outside of said right breast. Damn. I tried my usual tricks, massaging the spot while nursing, nursing a lot on that side, letting the hot water from the shower help open up the duct, massaging some more. I thought I'd taken care of it, until my 600mg dose of ibuprofen wore off and the chills came back last night. I spent the night alternately having chills and sweats, so I called the doctor this morning and asked for antibiotics. If you can't clear the infection with home remedies within 24 hours, it's not worth taking any chances. Mastitis can be serious stuff. I was hoping to avoid antibiotics, because that can lead to thrush, which is its own ball of trouble. Ah well. I got some probiotics to take along with the antibiotics, so hopefully this will be the end of it.

And, finally, I've decided to start pumping and storing breastmilk again, like I did with my second son, in order to donate it. I have someone in mind to give it to, if she wants it. A friend of my housekeeper's had a baby who was in the hospital for a few weeks after birth. She desperately wanted to breastfeed him, but she didn't have good support, and she didn't have a full supply established. I tried to pass along some tips, but I think it was too late. At three months old, now, her milk is dried up, and her son has had four ear infections already. She's terribly upset. I asked my housekeeper if she thought her friend might take donated milk, and said I'd be very happy to start pumping for her. I won't be able to give her enough to get him off formula, but even one bottle a day may help. Poor baby.

Let's Talk About Breastfeeding - Part II

I got a little clinical in the last post, and one of my goals for this blog is to keep it on a personal level. I do intend to bring in educational information when I find some that I think is interesting or important, and I will certainly include sources and quotes and useful knowledge when it directly relates to something I'm writing about, as with the Pitocin information a few posts back. However, I felt it was important to do a general post about breastfeeding before bringing it back over to my own experience.

Why did I want to breastfeed?

When I was pregnant with my first, I wanted to breastfeed, but I only had a vague notion of why. "It's better for the baby." (Better than what?) "Breast is best." (Breast, as opposed to what?) My mom and aunt breastfed, so of course I should too. It's just what you're supposed to do. Breastfeeding itself was a very abstract activity to me. I think maybe twice or three times in my whole life had I actually seen someone breastfeed, always when I was a small child, and the process and act had never really been directly explained to me. I didn't have a concept of how it worked, or what it should look like, or what the reality of it was. I had only heard how "I loved nursing," and "I nursed for 9 months," and "It's a really wonderful experience," without the accompanying truths, that it takes work in the beginning, that nursing a newborn is not like nursing a nine-month-old, that some people nurse into toddlerhood and beyond. I just didn't really know anything about it.

So when my first son was born and I expressed my desire to breastfeed, somehow I had this idea that I'd bring him to my chest, he'd start sucking, and we'd do that every few hours. I didn't know that milk supply is governed by baby's demand. I didn't know about proper "latch," and that what you eat can get into the breastmilk, and that there are specific ways to hold the baby. I didn't know about not giving pacifiers in the early days so as not to mess with the latch and sucking reflexes, or not to give bottles for similar reasons. I didn't, to be honest, really have a concept of what one might put into a bottle!

And yet, I wanted to breastfeed. Even after trying it, and not liking it, and not understanding it, and feeding formula for weeks, I still wanted to breastfeed. I still regretted "screwing it up" (as I thought of it). I regretted not having the information I needed in advance. I regretted not asking the right people for help. I wanted to breastfeed.

But WHY?

Honestly, I'm not even sure, now. I think part of it was that I felt like I had failed at something that should have been simple, and I'm not the sort of person who fails. I think part of it was that I felt like something was wrong with me, and I wanted to "fix" it. I also think that once I started learning about all the benefits of breastfeeding and breastmilk, once I talked to people in person and online about what breastfeeding is really all about, I really felt that I had missed out on something. Something big. Something important. And maybe, subconsciously, I realized that I had missed out on an important opportunity to bond with my son by not having to care for him in those vital early weeks.

By the time my son was several months old, I had tried and failed to relactate, although I did manage to give him a few weeks more of suckling (nursing is, after all, more than just for food), a few more drops of breastmilk. We moved across country and changed jobs, and I became a work-from-home mother, which meant I was with him a lot more often. I thought maybe at that point I could have been comfortable nursing him, except the one attempt I made to get him to latch, he looked at my breast like it was a UFO and had no idea what I wanted him to do. And that was that.

But, by then, too, we had learned that we had been blessed with a very picky bottle-feeding baby, who would only drink a full meal if it started out piping hot. He hadn't always been that way, but by the time he was about four months old, he literally would refuse a bottle unless it was hot. By then, we had learned the trick of warming the water before mixing the formula, which saved several minutes in the bottle-making process, but that wasn't always possible when we were out and about. We got pretty adept about asking for hot water in restaurants, but we were at a total loss if we were, say, at the zoo, or a gas station, or Walmart when he needed a feeding. Once I was near a Starbucks, so I went in and got a cup of hot water from them. For some reason, I remember that time very fondly. Anyway, my point is that my baby made formula feeding difficult. It also took us until he was 11 months old to figure out that we could carry hot water with us in a Thermos (duh). How nice it would have been to work that one out sooner.  (I realize that not all babies are so picky about bottle temperature, and many people can simply carry pre-measured bottles of water and a can of formula and quickly mix the formula and water and feed it. It wasn't this way for us, and he never grew out of it. He just eventually stopped needing a bottle, and our lives got so much easier.) Oh, also, he didn't digest the regular formula well, and it took us several weeks of trying in the beginning to find a formula that didn't make him terribly unhappy and gassy. It turned out that the kind of formula where the proteins are broken down more worked very well for him, and we were quite pleased to find a generic version of that particular formula, which saved us probably hundreds of dollars. But it was still about $14 per can, and by the age of four or five months, he was going through about two cans a week.

All of this added up to a lot of money and aggravation for feeding this baby. I now look back on that as somewhat of a blessing, because it made me very determined to breastfeed our next child. I had watched several mothers feed hungry babies by just opening up their bra and hooking them up, and I so wished it were that easy for me. Not to mention the number of times we got caught out longer than expected and didn't have a bottle or formula on hand. I once actually went to Walmart and bought a bottle and a can of formula so I could feed him while I was out. Very frustrating, and another problem I would not have had if I had been breastfeeding.

Combine this difficult bottle-feeding experience with everything I was learning about breastfeeding and breastmilk. I found myself spouting off all kinds of random information as I came across it, as if I were some kind of breastfeeding expert. I became a breastfeeding advocate even before I became a "breastfeeder."

It was no mystery, then, why I was so determined to breastfeed our second baby. I was obsessed with the idea. By the time he was born, I had read "The Womanly Art of Breastfeeding" cover to cover, had devoured articles about breastfeeding and breastmilk, had watched videos about how to obtain a proper latch, had learned all about milk supply and demand, how to know if your baby was reacting to something you were eating, growth spurts, night nursing, and why you shouldn't give a pacifier or bottle in the first four to six weeks. I had learned about how supplementing with formula often resulted in eventually terminating the breastfeeding relationship entirely, how feeding a bottle of formula before bed did not, in fact, make the baby sleep better, how formula actually messed with all the benefits breastfeeding had on the baby's gut, and even about things like oversupply and overactive letdown, which I may or may not have needed to know. In other words, I had all the book learning in the world, but I still hadn't actually nursed a baby for any appreciable length of time.

Well, book learning is great, but it's not the same as the hands-on (breasts-on?) experience, let me tell you right now. Having the knowledge is important - if you don't know the rules to basketball, you can't play it, but knowing the rules doesn't mean you can go out on the court and shoot a three-pointer. That takes practice.

So does breastfeeding. As much as I knew intellectually, when they first handed me my second son and put him to my chest, I had no clue how to actually do that breastfeeding thing. I was so determined to make it work, though, that I just nursed him. And nursed him. And nursed him. For the first six months of his life, that baby nursed every hour. (You measure the time between feedings from the start of one feeding to the start of the next, regardless of how long they are at the breast in between.) If I started nursing him at 9:15, he would need to nurse again at 10:15. In the early days, he was sometimes at the breast for 45 minutes. This meant I had 15 minutes between feedings to, say, pee, or eat, or type two-handed. This meant I couldn't so much as run an errand without having to plan to stop and nurse him while I was out. I learned to nurse in public very quickly, because I had no choice. I was going to nurse that baby. At about six or seven months of age, he finally stretched out to going two hours between feedings, and it only took about five to 10 minutes for him to complete a feeding, so things got considerably easier. But to this day, even though I'm not nursing at all, I am envious of those women whose babies start out going two or three hours between feedings.

I think if I had been less determined, the idea of letting someone give him some formula once in a while would have been very seductive. I can see how, despite having no big problems, like mastitis or thrush, bleeding and torn up nipples, low supply, or severe food intolerances, my son's nursing habits might have driven me, or someone like me, to give up. I did go a little crazy after a while, but I couldn't fathom any other option. And because I was with him almost all the time, he didn't even get very many bottles of expressed breastmilk (which I was more than willing for someone to give him if I couldn't be with him when he was hungry.) After a point, he wouldn't even take a bottle.

During the first several months, though, I did spend time every day expressing milk. Usually I did it once a day, obtaining between 2 and 4 ounces of milk between hourly feedings. I quickly learned to hand-express, mainly because setting up the pump, using it, and then breaking it down and washing it was really too much trouble when I didn't really have to do it. I also found hand expression to be more productive for me. I had a terrible, though not completely irrational, fear in those early weeks that something would happen to me like it had the first time around, and I would have to spend several days unable to nurse him. If that were to happen, I wanted to make sure I had a supply of breastmilk stored up in my freezer so that he would have something to eat.

As it turned out, not only was I healthy (thank G-d), but he rarely needed a bottle anyway, since, as I mentioned, I was almost always with him. I managed to store up a few hundred ounces of milk over time, much of which ended up getting thrown away. I gave a few ounces here and there to my older son when he was sick, figuring it certainly couldn't hurt, but he didn't really seem to like it. I did give 50 ounces or so per month to my housekeeper, who had had a baby a few months before me and couldn't pump enough for him when she was off cleaning houses or when her son was with his father. So her son got some of my milk, which makes me a little proud. I also shipped 75 ounces of milk from California to Florida to help out a woman whose baby, at four months of age, simply decided he didn't want to latch on the breast anymore. She was determined that he would not get formula if she could help it, but she was only able to pump about half of what he required and solicited milk donations to help make up the difference. I added my small contribution to her effort as well.

I can't say that I always "loved" nursing. I loved that I nursed, certainly. I love that I was able to provide that extraordinary benefit to my child.

So, why do I want to breastfeed my next baby?

I don't have to answer that one, do I?

My First Birth - Part IV - The Scariest Event In My Whole Life

So, after a reasonably traumatic c-section, serious blood loss, difficult recovery, and breastfeeding issues, we come to me at three weeks and one day postpartum. I was starting to come back to life, considering breastfeeding as a more viable option, up on my feet, able to care for baby alone. I was even getting a little work done from home. I was still in a lot of pain, but I hadn't needed the Percocet for a while, just ibuprofen. My blood count was coming back up. Things were looking good.

That Monday, I missed my afternoon pumping session, and when the baby got hungry, I decided to try just feeding him directly from the breast to see what would happen. According to my journal entry at the time, "It went OK." I was still unsure, but the decision was soon to be tabled. About three hours later, around 8:00pm, my husband went down the street to get us hoagies for dinner. The baby was asleep, and I was futzing around doing who-knows-what. The previous evening, I had had some uterine cramping that was a much more severe than it had been since the delivery, but it had gone away, and Monday had been fine.

Suddenly, the cramping started up again. I went to the bathroom to see if anything was going on, and I was bleeding more than I had been, which was surprising given that I was already three weeks postpartum. I decided to take some ibuprofen. On my way to the kitchen (we're talking a 1000sq.ft. apartment, so not a long walk or anything) to get water, I felt a gush of blood and instead ran back to the bathroom. When I sat down on the toilet, blood started to pour out of me. Sorry for the graphic detail, but I want you to get a sense of my terror: The usual course of uterine bleeding, whether a regular menstrual period or postpartum bleeding, is a start-and-stop sort of thing. Like, there's a spurt of blood, and then it stops, and then there's more at some point later on. My fellow female readers know what I mean. This bleeding I experienced was not like that. Rather, it was as if someone had turned on a tap or opened a vein. Blood just kept coming.

Remember, my husband was not home. I did not have a phone near me. The baby was in the bedroom, and I could hear him stirring. I didn't know what to do. My only thought was that I should get off the toilet, but I couldn't because my maxipads were too far away and I didn't want to bleed all over the bathroom trying to get to them. I don't think I realized just how serious things were.

After a few minutes, by which time I was trembling with fear and almost in tears, my husband came home with the hoagies. I called him to the bathroom, told him what was happening, and asked him for the phone to call the OB's office emergency line. This was not normal, I was sure. I also asked him to hand me a pad so I could get off the toilet. This was a smart move, it turned out.

I left a message with the OB office's answering service that I was experiencing severe postpartum bleeding. I then got up from the toilet and promptly collapsed to the bathroom floor and lay on my back on the bathmat. I was so dizzy I couldn't stand up. When we saw how much blood was in the toilet, there was no mystery as to why I had collapsed. My husband decided to skip waiting for the OB to call back and called 911 instead. He then called my mom to come over so she could watch the baby when the ambulance came. I remember feeling like my limbs were full of sand, and I kept yawning. My husband thinks I may have passed out briefly a few times.

A police officer came, followed by the paramedics. The paramedics told me I was hyperventilating, and their calm helped me to calm down. They told me to breathe deeply, and the sand-filled feeling subsided. They asked me a few questions, joked with me about how they were missing the hockey game, and loaded me on a stretcher and carried me to the ambulance, where I was whisked away to the same hospital where I had given birth (also the closest hospital). My husband followed in the car.

I was coherent enough in the ambulance to be impressed by how easily the paramedic got an IV started in a moving vehicle, considering the trouble many a nurse had had trying to do it while I was lying still on a hospital bed.

Once in the ER, I was examined first by an ER doctor wearing black scrubs and tended by some excellent nurses. They drew blood and determined my hemoglobin was back down to 8.8, low enough for concern. My OB had called back to my home after we had left for the hospital, and my mom told him we were already in the ER, so he came down to see me, an OB resident in tow. They each performed a pelvic as well and couldn't figure out where the bleeding had come from. Since lying down on my bathroom floor, the flow of blood had stopped - that was probably the smartest thing I could have done, though I didn't know it at the time - because I imagine it put the weight of my other internal organs on the source of the blood and caused it to clot. That's my guess, anyway.

My OB decided to order a CT scan and a unit of blood. They wanted to see what was going on, and they also felt I might need a(nother) transfusion.

The CT scan was a new experience for me and was fairly unrevealing. They saw I had a large clot (about the size of a Cutie orange, or clementine) in my uterus that hadn't been there before, but they couldn't tell where it had come from. They admitted me to the hospital and eventually found me a room.

They had me stay in bed all the next day. They did an ultrasound, which was marginally more helpful than the CT in its image of the clot. Another of my OB's came to examine me and also didn't know what might have happened. Her (and her colleagues') best guess was that my stitches had dissolved before I was completely healed, and a weak spot in the tissues had opened up. She said they hadn't had to readmit a patient to the hospital for postpartum bleeding in years.

My breasts started to feel a bit engorged, and the nurse offered to bring me down a breast pump. I pumped once but spilled the milk on my sheets, then figured it didn't really matter. I had created an association between nursing and this emergency, my mind figuring that since nursing causes uterine contractions, perhaps my breastfeeding attempt earlier on Monday had caused a contraction that led to the bleeding. Who knows.

I stayed in the hospital until Thursday afternoon. They did another ultrasound Thursday morning, and there had been no change in the clot. Since the bleeding didn't restart, they felt it was safe to send me home, as long as I restricted my activity. They also sent a home health nurse to check on my Friday. Everything was fine.

I stopped pumping, stopped breastfeeding, went exclusively to formula. Only about four weeks later, I started feeling very depressed about that decision and tried to relactate, with advice from the La Leche League leader whose help I had previously rejected. My attempt was unsuccessful, although I do have a few cherished photos of me with the baby latched to my breast as I sat on the couch. At least I know I tried, although I also knew that I couldn't pump and nurse 'round the clock, as I would have needed to in order to bring in any kind of useful milk supply after never having established a full supply to begin with and having stopped completely for a month.

I still, over four years later, regret that my older son didn't get as much benefit from breastfeeding as he was entitled to. I no longer blame myself, however, which I did for a long time. For a long time (years), I berated myself for my lack of dedication, my resistance to help offered, and for not educating myself better before the birth. Now, instead, I don't really blame anyone. But I am angry that the "system" failed me, that I was told from numerous sources that formula was just fine and not to feel bad if I didn't breastfeed, and that the lactation consultants and the pediatrician, on whose advice I relied heavily, led me down the wrong path.

I also still have anger that my older son's birth didn't go the way I feel it should have, which led to the scariest moments of my life, lying there on my bathroom floor. But, now I am channeling that anger into something productive - educating other women and offering support so that they can have a better chance at getting the birth and breastfeeding experience that they want. Hence this blog.

It's not all bad news, though. I look forward to my next post, in which I will tell the story of my second son's birth. I think you'll be as amazed at the contrast as I still am.

My First Birth - Part III - The First Weeks Home

I won't go into excruciating detail about the next three weeks of my son's life. Rather, I'll give some highlights. Basically, we came home with this newborn who was still jaundiced and needed to continue to be on the bililight. We were given a Wallaby, which is a portable bililight that you wrap around the baby. This makes it hard to hold him, hard to swaddle him, and hard for him to get comfortable. Thankfully, it was only needed for one very long day before his bilirubin levels came down into an acceptable range. He slept in the Pack 'n' Play bassinet in the living room. I slept in the bedroom. My husband slept on the floor beside the bassinet and got up to give him his night feedings.

To be honest, I barely remember those first few days home. I was in pain, pale, weak, and confused. I tried to pump, but the baby was getting mostly formula. I couldn't even really take care of him by myself, although over the next couple of weeks, I started to do things like laundry, wash bottles, make bottles, hold him, feed him, change his diapers... all the things you do when you're caring for a baby. I began to heal, and life got a little easier. My husband still took care of most of the night wakings. I remember one night when he was changing a diaper and the baby decided to continue to poo during the diaper change. I heard a "Ugh! Oh my God!" and went into the bathroom to find baby-poo had squirted clear across the room. Welcome to newborn baby care!

The first major event after coming home was the baby's bris (circumcision ceremony) when he was eight days old. I don't remember much about the day itself, but one conversation in particular comes to mind. A friend of mine, who was in the natural-birth and breastfeeding camp and had two kids of her own, actually offered to nurse the baby for me while I watched so I could see how it should look. I found this strange, somewhat creepy, and a little bit intrusive at the time, although now I appreciate what she was trying to do. She was trying to help. She wanted to see me succeed at breastfeeding, and she didn't know exactly what was going wrong, but she wanted to do what she could. And she could nurse. I declined, said that I knew his latch was good but that I didn't have much milk. She offered to put me in touch with a local La Leche League leader who had helped her out. I declined this offer as well. Frankly, I don't know why I was so resistant to offers of help. I think my attitude was, "They told me what to do in the hospital, and now I'm just trying to follow directions. I've got this." Which, obviously, I didn't. And, as it turns out, what "they" told me in the hospital was not the be-all and end-all of breastfeeding advice, and I still sometimes beat myself up over not letting go of my own ego and asking for help.

I did ask his pediatrician for advice. She said that sometimes women who don't have enough milk will breastfeed and then "top off" with a couple of ounces of formula. She suggested that maybe I could do the opposite - give him most of a feeding from a bottle, then "top him off" with a breastfeeding. That way, he wouldn't be frantically hungry while breastfeeding, so he might be more willing to latch and suck. I don't have to say that this is really not very good advice, do I?

Finally, when the baby was three weeks old, I made an impassioned post to my LiveJournal called "Thoughts on Feeding My Son," in which I lamented that the baby was only getting about three ounces a day of breastmilk, and did that little amount even matter? I asked, plaintively, if I should just try putting him to the breast next time he was hungry and see how he did. I asked for advice, finally, but I didn't want "biased" advice. I wanted "objective" advice, whatever I meant by that. I think I was very disillusioned by the "help" I had gotten in the hospital from the lactation consultants there, and I was hoping someone would just go ahead and tell me what to do. In fact, I think I'll copy here some noteworthy quotes from that post, so you can get a sense of what was going through my mind.

"I didn't have the dedication in those first couple of weeks to pump and nurse often enough and for long enough to boost my milk supply once I recovered from the blood transfusion, so now when I do pump and I only get 2 or 3 ounces from both breasts combined, it's very discouraging. Not to mention that I'm only pumping 3 times a day on a good day, and not actually nursing at all. It's no wonder I have such a low supply." 

This quote is interesting. I was convinced I had a "low supply" because I "only g[o]t 2 or 3 ounces" at each pumping session. I didn't know two very important things, and I only wish someone had told me. The first is that pumping is not an indicator of supply. In other words, I might have only been pumping three ounces, but he might have gotten a lot more if he actually nursed. Secondly, some women just don't respond well to the pump, and though they may have plenty of milk, they only pump an ounce in 15 minutes.

I was convinced I had a "low supply," by the way, because the lactation consultants in the hospital told me I would. I'm pretty convinced now, 4+ years later, that I actually had plenty of milk. Especially after nursing my very healthy second son and pumping extra besides, but only when I felt like it. (When I felt like pumping that is, not nursing. I nursed, um, a lot. But we'll get to that story in another post.)

Another quote:

"When he gets hungry again in a few minutes, should I simply put him to my breast and see what happens?"

As a matter of fact, I did decide to do this, he did latch and suck, and I felt like it actually went pretty well. In the next post, I'll get into why that was the last time we breastfed.

"I want a totally practically-minded opinion, and I feel like an LC would push me to try breastfeeding, when I find it so discouraging. It's the lactation consultants who first told me to pump 8 times a day, and I didn't manage to do that and it just made me feel bad."

I'm not sure if I wanted someone to tell me it was "okay" to formula feed, or if I wanted someone to tell me that breastfeeding would get better and easier if I just did it, or what. I'm not sure what I meant by a "totally practically-minded opinion." But the second sentence says it all. I somehow thought that all LCs would be as unhelpful as those in the hospital. I somehow thought that I didn't want someone to "push me" to try breastfeeding. Maybe I didn't at the time.

And, finally:

"Breastfeeding is the one thing only I can do for my son, and I'm not even sure I want to do it. I know I'm not alone. I know there are other mothers out there who tried to breastfeed and just didn't want to. But I never thought I'd be one of them. I never thought I'd find it so difficult or, frankly, unpleasant."

I want to go back to Jessica of November 2006 and pat her on the back and tell her it will be okay. I want to go back to her and say, "Yes! You're the only one who can breastfeed your son. So go for it! You'll do it! And you'll grow to love it." But, unfortunately, that isn't possible. So instead, I hope that other new mothers and mothers-to-be will see these words here and see a reflection of how she's feeling and know that "Yes! It will get easier!" and "Yes! You can do this!" and "Yes! It's so worth it."

The most important message I want to send, though, to those new mothers and mothers-to-be is ask for help. Don't be afraid of the advice you'll get. Ask for help. (But ask the right people!)


I put a teaser up there for the next post, in which I will describe what happened not three hours after my last breastfeeding attempt, and the definitive reason I ended up not breastfeeding. The drama continues...

My First Birth - Part II - Four Days in the Hospital

Picking up where I left off in my previous post, I had just had what at the time seemed to be the relief of a c-section, which ended a 29-hour labor and produced a large, healthy baby boy. I had made clear my intention to breastfeed, and they said my son would be brought to me, and that they would send along a lactation consultant to help, once I was settled into my room on the maternity ward. I was wheeled back to the L&D room for recovery, where I had apparently been given morphine on my husband’s consent, and where we met back up with my mom. I was very groggy and exhausted, very weak, and really had no idea what was going on. I do remember telling my mom our son’s name.

Over an hour after the delivery, I was taken up to the maternity ward and into my room. A nursery nurse came to report that sometimes large babies have problems with maintaining their blood sugars, and if our son did, would it be okay to give him some formula? My husband and I had no idea, so we said, sure, if that’s what he needs, go ahead. Then she asked what kind. We also had no idea. We hadn’t “researched” formula (any more than we had researched breastfeeding, to be honest), so we just asked what they recommended, and they said many mothers liked Enfamil with Lipil. We said okay to that.

The baby had been taken to the nursery, where he was cleaned and given all the initial pokes and prodding. It turned out his blood sugar was fine, so they brought him to me to attempt breastfeeding. He was lethargic (as was I!), and it was difficult to get him to wake up to want to feed. The lactation consultant taught us about stripping him down to his diaper and tickling his feet to try to get him to awaken, and he did latch and begin to suck. He had a very good latch and a very strong suck reflex, and she said he should have no trouble nursing. I was tired and weak and in pain and having trouble so much as holding my 9-pounder, and we didn’t nurse for very long before they took him again.

I, however, was not doing as well as the baby. I was white as a sheet. It turned out I had lost a LOT of blood in the delivery. Not long after my abortive attempt at nursing, I began feeling sweaty and hot and very strange. Alarms started going off, and nurses rushed in, and they told me I was tachycardic (my heart rate had shot up to 160) and was going into shock. I had lost so much blood that my hemoglobin had dropped to 6.8. The normal range is 12 to 15, and I had been slightly anemic while in labor, with a hemoglobin count around 11.

They sent a crisis nurse to sit with me and help me calm down and took some readings with some kind of heart monitor (EKG machine, I guess?), which they only sort of knew how to hook me up to. In spite of the trauma of the whole matter, I was almost amused at how they couldn't get the leads to stick to my sweaty skin, and they weren’t exactly sure where they were supposed to go. It wasn’t exactly encouraging, but I guess they got the readings they needed.

It was determined I needed a blood transfusion to restore my blood count, and I was quickly typed (for the umpteenth time) and cross-checked and two units of blood were brought up from the blood bank and hooked into my IV. My veins were so sunken that they had to call in a special IV team even to get the IV started, and even she had trouble finding a vein! But eventually, I was recovering with someone else’s generously donated blood dripping slowly into my body.

I didn’t see my son much that day. He could really only be in the room if someone else was there with me, as I couldn't even get out of bed to tend to him. I was told that I probably wouldn't be able to start making milk until my blood supply was restored.

They told my husband to go home and sleep at night and kept the baby in the nursery, feeding him formula from a bottle when he needed it. They told us if we wanted, we could provide our Avent bottles for him to use, instead of the disposable rubber nipples they had in the hospital, in the hope of preserving his latch. So my husband brought some. I have no idea if it made a difference.

They had me stay in bed all of Monday as well. My husband stayed with me most of the day. He fed the baby, was taught how to change his diaper and swaddle him, and held him. I watched. I remember just being so tired and having absolutely no connection to this baby I had worked so hard to deliver. I did get to try nursing again, this time with a different lactation consultant who man-handled my breasts and tried to teach me two different ways to hold him. I felt clumsy, weak, and bullied. I was discouraged that he was so big and heavy and I was so weak and drained. Somehow, I thought it would be easier, or make more sense, or that I should instinctively know how to do this. Watching someone else open a bottle of ready-to-use formula and feed it to him was much easier than this craziness.

Monday night, I woke up crying in the middle of the night. The nurse on duty insisted it was because I was in pain, said I should tell them right away if I was in pain so they could give me more Dilaudid. I said that wasn’t it, and that I didn’t know why I was crying. No one had told me about the “baby blues,” the ebb and flow as pregnancy hormones suddenly stop and other hormones take their place. It wasn’t helped by my sheer exhaustion, pain, and trauma of the surgery.

Tuesday, I was finally starting to recover a bit. They let me get out of bed and take a shower, which was both scary and wonderful. They wheeled me to the “mandatory baby bath demonstration,” where a nurse, who was also one of the lactation consultants, bathed one of the other new babies to show us how to do it. (I still wonder that they had this mandatory baby bath demonstration where they went into excruciating detail on how to give your baby a sponge bath, which is hardly the most complicated baby-care task, yet there was almost no instruction whatsoever on breastfeeding!)

The lactation consultant came back up to my room with us and brought along a hospital-grade breast pump so she could show me how to pump. She told me I’d need to pump eight times a day – every two to three hours – to bring up my milk supply. I could save my colostrum and they would give it to the baby at his feedings so he could benefit from whatever I managed to extract. The idea of hooking myself up to this machine eight times a day seemed ridiculous. I had visitors, and nurses in and out, and most of the time had no idea what time it was. I think I pumped maybe three times that day, and nursed the baby once. This made no sense at all, but I took her word for it.

Tuesday night, I woke up in the middle of the night with my left hand extremely swollen. I had been on a saline IV to keep my hydrated, and apparently after 48 hours or so on an IV, the vein can just collapse, so saline was dripping into my hand. It wasn’t a big deal, health-wise, but it was scary and a little painful. They moved the IV site and gave me a warm compress to help bring down the swelling. They said the saline would just drain out. Still, I already looked like I had been hit by a bus, and now my left hand was swollen to twice its usual size.

Wednesday I was able to pump eight times, as instructed. I still didn’t have any milk, and I had no idea that this was perfectly normal after a first baby and c-section. It was discouraging, however, and exhausting, and I didn’t want to do it. Plus, washing all those pump parts so often? What a pain! I did try breastfeeding again, and still felt like a moron who couldn't manage this simple task of holding my baby to my breast and letting him suck. How complicated could this be?

The baby also started to show signs of jaundice, and he had to be on a bililight any time he wasn’t being fed or changed. This was… inconvenient, at best.

Thursday morning, my OB came to check on me and told me that I could go home that day if I felt ready. She said if I was still too weak, she could probably get me another day in the hospital, saying I wasn’t sufficiently ambulatory because of my anemia. But another of my OBs came later that morning and strongly suggested we go home. The nurses concurred. They said we weren’t doing ourselves any favors staying in the hospital longer.

I was told it would probably be a good idea to rent a hospital-grade pump, so I could continue pumping eight times day at home. I had purchased an Avent Isis double breast pump ($300) before the baby was born, assuming I’d need to pump when I went back to work, but they said it wouldn't be able to handle the amount of pumping I’d need to do in the early weeks to bring up my supply. I took their word for it. They had given me the name of a woman I could rent a breast pump from, and she came to bring me the pump, wheeling her sixth child in a stroller. She also sold me a hands-free pumping bra and some milk collection bags.

Then, Thursday afternoon around 2:30, we packed up, changed the baby into a “going home” outfit, put him in his car seat, and went home.

And if you think that’s the end of this saga, well, wait until Part III!