A guest post from a practicing cardiologist:
Before getting pregnant, I had never set foot in our L&D ward. My only interaction with OB’s was when they needed ICU beds for their sickest patients (severe preeclampsia, catastrophic bleeding, amniotic fluid embolism, you catch my drift). From treating these patients, I have no illusions whatsoever about the potentially lethal consequences of childbearing. I had never spoken to the midwives at all.
My first glimpse of the ‘natural childbirth culture’ came from a nocturnal cardiology consult. I was called by a young OB resident for a postpartum patient with shortness of breath and low oxygen saturation. I requested a chest CT with intravenous contrast, suspecting pulmonary embolism. I was baffled when the resident refused to do this. When asked to explain, she said the patient should not be given intravenous contrast under any circumstances. This wasn’t for a severe allergy. It was because the patient’s breastfeeding would be disturbed by the IV contrast. Just to be clear, at this point the patient’s opinion in the matter had not yet been asked. And even if it had, I’m very doubtful that the decision-making capacity of a severely hypoxic patient would hold up in court if things didn’t end well.
I was, again, baffled for a few seconds. I had never before heard of a patient’s treatment being determined by any other motive than that patient’s best interest. I replied that this was a critically ill patient being denied the care she obviously needed, and that the resident would have a very hard time getting a dead woman to breastfeed her baby. This dose of reality did the trick, and the patient got the chest CT, heparin drip and ICU admission she needed. I must say I don’t really know how things ended with her breastfeeding, but she left the hospital alive.
Fast forward to my own pregnancy. I’d had a first trimester miscarriage before. When I went in for my 12 week ultrasound, I was pretty nervous about seeing that heartbeat. When the midwife-US tech called us in, I was very anxious to get on that table and see what was going on. First, however, she insisted on giving me an educational lecture about…. breastfeeding. That’s right, before establishing the presence of a live fetus! I politely sat through it, but I still don’t know what I’d have said if it had turned out to be another miscarriage!
My pregnancy was uneventful except for the breech position. My OB is very skilled and experienced in external version, but for various technical reasons I wasn’t a candidate. So an elective CS at 39 weeks was agreed upon. However, just like in critical care, there is no planning in obstetrics.
At 36 weeks, I came to work feeling well, and started my rounds. After the second patient, I had to sit down. I had a headache, a stomachache and was seeing flickering stars. Also, incidentally, I had gained ten pounds in the past 2 weeks. People all around were commenting on how swollen I looked. I myself was firmly in denial of the glaringly obvious diagnosis, and tried to sneak home muttering something about a stomach bug. A collegue with more common sense simply grabbed my sleeve and dragged me to L&D. My OB lost no time in diagnosing pre-ecclampsia and admitting me. Overnight I deteriorated and the next morning I had my c-section. Which was the start of an extreme culture shock…
I had been planning to breastfeed my baby, to the extent that I hadn’t even listed for any bottles or feeding accessories. As the baby was 3 weeks early and I literally hadn’t had a single day of maternity leave before I delivered, I hadn’t read up on breastfeeding practicalities yet. However, the baby-friendly hospital protocol sprung into action, and my little girl was put to my breast before I had been wheeled out of the OR. As I lifted my hospital gown to latch her on, the midwive tsk’ed: “you have extremely flat nipples”.
Never before had my nipples been called deficient in any way, but as soon as my baby tried to latch, I saw the problem. She was slightly premature with a small mouth and a weak suck, and there just wasn’t enough for her to grab. Moreover, for all her enthousiastic attempts, absolutely nothing came out of said nipple.
The following 72 hours we continued in that way, being encouraged and aided by a variety of midwives and lactation consultants. I’ve had at least 10 different perfect strangers manhandling my lady parts. All commented on my apparently severely deficient nipples, as if there was something I could do about them. Silicone prosthetics were called in, but that didn’t get us any milk. For our efforts, I got cracked and blistering nipples and extreme sleep deprivation, and baby got absolutely nothing. She made her displeasure known at ever increasing volumes, until she got so exhausted she stopped trying and slept continuously. I was in the middle of my ‘baby blues’ period and literally hadn’t slept since the c-section as I was told to latch and pump every 3 hours day and night to get my milk in. I cried continuously, and looking back I believe I have never felt so desperate and miserable in my life. I felt like a total failure. I’m an alpha type personality, one of my core beliefs being that hard work can achieve almost anything. Breastfeeding, however, doesn’t work that way.
The pediatrician saw baby’s weight loss and stepped in: she needed formula. Another defeat, and even less sleep as my 8 shifts a day now consisted of a/ latching baby on, b/ giving her bottle and c/pumping (which yielded next to nothing). As befits a baby friendly hospital, mom and baby couldn’t be separated under any circumstances ever, so the midwives stepping in for any of the night feeds was out of the question. There I was, 4 days post laparotomy, not allowed any pain medication to speak of for my grotesquely swollen and extremely painful breasts, and unable to get any REM sleep for over 96 hours. Miserable doesn’t begin to describe it.
In the ICU literature there is a massive load of evidence that sleep deprivation produces undesirable outcomes. Sleep deprived patients have more deliria, worse wound healing, more infections and about any other complication you’d care to name. ICU staff try their very best to get patients to sleep at night. Apparently, none of this is valid or applicable to obstetrics. When I begged the midwives to help me get at least some sleep, they flatly refused. I had to keep on trying breastfeeding, under no circumstances would they consider taking the baby for part of the night or letting me skip the fruitless pumping. Didn’t I want what was best for my baby? And, driven by guilt, I soldiered on.
My husband and family got very worried: I looked terrible. When I look at pictures from those days, I barely recognise that pale, distraught woman with the dark circles under her eyes. My husband begged me to stop the breastfeeding attempts, but I would not take it from him. I was determined to be a good mother. When my husband tried to share his worries with the midwives, they reacted very passive-aggressively: they were not making me do anything, the decision to breastfeed was entirely mine, they only pointed out the best interests of our child. It sounded as if I was considering taking up smoking.
In the end, rescue came from a friend of mine who is a private CNM. She came to visit me in the hospital, saw what was going on and told me to just stop it. Running myself into the ground would not help my baby, she said. It was time for me to start to heal. Coming from her, I could accept this as the truth. I told the hospital midwives that I would stop my attempts at breastfeeding, as my baby was almost entirely formula-fed anyway.
The midwife didn’t say anything, she just removed the pump and all accessories from my room without comment or explanation. 6 hours later, I thought my breasts would explode. I was in terrible pain. No-one had said anything about the need to gradually diminish pumping in order to avoid mastitis. It was as if they had simply dropped me as a patient. I called my CNM friend for advice, and she advised me to ask for the pump back so I could gradually decrease my pumping frequency. The pump was put back grudgingly, without comment or advice. I pumped 2 more times and then went home with a rented pump and the help of my CNM friend.
I handed the baby to my husband, took a good painkiller and slept for 24 hours while he took care of her. I was a different person afterwards.
Looking back, I don’t feel guilty anymore. Just angry. What were they thinking, treating me like that? Did they really believe that by keeping me awake, in physical pain and psychological distress endlessly, somehow the breastfeeding would magically work out? Or were they dumbly following a cookie-cutter protocol, waiting for me to buckle and give up so the responsibility would be mine and not theirs?
And what objective was really being served throughout my hospital stay? It certainly wasn’t my or my baby’s best interest! Shouldn’t ‘first do no harm’ be the first rule of any patient-provider relationship? I feel like they did us a lot of harm. At the very least, they turned the first week with my baby into a purposeless bootcamp. I went through internship, residency and 2 fellowships without ever getting as miserably sleep deprived as I was in that maternity ward. And none of it brought me or my baby any advantage.
It seems like “baby friendly hospital” is really code for “breastfeeding before patients’ interests hospital”.
How did this crooked situation come into being? Whose interests are served by all this? I really don’t know. You tell me!
Will I ever try to breastfeed my next child? Right now I don’t think so. My daughter is a happy, thriving baby and her father and I are equal partners in her care. I don’t see any reason to put myself through all that misery again. My nipples haven’t gotten any less flat, so a repeat of this scenario is very likely. Now that I’m a rational human being again, I don’t see any reason to feel guilty anymore. I’m just happy with what I’ve got, bottles and all.