Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

The Good, The Bad, and The Icky on Vomiting in Labor October 19, 2009

vomiting logo

 

Submitted on 2009/10/18 at 9:43pm

Comment left at: Top Ten Things Women Say/Do During Labor (And trust me… they are totally normal!)

 

 

Dear NursingBirth,

 

Hello, I know this is an old post, but I’ve been searching information on vomiting during labour for a few hours (lol!) and can’t quite find what I’m looking for.  So with the housework waiting I thought I should just come out with it and ask!  Your post is very informative and you seem lovely so I hope you are able to help me! (Or others who have been through it!)

 

I have emetophobia (fear of vomiting), and find I am able to calm myself about the potential of vomiting (because I have had to face that fact that I can’t just escape it!), if  I

 

#1: Know that “everything will be ok” if I do vomit. (i.e. Mainly that people won’t be disgusted, or freaked out and that someone will be able to deal with, well, the result, if I’m not able to.  Even though I’ve never vomited anywhere except in a toilet, it’s just the potential that terrifies me!  My husband is a wonder, and it’s only actually since being with him that I’ve begun to get over the phobia because he’s not scared about it, and not fazed by it).

 

And

 

#2: Remember that I can handle vomiting much better if it isn’t preceded by hours and hours of painful nausea.

 

 

SO, I find myself trying to prepare mentally for the possibility of throwing up during labour, and I have some questions stemming from this for you (I know it is an irrational fear, and these questions seem trivial but they are things that really stress me out – I actually lose sleep over them – so I appreciate your answers):

 

#1 Will the midwives be ok if I throw up all over the place? Will the staff get disgusted or freaked out?

 

#2 Will the staff clean it up or will I or my husband have to?

 

#3 What happens if it gets in my hair?

 

#4 Will I choke because I might be lying down?

 

#5 Will everything be okay if I do vomit?

 

And, finally

 

#6 Is it a different kind of vomiting – one that just kind of happens, rather than following hours of terrible nausea?

 

 

Anyway, I don’t mean to waste your time, and many thanks in anticipation of any answers – I’m just trying to mentally calm myself so I can focus more on the really important things about labour – like my baby!!

 

Sincerely,

 

NervousMumToBe

 

 

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Dear NervousMumToBe,

 

 

First of all I am sending you one MAJOR cyber *HUG* right now complete with back patting and me saying “You can do this!!”  🙂

 

 

Second, you are NOT wasting my time so don’t mention it!!  I have written before about worrying, that is that “WORRY is the WORK of pregnancy!”  In her book Birthing From Within, certified nurse midwife Pam England tells the story about a patient of hers (Hannah) that worried a lot about having a natural birth experience after having had a highly medicalized birth with her first baby.  She writes that Hannah longed to hear her say things like “Don’t worry” and “Everything will be alright” but instead England encouraged her to face her fears.  She instructed Hannah to write down all of her worries and explore each of them with questions like “What, if anything, can you do to prepare for what you are worrying about?” and “If there is nothing you can do to prevent it, how would you like to handle the situation?” 

 

 

 England lists the “Ten Common Worries” of Labor as:

 

1)      Not being able to stand the pain

 2)      Not being able to relax

 3)      Feeling rushed, or fear of taking too long

 4)      My pelvis not big enough

 5)      My cervix won’t open

 6)      Lack of privacy

 7)      Being judged for making noise

 8.)      Being separated from the baby

 9)      Having to fight for my wishes to be respected

10)  Having intervention and not knowing if it is necessary or what else to do

I would like to add #11:

           11) Fear of pooping in labor/Fear of embarrassment regarding bodily functions

 

 As you know I am a labor and delivery nurse and have estimated that I have been present at over 300 births during my career and still, I would have to say that when it is my time to give birth, #1 through #6 are top on my list of worries!!  And I witness the amazing power of women everyday!!  So NervousMumToBe, don’t *worry* about “worrying” about vomiting!  I am so happy that you are FACING YOUR FEARS!!  If vomiting is something that you are really concerned about, no matter how trivial it might seem to others, it is important to you and that is all that matters!  So I applaud you! 

  

Okay now that the most important thing is out of the way (i.e. the hug) lets get down and dirty about the #2 thing on every pregnant woman’s mind…VOMITING IN LABOR!!  (If you are wondering what the #1 thing on every pregnant woman’s mind is it is POOP.  Don’t believe me?  Check it out here.)  I want to preface the following post with a few things in the interest of full disclosure:

 

  • I am drawing from both my experience as a labor and delivery nurse (as well as a medical/surgical nurse and nurse’s aide) and the research I have read on this subject to write this post as I do not have any personal experience with going through labor myself.  That being said…

 

  •  I have thrown up a time or two myself (I did go to college after all 🙂 ) and know how it feels to do so.

 

  • Some readers might have personal experiences that are different than what I describe.  However it is important to remember that if I make a statement like “In general I have found most women in labor to do x, y, or z” I do not mean to say that there isn’t anyone out there that had a different experience.  There are exceptions to every rule. 

 

  • Although I have only been working as either a nurse or nurse’s aide for approximately 5 years (which I understand does not make me the most experienced nurse out there) I have certainly been working directly with patients for long enough to know a thing or two about bodily functions, including when they are likely to happen, how to make someone feel better, and how to clean them up.

  

  • I cannot speak for every labor and delivery nurse and midwife out there.  After all, I have only worked in one labor and delivery ward (not counting nursing school clinical).  But since you asked me I will answer your questions as if I was your nurse or midwife.  I will also take into consideration what the other nurses and midwives I work with on a daily basis would do and how they too would react to the situations you present.   

 

 

Now to some answers!!  I will take your questions one at a time:

 

 

#1 Will the midwives be ok if I throw up all over the place? Will the staff get disgusted or freaked out?

Yes and No!!  YES!  The midwives and the labor and delivery nurses will be okay if you throw up all over the place and actually, they probably will not even bat an eye if you throw up!  And NO!  The staff will not get disgusted or freaked out if you throw up!  If bodily functions bothered us, we wouldn’t be working in healthcare!  I have been thrown up on before…more times than the average person for sure!  I have been splashed with blood, amniotic fluid, pee, spit, and mucus.  I have also cleaned up my fair share of explosive diarrhea.  And if I do get splashed with something I just kept on doing what I was doing until I have a break where I can go change.  (Remember L&D nurses usually have to wear hospital scrubs just in case they end up in the operating room.  The other bonus to this set up is that if you get splashed with something gross then you just go in the locker room and change into a new pair of hospital scrubs!)  I am sure over the course of time there has been some burnt out nurse that has said something really nasty or insensitive to a mother if she has thrown up but in reality, it’s all part of the job and the vast majority of nurses and midwives don’t get bothered by vomit!

 

 

#2 Will the staff clean it up or will I or my husband have to?

This question is assuming two thing:  #1 That you are going to vomit (remember not all women vomit in labor) and #2 That if you do vomit that you will make a mess (remember not all women who vomit miss the bucket or don’t have a chance to throw up in a bucket).  That being said…

 

I know I can’t speak for every single nurse out there but I would NEVER EVER expect a husband (or any coach for that matter, including the mother herself) to clean up something like that.  After all it is the husband’s (or partner, coach) role to support the mother and if the mother did throw up, say, on the floor, I would ask the husband (partner, coach) to stay with the mother while I went to grab some towels to clean it up.  And then I would clean it up quickly.  And then it would be a non issue!  Done! 

 

One time I had a mother who was taken off guard by her need to vomit and accidentally threw up all over her bed.  She was very apologetic but apologies were not necessary.  I knew that she didn’t mean it!  With the help of her husband I walked her into the bathroom and had her sit down on the toilet to pee.  Her husband stayed in the bathroom with her.  Within 5 minutes I had the completely remade the bed with clean sheets.  Then I helped her into a fresh, new, warm gown and then back to bed.  It was like it never happened!  We all moved on and no one mentioned it again.  After all, who was thinking about a little vomit when there was a BABY about to be born! 

 

I learned from that experience and ever since then I always make sure that I give every mom a bath bucket when she is admitted and I put it right on her bedside table so that if she needs to throw up, it is right there for her.  Because I do this, I have rarely ever had a mother throw up in labor and not use the bucket.  Since you have a concern about vomiting, I would recommend that you ask your nurse for a bucket when you get to the hospital, just in case.  And when I say bucket I mean bath bucket (or wash basin), not those ridiculous kidney shaped “emesis basins” that wouldn’t even be helpful to catch ladybug vomit!

 

emesis basin and wash basin

 

Remember, although it is not rare for a mother to throw up in labor, it is rare that she throws up all over the place, or has no idea that it is coming.  In my experience the vast majority of moms who vomit in labor do indeed make it into the bucket and therefore, there is nothing to clean up!  Also remember that labor vomit is different that “stomach flu” vomit.  That is, there is no risk to me as the nurse of getting sick from a laboring woman’s vomit because it is not caused by illness.  I’d rather clean up your labor vomit over my own stomach flu vomit any day!

 

 

#3 What happens if it gets in my hair?

If you were my patient and you started to vomit I would hold your hair back.  And I am sure that your husband would do the same for you too.  That way you wouldn’t get any vomit in your hair at all.  Have you considered putting your hair into a pony tail or clip while you are in labor?  If your hair was up it would be very unlikely that it would get any vomit in it.  Perhaps you can pack a few extra clips or elastics into your hospital bag just in case you need them.  If you don’t usually wear your hair back you may want to consider wearing a few hair elastics around your wrist so that they are readily available if you need them to tie your hair back if you feel nauseous.  I also have been known to cut the opening off a rubber glove and use it as a make-shift hair tie for just this type of circumstance! 

 

However if a little bit of throw up did get in your hair and if I was your nurse I would probably wet a warm washcloth and clean it out.  And then I would put your hair into a pony tail or clip for you to get it out of your face.  If it was really bad (I have never seen this but I suppose that technically it could happen) and if your midwife allowed, I would help you into the shower.  After all, many women find laboring in the shower to be extremely soothing and helpful!

 

 

#4 Will I choke because I might be lying down?

NO!  You will not choke, even if you are lying down.  Only people that are unconscious, have an impaired gag reflex, or are debilitated in some other way have a risk of choking on their own vomit.  I have never seen a conscious laboring mother choke on her own vomit…NEVER.  Why?  Because every single healthy, able-bodied, conscious person sits up or leans over automatically when they start to vomit.  I have never even seen a mother who was positioned flat on her back and numb from the breasts down for a cesarean choke on her own vomit.  Why?  Because every single healthy, able-bodied, conscious mother in that situation automatically turns their head to the side to vomit. 

 

If necessary every hospital room and operating room has (or at least should have) a suction canister in it with a yankauer suction set just in case a mother does lose consciousness and her mouth needs to be suctioned.  You might not have seen it when you toured your hospital because most birthing suites keep that kind of equipment behind pictures or in cabinets so that the room doesn’t look too “hospital like.”  But they are there.  I personally have only had to use the yankauer suction set ONE TIME as a labor and delivery nurse and I used it because my patient had an eclamptic seizure (a rare complication of preeclampsia) and when she came too she was really out of it (“post-ictal”) and her mouth needed to be suctioned because it was full of secretions.  That’s it, one time only.   

 

 

#5 Will everything be okay if I do vomit?

YES!  In fact, labor and delivery nurses get excited when they see a patient vomit because vomiting is usually a sign of transition which is the last stage of active labor (usually 7-10 centimeters) right before a women begins the pushing phase.  Remember whether or not she has been eating throughout early labor, a woman may still vomit when she enters transition so it is not necessary to starve yourself on purpose because you are afraid to vomit later on.  In fact, some women vomit because they have done just that!  (I know I personally get very nauseous as well as get a headache if I haven’t eaten anything all day).  I always think of it as a way the body is “making more room” for the baby! 

 

Also since vomiting, like holding your breath or making a bowel movement, is a vagal response, it inadvertently helps your cervix dilate and hence, is a great sign to a labor & delivery nurse!  The body does awesome things to help the process along!  So really it is not just okay if you vomit, it is GREAT if you vomit because it may help you cervix dilate!  I also want you to know that you will not hurt anything if you vomit, including the baby or your cervix.

 

 

 

#6 Is it a different kind of vomiting – one that just kind of happens, rather than following hours of terrible nausea?

 

In my experience as a labor and delivery nurse most women who have a natural, unmedicated, spontaneous labor do NOT have hours and hours of nausea before they vomit.  Instead, once there labor really starts to ramp up for the last few centimeters they get a feeling of nausea that gives everyone enough warning to grab the bucket and then they throw up.  After throwing up, the vast majority of women have told me that they feel better.  It is very rare that I have taken care of a woman who continues to throw up once they are 10 centimeters dilated and begin to push or is nauseous for hours and hours before they vomit.  That being said…

 

Nausea and vomiting are very common side effects of narcotic pain medications (e.g. stadol, nubain, demerol, morphine etc.) as well as ALL forms of anesthesia (including labor epidurals as well as spinal blocks often performed for cesarean sections).  Because of this, some physicians and midwives prescribe an anti-emetic (aka anti-nausea medication) like Phenergan, Zofran, or Reglan to be administered with the narcotic, epidural, or spinal to counter act this side-effect.  Sometimes it helps, sometimes it doesn’t.  Because you have such a fear of vomiting I want you to be aware of this fact.  

 

 

So there you have it: the skinny on vomiting in labor!  I hope this has helped calm your fears and worries however if you have any more questions about this topic please feel free to leave a comment!! 

 

Thank you for writing in to me.  You are certainly not alone in your fears!!!  I know that your question will help other women out there who experience the same fears as you!  GOOD LUCK with your upcoming birth and CONGRATULATIONS to you!!!  And remember, although birth might be one of the messiest experiences of your life, no amount of fluids, cursing, farting, pooping, striping naked, howling, crying, peeing, bleeding, or vomiting will take away from how honestly empowering, mind blowing, and touching this experience can be for you and your family!!

 

 

Sincerely,

 

NursingBirth

 

Urgent Message from ICAN! Please Spread the Word!! October 18, 2009

Filed under: In The News — NursingBirth @ 10:07 AM
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Hello Everyone!

 

Please check out an urgent message sent from Gretchen Humphries, the Advocacy Director of the International Cesarean Awareness Network (ICAN).  She needs our help to spread the word and send in stories about a most critical healthcare issue:  insurance discrimination.

 

For more information on this story please check out ICAN’s website.

 

Thank You,

 

NursingBirth

 

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From: Gretchen Humphries <advocacy@ican-online.org>
Date: Fri, 16 Oct 2009 1

Subject: Urgent request for stories

 

I have sent you this request because of your connections within the Birth
Community. I hope that you will see if there is any way you can assist ICAN
with this request.

 

We have made this request before but now the stakes are really high. Peggy
Robertson
is a woman from CO who testified yesterday before the HELP
committee (the Senate Health Education Labor and Pensions Committee) about
being denied coverage because of a previous cesarean, unless she could prove
she had been sterilized. (We managed to work in a couple of comments about
VBAC bans too! Which got some response from a couple of Senators!)
Senator Mikulski, who chaired that hearing, has asked for more stories
similar to Peggy Robertson’s. Please distribute this request as widely as
you can –

 

ICAN needs stories about discriminatory insurance practices based on a
previous cesarean. This can include but is not limited to demands for
sterilization, restrictions on how soon you can have another pregnancy and
be covered, higher premiums, restrictions on the total amount of benefits
they will pay, excessively high deductibles for maternity care. Even if all
you have is your name, state, contact information (email is fine) and a
description of the circumstances (with the name of the relevant insurance
company(ies) if possible) we can use it. If you have written documentation,
that would be pure gold.

 

There is interest about this at the highest levels of the Federal Govt. and
we will use this to open the discussion on other areas of discrimination
(like VBAC bans, lack of transparency, etc)….so please, take a moment and
get the information to ICAN. You can email me at advocacy@ican-online.org
or you can snail mail to ICAN of Ann Arbor, PO Box 48, Stockbridge, MI
49285.

 

Your story could make a difference that would improve the care available for
millions of women and their babies.

 

Thank You,

 

Gretchen Humphries
Advocacy Director, ICAN
advocacy@ican-online.org
(517) 745-7297

 

Connecticut Docs & Midwives Speak Out For Midwifery! October 16, 2009

Filed under: In The News — NursingBirth @ 9:40 AM
Tags: , , ,

Yesterday the Connecticut newspaper New Haven Register published an opinion piece entitled “Media out of focus on midwifery” by Holly Powell Kennedy, CNM, Charles J. Lockwood, MD, and Edmund Funai, MD and I have to say, I am very very pleased to read such a focused, well-reasoned, supportive article on birth choice, the safety of homebirth, and the need for hospitals around this country to step up and better meet the needs of birthing families!  And for it to be written by two obstetricians and a certified nurse midwife….its just too good to be true!!

 

Favorite quotes of mine include:

 

  • “Women are not seeking “designer” births. They are looking for humanistic care during pregnancy, labor and birth and are increasingly having difficulty finding that in many hospitals.”

 

  • “It is essential that women are provided with the opportunity to have a supported and safe birth. This means protecting them from preventable harm, and ensuring that clinicians are skilled in appropriate low intervention care and know when it is necessary to intervene.”

 

  • “While midwives and obstetricians will continue to debate the safety and appropriateness of home birth, less controversial is the fact that some women seek to give birth in alternative settings because they do not see hospitals as meeting their needs.”

 

 

Yes, Yes, and YES!

 

Thanks to Christina at the Massachusetts Friends of Midwives Blog posting about this article!  What a great start to my day!!

 

Super Comment! Unexpected Guest Post from a Mother-Friendly L&D Nurse October 14, 2009

A couple days ago I posted this:  One Woman’s Journey To Her Own HBAC Water Birth and 360 Degree Career Change

 

Like always, I woke up this morning and sat down in front of my computer with my bowl of Cheerios to check the comments left on my blog.  I was pleased to see that I had a few comments about that post.  One in particular however, actually brought me to tears.  I was especially moved by her “garden” metaphor.  (I know, I am such a sap!)

 

Alethea is from Colorado and has been working with birthing families as a labor and delivery nurse for the past 8 years.  When she comments on my blog, she often writes about how she is truly inspired and amazed by the power of birthing mothers. She became a trained BIRTHING FROM WITHIN® mentor out of her desire to help guide more women along the path of empowerment through their birth experiences.  Alethea is also a co-founder of Colorado Conscious Birthing.

 

I think I was so moved by Alethea’s comment because I feel the same way about being an L&D nurse as she does.  Witnessing the miracle of life, the power, strength, and determination of women, and the overwhelming love of family and friends as your job is pretty amazing.  And I love it.  Even when I am having the worst day imaginable, I still love it. 

 

So I just couldn’t let this comment die, hidden away for only a few stragglers to read as they come across the old blog post.  I hope you enjoy it as much as I did!  It really brightened my day!!

 

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Dear NursingBirth,

 

This post spoke to me in ways that I can not express in written word, but I will try.  I also am all four of these women you write about. 

 

1) As a woman who has yet to give birth.  The power of a woman giving birth the way nature intended (regardless of the setting) takes my breathe away every time.  This was a beautiful, inspiring, empowering montage.  I hope to some day be empowered by my own strength and beautiful birth.

 

2) As a labor and delivery nurse.  My inspirational theme song is Ben Harper’s With my own two hands:

 

 …”I can change the world, with my own two hands.  Make a better place, with my own two hands…make a kinder place….I can make peace on earth…I can reach out to you….gonna make it a brighter place, gonna make it a safer place, gonna help the human race… with my own two hands…I can hold you…I can comfort you…but you got to use, use your own two hands…” 

 

Empowering women to search inside themselves and tap into their deep well of intuitive knowledge and strength is what keeps me coming back for more despite how tired, burned out, and sick of the politics I might be.  Forgetting the hustle and bustle outside in the hallways, my job is to delicately plant the seed that they can do this, they are strong, they are capable.  Bearing witness to the strength and power that women are capable of is an honor.  I am an advocate of normal birth, an advocate of women, an advocate babies and daddies and doulas and new families.  I am a labor and delivery nurse because I love supporting women with my own two hands, occasionally being lucky enough to be the first human to hold new life in my own two hands, but especially helping to break the cycle of doubt and fear in order to inspire women to understand that they can birth with their own two hands (or on their own two hands and knees).

 

3) As a labor and delivery nurse who has yet to experience birth.  It seems to me that because Lindsey is a home birth midwife she had the distinct advantage of seeing mostly normal, natural, beautiful births to inspire her.  And yet she still had that little seed of doubt threatening to take over her mind.  Like a weed in a garden, we have to pull up those seeds of doubt so they don’t take over our beautiful gardens.  We must lovingly attend to our gardens (growing baby, growing minds) nurturing the beauty, inspiration and trust.  Sometimes we pull up a weed, but we don’t get the entire root, and it comes back, even stronger and with a vengeance.  Threatening all the beauty and strength we have worked so hard to grow.  Pregnant and birthing women need to surround themselves with people who want to help tend to the garden, and avoid people whose defeatist attitudes are apparent in their neglected gardens (minds, attitudes) full of weeds (doubt).

 

Working in the hospital we do see a lot of “failure”.  Failure to progress, arrest of decent, fetal growth restriction etc, etc, etc.  The weeds (negative thoughts) in the hospital birth culture are rampant.  It takes even more hard work and dedication for those of us immersed in it to remember that the majority of birth could be normal and natural and beautiful if we nurtured and support physiologic birth and weeded out unnecessary intervention.  I am confident in my body, in my strength and in my capabilities.  I actually feel so blessed to have been a labor and delivery nurse for so many years before I have children.  I am well educated and well informed about my choices.  I have seen powerful births, and tragic births.  And through all I have seen I have learned so much.  I truly understand how my mindset, my choices and the people I choose to surround myself with when my time comes to give birth can impact how my birth plays out.  I am not denying the potential for an outcome I would love to avoid, or the potential need for medical interventions.  But I know what I need to do and what I need to avoid to put myself in the best possible position for an outcome that will make me proud to be a woman and confident in my capability to be a awesome mom.  I will not let the nurses who believe in the “The curse of the nurse” destroy my dream of an empowering birth.  We have the power to create magic with our words, I choose to surround myself with people who want to bless me not ones who wish to put a curse on me.

 

4) As a nurse with dreams of becoming a midwife.  When one has been called to something in life, you can only ignore that calling for so long.  I too feel that pull to empower women and touch their lives in an even deeper and more meaningful way.  As an LD nurse we often meet women for the first time when they walk in the door in active labor, and after they deliver, we may never see them again.  We don’t know if they felt empowered or deeply wounded by their birth experience.  I dream of working with women throughout pregnancy, birth and postpartum to help guide them to experience birth as the wonderful, life changing right of passage that it can be.  The time is not right now.  So I will give what I can and continue to pour love into my current role in birth, but not let go of that dream that someday I will be a midwife too.

 

Thank you NursingBirth for inspiring me to write about my experiences with birth and providing the forum for sharing my love of the work that I do.

 

Sincerely,

Alethea

http://www.coloradoconsciousbirthing.com

 

One Woman’s Journey To Her Own HBAC Water Birth and 360 Degree Career Change October 12, 2009

I found this video on It’s Your Birth Right! this morning and was so incredibly moved that I had to share it with you all:

 

My Journey to a VBAC by Lindsey Meehleis
 

 

What an amazing and empowering story to watch on so many levels!  I am inspired by Lindsey’s story in many ways:

 

First, as a woman who has yet to have any children.  After watching this video I am left with feelings of awe, reverence, and respect for what we as women are capable of!  I can’t help but be excited about my own potential as someone able (I hope of course) to conceive, grow, nurture, birth, and nourish a new life!  (I am giving myself goose bumps just thinking about it!!) 

 

 

Second, as a labor and delivery nurse.  Watching this video reminds me not only of what consumers of maternity care are capable of but also of how much of a difference each one of us can make just by changing our own attitude, educating our own minds, and stacking the cards in our favor to help shape our own experiences!  (Now I’m going to be humming Michael Jackson’s Man in the Mirror for the rest of the day: “If you wanna make the world a better place, take a look at yourself, and then make a change!  Na Na Na, Na Na Na, Na Na, Na Nah!”  J)  And as a labor and delivery nurse I hope to help as much as I can help by strategically, respectfully, and appropriately planting little “seeds” of encouragement, knowledge, and know-how in the minds of the many women I am fortunate enough to meet in my personal and professional life.

 

 

Third as a labor and delivery nurse who has yet to have children!!  Lindsey wrote, “As the years pass and [my daughter] grows I soon find myself sending my baby off to kindergarten!  Fighting off the urges to have another baby over the years because of the intense fear I have of having the same birth experience again.   I know that its time and I must face my fears head on!  All of my training and experience with over 175+ births has surely had to of taught me something!  Without looking back I take a leap of faith and trust my body will work!” 

 

I hear nurses I work with all the time say “Oh I am so glad I had my children before I started working here!  I would have been a nervous wreck if I was in your position!”  My first thought it always “Umm yeah thanks, that isn’t very comforting.”  But I also know that I am so very fortunate to have worked where I work before having kids.  I think about how much I didn’t know before I started and how I very easily could have been a victim of situations like these.  However, as much as I know in my heart that I want to take that leap of faith and trust my body will work as I have seen it so many times before, even labor and delivery nurses like me have that little voice of doubt in the back of their minds.  You know the one that says “But can I really do it?”  So reading stories like Lindsey’s where even a midwife has that little voice is very reassuring to me that a certain amount of worrying and doubt is totally normal and doesn’t mean that I will fall victim to the old adage “Oh she’s a nurse?  Set up the back for a cesarean!” 

 

 

Forth, as a nurse with aspirations of becoming a midwife.  Lindsey wrote, “I knew at the deepest level of my being that I had to help women, educate women” and I have to say, when I have the privilege of being part of an incredibly empowering birth experience I can’t help but think to myself, “I have to be a midwife!  I just have too!”  Likewise, when I find myself in one hell of a mess at work (especially if a midwifery model of care and the Six Healthy Birth Practices that Support Normal Birth are not followed for any other reason besides true medical necessity) I also think to myself, “I have to be a midwife!  I just have too!” 

 

 

I hope you enjoyed this video as much as I did.  Stay tuned for next time as I have been excited to tell you all about an absolutely amazing birth I was lucky enough to be a part of where I had My First Catch

 

Why Educating Our Patients is a Professional Responsibility and NOT About Guilt October 11, 2009

Filed under: Ramblings — NursingBirth @ 12:43 AM
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Yesterday I wrote a very long response to a comment left on my blog regarding a post I wrote entitled New Study Hypothesizes Bottle-Feeding Simulates Child Loss Increasing a Mother’s Risk for PP Depression

 

I woke up this morning and read all of the comments left on that blog post.  I wanted to take this opportunity to thank everyone who wrote in with support and encouragement!   You all keep me blogging.  Although I have many issues with a couple of responses, overall they were positive and well written.  Thank you! 

 

I have read FearlessFormulaFeeder’s response on my blog and on her own.  I truly don’t think I could write anything better to respond than this article emailed to me by one of my readers:

 

<tongue in cheek> Confessions of a proud breastfeeding zealot </tongue in cheek> by Katie Allison Granju

 

I make a conscious effort every day as both a nurse, an activist, an everyday woman, and a blogger to never use guilt based techniques to support any certain “way” when it comes to choices in labor, childbirth, and breastfeeding.  That does not mean that some choices do not carry more risks than others.  Not all choices are equal in their efficacy or safety.  This is a fact.  I also know some people do use guilt, either intentionally or subconsciously, to influence their peers or patients; Even nurses, doctors and lactation specialists are sometimes at fault for this!  And it’s not just breastfeeding supporters that sometimes use guilt; both sides are guilty of using GUILT to further their cause.  However I am NOT one of those people and I feel that my past posts on controversial topics speak for themselves.  I certainly have a strong opinion but I never (until FearlessFormulaFeeder came along)  have been accused of making other mothers feel “bad” after providing sound, well researched, evidenced based information to my readers.

 

I promise you that I will continue to educate myself regularly on the newest research and practice evidenced-based nursing.  Furthermore I will continue to ask my patients appropriate questions at appropriate times in order to assess their knowledge base, background, and learning needs with the aim of providing them with age appropriate, culturally competent information and care to assure that any decision that they make is an informed one.   In fact, it is my professional responsibility to do so. 

 

As a nurse I am so much more than an executor of orders.  I am an advocate, a caregiver, a leader, a listener, a teacher.  Since I do not personally subscribe to the philosophy that women should be guilted or bullied into making certain decisions I will not take responsibility for any other person who does choose to act in that manner.  I am only responsible for my own actions.  Likewise, if providing evidenced-based information, including the risks and benefits of a particular choice in a sensitive way at some point causes a person to feel guilty about one thing or another, it will not stop me from providing that information.  This includes reporting and commenting on the latest research. 

 

In my own practice as a nurse I often ask people the question, “Do you feel that you have received enough information on the risks and benefits of ______ to make an informed decision?”  (I have to ask about things like plans for pain medication/epidural, plans for VBAC/repeat cesarean, plans for breast/bottle feeding during my admission or triage interviews).  If a patient answers “YES“, I then ask, “Do you have any questions for me or your doctor/midwife?”  If a patient answers “NO” I ask more questions to find out what they still have questions about.  I have found this line of questioning to be the most efficacious when talking to many mothers/couples since the feedback I have received is that it is a non-threatening/non-judgemental way to open the dialogue between patient and nurse.  And boy have I stumbled upon some moms that have been given some misinformation! 

 

Here’s an example of an actual conversation I had with a patient once.  This mom was a 21 year old single white female with a long-term boyfriend.  She worked as a nurse’s aide, her boyfriend as a UPS carrier.  They had family in the area but lived together in an apartment in the city.  She was pregnant with her first baby and was being admitted for an induction for post-dates:

 

Me:  “Are you planning on breast or bottle feeding?”  [**see addendum below**]

 

Mom: “Bottle.”

 

Me: Do you feel that you have received enough information on the risks and benefits of bottle feeding to make an informed decision?”  [**see comments section**]

 

Mom: Well yeah, because I have to go back to work after 6 weeks so I can’t breastfeed.

 

Me:  “Many mothers feel overwhelmed about the fact that they have to go back to work very soon after having their baby.  However, some mothers don’t realize that any length of time that they breastfeed their baby is absolutely wonderful and even breastfeeding for the 6 weeks that you are home from work can provide you and your baby with many benefits.  Especially since the first milk you make, called colostrum, is filled with so many great antibodies that help your new little one stay healthy and grow during those very important first few weeks. 

 

Mom:  “I didn’t realize that you could breastfeed for only 6 weeks!  I thought if you were going to breastfeed you had to breastfeed for like a year!”

 

Me:  Some moms start breastfeeding without a set goal of how long they are going to breastfeed and just take it one day at a time.  Some mothers will stop breastfeeding before they reach 6 weeks.  Others will breastfeed up until they have to go back to work.  And others are lucky enough to work something out before they have to go back to work so that they continue to breastfeed even after they return to work.  The great news is that no matter how long or short of a time you breastfeed for, your baby will benefit from having your milk to help him grow and stay healthy!!  If I brought you some information in about breastfeeding would you be interested in learning more about it?

 

Mom:  Yeah!  That would be great!  Thanks!!

 

I had the priviledge of being a part of this mom’s birth and was honored to assist her in getting her son to latch on for the first time.  She breastfed her son throughout her hospital stay and did leave the hospital without supplementing with any formula.  Unfortunately I do not know what happened to her once she got home.  She could have had troubles and switched to formula, she could have successfully breastfed for her six weeks, or she could still be breastfeeding her 8 month old!  (This is one bummer about being an L&D nurse with no ability to follow up on patients.)  But I do feel that she learned quite a bit from our conversation during her admission interview and from the information I provided to her that she read during her induction and I am proud that I was part of the reason she decided to give breastfeeding a try. 

 

**Addendum**  After a great comment left by Lonely Midwife on 10/11/09 I have decided to make a change in my practice.  Instead of asking “Are you planning to breast or bottle feed?” she has suggested I ask “How are you planning to feed your baby?” as it is a more open-ended question with less chance of being perceived as judgemental.  I really like that and have decided to adopt that question into my practice.  This is also much more like the question I already ask about pain management in labor since during my admission interview with patients I ask “Tell me about your plans for pain management during labor” instead of the more common question “Are you planning on having an epidural or using IV pain medication for your labor?”  Thank you to Lonely Midwife for opening my eyes to some hidden judgement in my admission interview. 

 

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My point is that the “mommy wars” are out there.  I certainly am not looking forward to them when I one day become a mother and often speak out against them.  But I personally have made a conscious decision as a nurse to not use guilt based techniques to influence or educate my patients.  I use facts and regardless of my own personal beliefs, I provide both the risks and benefits of any choice or option when counseling patients.  And because I do that I do not and will not take any responsibility for another person’s guilt even thought it is true that I feel badly that a person might feel that guilt.  After all, guilt is a cognitive or an emotional experience that occurs when a person realizes or believes – whether justified or not – that he or she has violated a moral standard, and is personally responsible for that violation. 

 

Fellow blogger Stork Stories has shared with me some very important wisdom that she has learned over her very impressive career as a labor & delivery nurse and lactation consultant fro 35 years.  I would like to share her wisdom with you all.  THIS (NOT guilt based persuasion) is MY philosophy on breastfeeding education.  I couldn’t have said it better myself and I thank Stork Stories for sharing!

 

* It is inappropriate for a health care professional to indicate to a mother directly or indirectly that formula feeding and breastfeeding are equal. Human breast milk is the superior food for human infants. Properly prepared infant formula is an acceptable substitute for those who cannot or choose not to breastfeed.

* The first approach is probably the number one factor in gaining a mother’s interest in what you have to say.

* The education process to a mother needs to be in small doses, sensitive to her unique learning abilities, her cultural beliefs and practices and most importantly, her choices and individual breastfeeding goals.

* With that in mind, try to provide her with the information she needs to make her decision.

* Never overestimate a mother’s desire to breastfeed her infant.

* Never underestimate a mother’s desire to breastfeed her infant.

* Listen to the mother; help her define her true desires and goals.

* Many times, the first question she asks may not be what she really wants to ask.

* The mother’s individual breastfeeding goals, how she defines them, how important they are to her and how she relates them to her actual breastfeeding experience all help define how she measures success.

* Support the mother, support the mother, and support the mother.

 

 

I’ve said my peace.

 

~NursingBirth

 

The conversation continues over at Stork Stories with her post:  **ROAR** on Breastfeeding Guilt 

Please check it out!!

 

Why It’s Not Irresponsible to Research the Hazards of Formula Feeding October 9, 2009

Filed under: Ramblings — NursingBirth @ 1:48 PM
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Submitted on 2009/10/05 at 11:23pm

In response to: New Study Hypothesizes Bottle-Feeding Simulates Child Loss Increasing a Mother’s Risk for PP Depression

 

 

Dear NursingBirth,

 

As so often happens with interpretation of breastfeeding studies, you are ignoring the fact that this study was observational. Yes, certain factors were controlled for; however, since it wasn’t a case where they took 100 women with postpartum depression (PPD) and forced half to breastfeed and half to formula feed, you have to look at the results with some perspective. One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD. It certainly did for me, and for many women I have interviewed for a book I am working on.

 

I am certainly not anti-breastfeeding; I think it is a wonderful thing. But there are cases where formula feeding is the best – or only – choice, and implying that formula feeding can cause PPD is just plain irresponsible, in my opinion. The LAST thing women struggling with PPD need is pressure to do anything. If they want to breastfeed, then great; however, it is often far more useful to get on antidepressant medications, which are not universally recommended for lactating women. There have been studies saying that the long-term effects on babies who’ve been exposed to antidepressants in breast milk are negligible, but as my own pediatrician said, “none have proven this without a doubt.”  If nursing is going to keep a woman from taking needed medication, then I do not think it is a healthy thing for baby or mother.

 

Just another opinion….

 

~Suzanne

fearlessformulafeeder.blogspot.com

 

 

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Dear Suzanne,

 

Thank you for commenting.  I appreciate all comments left on my blog, both assenting and dissenting, as long as they are not ad hominem attacks.  I also see that you are a new blogger and would like to welcome you to the world of blogging!  If you are anything like me, you will both love it and hate it!  I don’t know how long you have been following my blog but I invite you to take a look at one of my past blog entries entitled My Philosophy: Birth, Breastfeeding, and Advocacy.  Here is an excerpt:

 

“I believe that pregnancy, birth, and the postpartum period are milestone events in the continuum of life that profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.

 

 I believe that breastfeeding provides the optimum nourishment for newborns and infants which does NOT mean that I am not grateful for the advancements in artificial milk for those mothers and infants who truly require it.”

 

 

Now that you know a little more about me, I’d like to respond to your comment.  I will number the points for ease in reading:

 

#1  You write, “As so often happens with interpretation of breastfeeding studies, you are ignoring the fact that this study was observational.”  I fail to see how I am ignoring the fact that this study was observational.  For one, I posted a direct link to the original study in which the authors discuss the method of their study.  The authors write:

 

“We recently completed a study of over 50 mothers recruited through local pediatric offices at 4–6 weeks postpartum.  Consistent with previous reports, we found that those who [formula] fed their babies scored significantly higher on the Edinburgh Postnatal Depression Scale than those engaged in breastfeeding. The increased risk of depression among mothers who relied on [formula] feeding held true even after we controlled for such things as age, education, income, and the mother’s relationship with her current partner.”

 

No where in there do they claim that the study is a randomized controlled trial, often regarded as the gold standard for research as it is considered to obtain the highest level of evidence.  However not all research questions can ETHICALLY be answered with a randomized controlled trial.  You wrote:

 

“Yes, certain factors were controlled for; however, since it wasn’t a case where they took 100 women with postpartum depression (PPD) and forced half to breastfeed and half to formula feed, you have to look at the results with some perspective.”

 

 

The fact of the matter is Suzanne that that type of study is completely unethical in this situation and therefore completely implausible and therefore it is unfair to suggest that this is a flaw in the author’s study.  It is certainly a limitation but not a flaw.  This is a problem that is realized the by research community, that is, that you can’t always randomly assign patients/subjects/participants to a certain cohort because you, for example, cannot force someone to breastfeed or someone else to bottle feed.  Or force some to have a vaginal delivery and someone else a cesarean section.  Or force someone to have a hospital birth and someone else a home birth  Or force someone to smoke cigarettes and someone else not to smoke cigarettes.  For this reason observational studies may address these problems to some degree and might therefore be the best way to answer research questions that cannot ethically be answered with a randomized controlled trial.  The bottom line:  It is careless of you to dismiss the implications of this study just because it is not a randomly controlled trial. 

 

I also wrote about how this study was observational in nature in my post:

 

“The paper’s authors (who work in the Department of Psychology at the University of Albany/ State University of New York, Albany) recently completed a study of over 50 mothers recruited through local pediatric offices at their 4-6 weeks postpartum visit and evaluated them using the Edinburgh Postnatal Depression scale.”

 

Seems like transparent writing to me!  I fail to see how I was “ignoring” anything.

 

[Side note: I am truly interested in learning more about your educational and professional background as I feel that you may lack experience in reading healthcare research if simply for the fact that you continue to misuse words like “cause.”  Being that this study is a Level II observational study without randomization the authors by definition and design cannot (and DO NOT) claim or imply that formula feeding CAUSES anything!  They can only imply that formula feeding might be a risk factor for PPD, which is exactly what they do.  Being a “risk factor” for something and “causing” something are not one in the same.  For example Human Immunodeficiency Virus (HIV) causes AIDS.  Having unprotected sex with multiple partners and sharing dirty needles are both risk factors for acquiring HIV and hence developing AIDS.  Having unprotected sex with multiple partners and sharing dirty needles do not cause AIDS.  See the difference?

 

Proving true causation is very very difficult (and for some questions, theoretically impossible) and requires multiple studies at different levels of evidence that can be duplicated with different populations by different researchers at different times.  One book that I found helpful to learn more about research was Nursing Research: Methods, Critical Appraisal, and Utilization by Geri LoBiondo-Wood and Judith Haber.  I had to read it for a class I took in nursing school.  Even if you are not a nurse I still think it can be a great learning tool for you, or anyone, who is interested.]

 

 

#2 You write:

 

“You have to look at the results with some perspective. One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD.”

 

First off, I do not deny that feelings of guilt regarding a variety of things can exacerbate PPD.  Secondly I do believe that the authors are interpreting the results of their study with “perspective.”  In fact their conclusion at the end of the article is written as follows:

 

“Bottle feeding practices and hospital procedures that simulate child loss may increase the risk of postpartum depression and fall within a growing number of medical issues that could benefit from an evolutionary perspective.”  [Emphasis mine]

 

In addition, in my blog post on the study my conclusions are as follows:

 

            “This is a fascinating article to me for a variety of reasons.  First off, it is written by psychologists, not health care professionals and hence, takes a look at this very important topic from a completely different perspective.  Second, it is a study/analysis that focuses “not on the advantages of breastfeeding per se, but rather on the negative psychological consequences of the decision not to breastfeed.”  Thirdly, for mothers who cannot breastfeed (as related to the health of the baby or mother for example) or choose not to breastfeed, this article shows us how important it is as health care professionals to assess these mothers thoroughly for signs and symptoms of postpartum depression as well as to educate these mothers and their loved ones about their potentially increased risk for postpartum depression so that they can obtain help and/or counseling if their “baby blues” turn into something more serious.

 

Sounds like a whole lot of “perspective” to me!!  NO WHERE in either the study or my blog post did the authors or I ever make any claim that the results of this study are completely definitive or that formula feeding your child will most definitely cause you to suffer from postpartum depression.  In fact the perspective the authors are taking is an evolutionary one.  As any good study does this one raises more questions than it provides answers to and it opens the door to thinking about breastfeeding from the perspective of evolutionary medicine, or human history.

 

To deny the existence of the complex cocktail of hormones involved in labor, birth, and breastfeeding as well as their importance is something that mainstream medicine has been doing for decades.  This study does not make judgment calls on women who either cannot or choose not to breastfeed and neither do I.  But it is foolish to not at least take into consideration that we, as human beings, are indeed MAMMALS and by design are intended to nurse our young and if we do not or cannot, that we and our offspring as mammals might suffer some consequences.

 

Second, as far as your “One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD” comment, you are incorrect.  In theory someone might be able to make the opposite interpretation but YOU cannot make such an interpretation (and neither can I) since YOU (nor I) have access to the study’s data and the authors did not elaborate on what else besides age, education, income, and the mother’s relationship with her current partner they controlled for.  They could have controlled for other emotions the mothers were feeling…no one but the authors know… and perhaps not controlling for “guilt” is another limitation of their study.  But neither YOU (nor I) can take such a leap without access to a more thorough description of the method (which was not provided by the authors) or the raw data itself.  If you feel there might be another explanation other than the author’s explanation for the results, it would take another study to test your hypothesis.  You cannot derive a conclusion from a study about a hypothesis that you didn’t test for.  That’s research 101.

 

Thirdly, you comment that “studies like these” will exacerbate a formula feeding mother’s PPD reveals your lack of respect for research in general.  The studies on depression that have been carried out over many decades have led to a better understanding about the disease and better care for people who suffer from the disease.  Don’t mothers who suffer from PPD deserve the same? 

 

 

#3  You write,

 

“I am certainly not anti-breastfeeding; I think it is a wonderful thing. But there are cases where formula feeding is the best – or only – choice, and implying that formula feeding can cause PPD is just plain irresponsible, in my opinion.”

 

I ask you Suzanne, why are you so afraid of the possible evolutionary and biological connection between the early cessation of lactation and neonatal loss?  The authors of the study write,

“The present paper focuses on the decision people make to unwittingly depart from one of the defining features of mammalian evolution: to [formula] feed rather than breastfeed their infants. For 99.9% of human evolutionary history the decision not to breastfeed would have been tantamount to committing infanticide. The technology that lead to [formula] feeding as a substitute for the breast (e.g., bottles, rubber nipples, formula) has only become available within the last 100 years.

 

Opting not to breastfeed precludes and/or brings all of the processes involved in lactation to a halt. For most of human evolution the absence or early cessation of breastfeeding would have been occasioned by the miscarriage, loss, or death of a child. We contend, therefore, that at the level of her basic biology a mother’s decision to [formula] feed unknowingly simulates child loss. The death of a child is a well documented trigger for profound parental grief and depression, and evidence shows that mothers tend to be more affected than fathers. Suarez and Gallup theorize that depression as a response to the death of a child may be an adaptive mechanism that functions to (1) punish instances of inappropriate parenting or neglect, and (2) trigger social and psychological support from close friends and relatives during the particularly difficult period following the loss of an infant. Because [formula] feeding simulates child loss at a physiological level it may also play an important role in postpartum depression.”  [Emphasis mine]

 

I ask you Suzanne, what do you find so objectionable about those paragraphs?  What do you find so objectionable about my own conclusions?  What do you find so objectionable about the possibility that formula feeding (and not using your breasts for breastfeeding) could be a risk factor for developing PPD simply for the fact that there are levels of HORMONES involved in breastfeeding that are not being released when you formula feed!!!  For goodness sake it’s BIOLOGY! 

 

Biology Fact #1: When an infant suckles at the breast as during breastfeeding, the pituitary gland releases both prolactin and oxytocin in the mother. 

 

Biology Fact #2: Prolactin is a hormone also known as the “motherhood hormone” that stimulates development of the breast during pregnancy, controls the production of milk, is responsible for nest building in animals, and triggers aggressively defensive behavior in lactating females.

 

Biology Fact #3: Oxytocin is a lactogenic hormone also known as the “hormone of love,” is released during suckling, labor, birth, sexual intercourse, and while sharing a meal with others and is responsible for uterine contractions, male and female orgasm, the ejection of milk from the milk producing sacks in the breast, and feelings of calmness and bonding during childbirth and breastfeeding.

 

Biology Fact #4: If a mother does not breastfeed, prolactin levels usually reach non-pregnant levels by 7 days postpartum.  Mothers who exclusively breastfeed have higher oxytocin levels over time than do women who supplement with formula or exclusively formula feed.  When a mother supplements with formula or exclusively formula feeds her infant, prolactin levels decline markedly and fall even further over time, and oxytocin levels remain depressed and do not climb. 

 

Biology Bottom Line:  Mothers who exclusively breastfeed experience levels of hormones that mothers who supplement with formula or exclusively formula feed do not.

 

(References: Breastfeeding and Human Lactation by Jan Riordan & Birth and Breastfeeding by Michel Odent)

 

What is so objectionable about taking a further look into these hormones and their potential link to PPD?!  What is so objectionable about educating gestating and new mothers about the benefits of breastfeeding the potential hazards of formula feeding so that they can make a truly INFORMED decision about whether to breast or bottle feed?  And if in the end these mothers choose to bottle feed, as health care providers, what is wrong with being more aware of the potential increased risk these mothers have to developing PPD, just as we would be more aware of the increased risk of developing PPD with mothers who have experienced a loss or with mothers who have a history of depression.  It’s called being a RESPONSIBLE HEALTH CARE PROVIDER and therefore I reject your claim that this study and by default my blog post are irresponsible!

 

#4    As far as your statements about the use of antidepressant medications during lactation, I believe that just as with the use of antidepressant medications during pregnancy, every mother should be counseled by her health care provider on a case-by-case basis where the risks are weighed against the benefits for both the mother and fetus/baby.  I personally am not an expert in the use of antidepressant medications in pregnancy or lactation but I understand that there is an important debate regarding this issue that I have to learn more about. 

 

In conclusion I am excited about all of the breastfeeding research that is out there, both past, present and future!  And as far as your position as a “fearless formula feeder,” one point that I agree with you on is that mothers (and fathers) have to STOP the guilt trips and senseless competition.  But unlike some other choices, I feel like the “to breastfeed or formula feed as a choice” question is not one that should be taken lightly (and I am not talking about the mothers or babies that cannot breastfeed for other reasons besides choice). 

 

The more research that is done on breastfeeding the more we are learning that breastfeeding should no longer be considered “just nice” or “better” or “best” and formula feeding should no longer be considered “good enough”.  The “choice” to breastfed should not be on par with the decision on what new car to buy [“Well the Lexus minivan is better but the Chrysler minivan is good enough].  Breastfeeding is NORMAL and more and more research is showing that formula feeding puts your baby AT RISK.  If the benefits outweigh the risks when it comes to formula feeding for you or your baby then so be it.  If not, but you still choose to formula feed, my only concern as a healthcare provider is that your choice is based on INFORED CONSENT and NOT misinformation, pressure from family or friends, untruths, or lack of support or resources.  There are too may women out there who want to breastfeed but lack the support from family, friends, nurses and even doctors as well as lack the resources, and/or knowledge to do so.  I am sorry but the cause of those women needs more attention which does not mean that I condone the “guilting” or judging of women who choose not to (and certainly not towards women or babies that cannot) breastfeed.  

 

I dream of a world where ALL mothers who are willing and able to breastfeed get the support and encouragement and resources they need to do so!  And I work everyday to make my dream a reality.

 

Sincerely,

NursingBirth

 

 

P.S.  I encourage you to read a couple of my past blog posts:

            My (Aggravated) Response to “Ban the Breast Pump”  and Why The Today Show Hurts America (or, Battling The Case Against Breastfeeding)