She thinks Isaac is terrific (she misbehaves for us instead—man, am I tired of the tantrums every time I ask her to do something) and she makes me crack up laughing. Actual conversation from last week:

Aliza says: “You’re not the boss of me!”
Me: “Really? Are you the boss at school?”
Aliza: “No, the teachers are.”
Me: “And at home?”
Aliza: “Daddy.”
Me: “Nope, Daddy and I are both the boss.”
Aliza: “I have TWO bosses? I hate having two bosses!”

Also, this week, after I made boxed macaroni and cheese, which I don’t usually make:
Aliza: “I like your macaroni and cheese, Mommy.” *pause* “But I’m not a fan.”

Mini photo retrospective:

From this:

to this

to this:

To this!

Isaac is 3.5 months old. We’ve had some challenges. He was diagnosed with reflux. The NP was fairly dismissive because he was gaining well. Since I was already doing all the reflux ideas (paced feeding, keeping him upright, etc) she fobbed me off with a small dose of Zantac, which did nothing. I came back and said he wasn’t better. When I described all his symptoms, she admitted he might have a dairy problem. He went on to soy. This helped in some ways, but he’s still puking. In fact, it’s worsening, especially as he takes in more at a feed. Even my husband, who thinks I overreact when it comes to health, admits it’s a problem, but the NP says it’s not frequent enough (only 2-3 times a day) and he’s gaining. I am not happy with how they’re handling it especially as I asked about the AAP’s recommendation that soy not be used in cases of suspected milk protein intolerance due to the high rate of soy intolerance (and the possibility that the baby will go on to develop soy intolerance/allergy) and got waved off. On the other hand, he’s not screaming for hours at a time, so it definitely did help. She’s also still giving the “put Karo in his bottle for constipation” advice. For some reason, I got scheduled with the NP instead of one of the doctors, and they have a policy of keeping you with the same provider. I’m really tempted to ask to see someone else.

He’s starting to get more of a personality, though. I can’t get a photo of him smiling yet, but he smiles and laughs.

Gratuitous photo time!

Both of them:

(I have an overactive flash on my camera, which creates odd shadows. Unfortunately, manually shutting off the flash slows the shutter speed and I get blurry photos. I’m not good enough to play with it. One of the many, many reasons I will never be a famous blogger.)

And a hospital picture, because I don’t think I posted one:

(No, he’s not a year old. That was my parents’ camera.)

Before I gave birth, I made a promise to myself. I would try to breastfeed. I would give it my best shot. If it didn’t work, I would use formula and that would be that. I vowed that I would not drive myself crazy with pumping and supplements. I wound up not enjoying Aliza as much as I should have because I was so upset about nursing. I wasn’t that optimistic, because things seemed to be heading down the same road as the first time—no breast growth again.

When I was admitted at 32 weeks, they sent the LC down to see me in case I delivered. She was helpful but a little pushy—I got an eye roll when I said I might be having a 37 week repeat CS. She also said it sounded like I hadn’t had enough stimulation at the breast and she did say she thought I would need to pump this time. I think she saw me as another potential failure who was going to drop at the first hurdle, but I was okay with that. She was pleasantly surprised that not only was I aware of the Making More Milk book, but that I had read it.

After delivery, I nursed. He latched well, things were going okay—except I was sick and I sent him to the nursery. I didn’t feel guilty then and I don’t now, because I was just so sick. There were times that first day when I didn’t trust myself to hold the baby at all because I was so dizzy. I had some trouble positioning him on my own the next couple of days, but I did it. The problem was, he was hungry. The LC rolled her eyes at me when I said that, but this is my second child. I know that hungry scream, and my mother heard it too. I tried telling her, “His stomach can only hold a tablespoon; he can’t be hungry because he’s just nursed.” She just looked at me. He screamed and screamed, and I asked for a bottle, and he drank 25ml and slept. The LC dismissed it with “Of course he drank it, it’s easy.” I’m not convinced. I’ve tried to shove a bottle in the mouth of a full baby, and it doesn’t work. This was a jaundiced newborn. I’ve done that before, and you nearly have to drip the formula down the back of their throat half the time, because they are so sleepy and don’t want to eat, no matter how easy you make it. At one point I got resentful and thought I would just go to formula when I got home, because it was difficult, I was post-surgical and I felt discouraged.

I got home and we were still trying, but not really as much as we should have; with my parents there, and a small house, it was extra hard. I really thought about quitting. Then on Saturday, my milk actually seemed to be in, and my husband even said “hey, I think they are bigger” and I had a change of heart. He nursed well, and I thought, “maybe it’s different this time.” Starting on Sunday he was nursing but not terribly well. He was sleepy, so he’d drop off every minute. I decided to try pumping for a little bit. Not a month again, but see if maybe I had more supply, enough to make it worth it. A week later, I was forced to concede that I didn’t. He didn’t want to nurse much, and I think he knew. LCs will mutter about the bottle and the faster flow, but I tried the “supplement first” technique and it didn’t work either. Intuitively, that made sense even without the reasons I’d read for it—a hungry, frustrated baby is difficult to latch. By taking the edge off, the baby is calmer and more willing to cooperate. I think he was frustrated by getting so little, and he associated nursing with sucking for nothing. I was on the couch, trying to get him to latch on, and Aliza asked what I was doing. I told her. She said, “Why don’t you just give him a bottle?” I said, “This is better for him.” She looked at us and said, “I think he likes the bottle better.” That made me cry. Maybe he wasn’t willing to work hard enough to get what little was there. I was supplementing because I knew that I certainly did not have a huge supply, the ped was concerned with how much weight he’d lost so quickly, and I wasn’t willing to starve him into submission, even temporarily.

That opens up the “What If” Pandora’s box. What if I had nursed nonstop after delivery? What if I had pumped right away rather than resisting it? I’m never going to know. I have come to the conclusion that while maybe it would have helped, it’s unlikely to have changed things that dramatically. I’ve heard that the initial phases of milk production are hormonally driven, and production really kicks into the equation a little later. I also hear about women whose milk comes in whether they want it to or not. I was facing an uphill battle. Perhaps I could have achieved more supply, but I wasn’t just going to feel a full supply arrive on its own by breastfeeding more in the initial days. The fact is, I never felt anything the books and articles told me I was supposed to. I never really felt my milk come in; I discovered it almost by accident when I was trying to latch him on. I was never engorged by any stretch of the imagination. I never felt full before nursing, or empty afterwards. I never felt let-down. I saw his jaw move, so I know that he was actively sucking, but almost never heard swallowing. I know that none of these things are definitive, but all together, I’m suspicious.

That begs the second question: How much effort is worth it? There’s an unspoken assumption from some breastfeeding advocates that any effort is worth it. I don’t think it is. The advice dispensed for low supply is simply impractical. Nursing, supplementing, and then pumping eight times a day was difficult enough with one child; it was a disaster with a second to look after as well. I made the mistake of searching for information on low supply and insufficient glandular tissue. I didn’t think I would find anything terribly useful, or that was very different from what I’d found nearly 5 years ago. What I found were breathless, chirpy descriptions of pumping and donor milk and using an SNS. They didn’t make me feel better; they made me cry. They depicted a worldview where breastfeeding reigned supreme and whatever you needed to do to achieve it, or even preserve the illusion that you had, was the most important thing. They pointed out, “Only 3% of women are physically incapable of breastfeeding!” If you’re in that 3%, it doesn’t make you feel any better to be a freak, and if it is situational, is that any better? There’s a hidden subtext: If you can’t at all, then it’s acceptable. Not okay, just acceptable. Maybe, if you can prove that your situation this time totally stopped lactogenesis, then we’ll pat you on the head and tell you better luck next time. The rest of you? No excuses! At best, there’s blame for “the system” which I find infantilizing. It’s as if some breastfeeding advocates are incapable of envisioning a situation where someone makes a genuinely informed choice to feed formula. As far as they’re concerned, either you were pushed into it, or your decision making process was corrupted by our pervasive culture of formula. I even found posts doubting the numbers of women with IGT and accusing some of using it as a convenient excuse, which I find hard to believe. IGT is not widely known. Even OB/GYNs and LCs are often poorly versed in it. Why would someone go to that trouble, rather than just make up an easy, plausible excuse (if an excuse is what they want)? All of it seemed to shy away from the question of how far you should go. It’s obviously a personal decision. Some women are willing to use an SNS, and some are not. But very little of it faced the issue head on, or discussed how you should make that decision, or what steps were reasonable. They simply told you what you could do. It’s nice to think  that they’re just leaving the decision up to the reader, but it didn’t feel that way. It felt like all these approaches were being handed out as a bloc.

I view breastfeeding primarily as a breastmilk delivery system. The bonding is nice, but as a second time mother, I can’t read paeans to the sacred breastfeeding relationship with a straight face. Maybe there’s a magical level of bonding I could have achieved with my first and which I will never know, but once I got used to bottle feeding, it seemed okay to me. I learned to enjoy the quiet cuddling time. I used a binky for that all important “suck on something to keep quiet” time. (Which reminds me of a line from the postpartum care booklet I got: “Babies do not use their mother as a pacifier. A pacifier is a plastic substitute for a mother.” It rubbed me the wrong way.) That doesn’t mean it’s all or nothing, but if I’m mixing formula after every nursing session, then the effort is outweighing what I get from it. It’s just twice the work. At that point, it’s all about the “relationship.” If that matters to you, that’s fine, but it’s not important enough to me to go to those lengths, and the breastfeeding webpages made me feel like I was a lazy slacker for thinking that way. I don’t hate breastfeeding, but I don’t love it, either. It’s fine. It’s tolerable. Again, I just don’t know what it would be like to nurse for any length of time, and to get past the initial hump—as people have (rudely, in some cases) reminded me. I’m on the outside looking in, and it’s not all that fun.

That winds up making me feel guilty. Because I’ve only experienced breastfeeding negatively, I feel alienated from my friends who talk about breastfeeding. When they complain about all night nursing, or being pestered by toddlers, I secretly feel relieved that I don’t have to deal with it. I have said “gosh, these women are really not selling anyone on breastfeeding when they talk about how they haven’t slept a full night in two years” about some Mothering crazies, but I can’t be open about feeling that way during much less extreme discussions. There are circles where breastfeeding is gross and everyone is open about how terrific and liberating formula is. I don’t know many people like that. The majority of my friends breastfeed, and the ones who don’t at least pay lip service to the “breast is best” ideology. I’m not a fan of those comment pieces about the tyranny of breastfeeding and how women are guilted into pretending to like it, because this is a very limited phenomenon—in my experience, middle class white women in urban areas, particularly in the Northeast and the West Coast. (For the record, I loathed that Hanna Rosin piece that got around the blogosphere a couple of years ago.) By and large, society is not forcing women to breastfeed. But, if your friends do, it feels wrong to talk about how much you love formula. In that context, it almost feels like judging another woman’s choices. It’s also because I didn’t choose formula; I had it foisted on me, and it’s complicated to have positive feelings about a choice you didn’t want to make. If I had chosen to use formula, I could feel good about it, the way I’m pretty much okay with my section. It wouldn’t be that breastfeeding didn’t have positives, it would be that I had made a considered decision about which things were important to me. But since I didn’t choose, my ambivalence makes me uncomfortable; I almost feel like if I had been that committed to breastfeeding at any cost, it would have worked.

Oddly, what made me feel a little better was not chirpy or uplifting. In fact, in other contexts, it would have been depressing. What was helpful were studies and reports on women like me. I actually found a few this time. Women who fit my profile (one had the case studies listed individually) had poor results with breastfeeding. It was fairly consistent. That at least made me feel like it wasn’t me. I got let down by a cruel trick of biology, but it wasn’t failure of effort. It took the responsibility off me, and let me quiet the what-ifs. Maybe I could have achieved partial supply with superhuman effort, but it wasn’t going to be 100% by any means. That external validation made me feel better, more than just my friends saying “You’re doing a great job, you have a gorgeous baby, and all that matters is him being fed.”

If you’ve made it to the end, you’ve earned a drink.

I can’t remember the exact order in which this happened, but this is about right. I was in recovery, and I wasn’t feeling perfect, but I didn’t expect to. My OB came in and explained that my hemoglobin had been only 9.8 before surgery. (I have to accept some blame here—I should’ve been better with my iron tablets.)  They’d done their best to minimize blood loss, but it had still been nearly 1L. Add in the spinal, and my blood pressure was in the toilet. My unmedicated blood pressure normally runs 160/105. Medicated, I’d been 120/80 or just under prior to birth. After? They were having trouble keeping me up to 90/50 and I don’t know how low my hemoglobin got. She said that if my blood pressure and labs stayed at that level, I was looking at a transfusion. I managed to avoid that, but I felt awful—sick and dizzy. I couldn’t hold the baby at times. I must have looked terrible, too, because the next day the OB commented on how much better I looked.

As a result, I kept my IV in for over 24 hours, and my catheter for about 20. Neil stayed in the hospital till nearly 10pm to help. My hospital is optional night nursery only, from 10pm to 6am, and he didn’t want to leave me alone with the baby, as I was having trouble with moving and picking him up. So he stayed until the nurse was ready to bring him to the nursery. I was sick enough that when they asked if I wanted him brought back for feeding, I said no. I wasn’t even sure I could manage to position him without help.

The good part is that I felt much better in the morning. I was able to get up and go to the bathroom (provided the nurse disconnected my monitors from the wall and helped me drag in the pole), my head had stopped spinning, and I could sit up. I even cared enough to put a pajama top on instead of the hospital gown that kept falling off. (TMI time: When you’re bleeding straight onto the chux, you lose all sense of modesty. Day 2, at least I had the mesh on. By day 3, I was wearing real pj’s.) They were good with pain management. I had Duramorph in my spinal and Toradol IV. The pre-op consult had mentioned IV PCA instead, but I’m fine with Duramorph. I don’t itch. After that, it was Percs PRN, 2 every 4 hours max. I am a tiny little bit macho, so I tried 1 the first time. It didn’t do it, so I went to 2, but I tried to push it to every 6. When I got my discharge meds, I discovered why I’d needed 2: They’d only given me 5/325 Percocet. I also got Advil on request, which I knew I’d need for the afterpains. They were grown up enough to just give me a card of tablets and a sheet where I could write down what I’d taken.

Originally, I’d been hoping to get out on Wednesday, before the holiday. This was overly optimistic on two counts: One, I needed that 3rd night, which had been my original estimate. Two, and more importantly, Isaac’s direct Coombs test came back positive. It took longer to hit this time, and not as badly, but I got a second jaundiced baby. With Aliza, being a bit earlier, it hit within 24 hours. Isaac was a little older, which helps, and his bili levels didn’t go high enough for phototherapy until Wednesday. He needed the full lights, so he had to go to the nursery for a day. So we didn’t get out till Thursday, at which point I was feeling pretty good.

I pushed myself too far when I got out and paid for it, but overall, I’ve recovered well. I took Percocet regularly through Friday, a couple of times over the weekend, and not after that; Advil lasted a few days longer.

Before I left, I had to call in to L&D to make sure there hadn’t been any emergencies that bumped me off the schedule. Luckily, everything was quiet, so I said goodbye to Aliza and my parents and Neil drove me to the hospital. We went up to L&D and they showed us to an LDR. That surprised me a little at first, because obviously I didn’t need the L&D parts of the room, but on reflection it was nice to be treated like any other pregnant woman and not just a surgical case. With my first, I went from the antenatal ward to surgery and then to a recovery bay next to the OR; I never saw the L&D unit. I had a brief moment of sadness as I saw the labor map and position posters on the wall and knew I would never need to know anything on them.

Two nurses came in and introduced themselves. I gathered from their conversation that it was the first day for one of them, so she wasn’t working on her own yet. They put me on the monitor to check the baby, inserted my IV, and drew blood work. The OB came to check on me, and then the anesthesiologist came in and introduced herself and checked me. I checked on my surgical requests (no strapped arms, catheter after spinal, and sutures not staples) and got okayed. By 8, we were ready to go. The OR is inside the L&D unit—just across the hall from the LDR I was in. I got wheeled into the OR by myself—husband not allowed in during anesthesia this time. They did a spinal, which went in fairly easily, and then everyone got assembled for surgery. A few minutes later, some pushing, some pulling—out comes the baby! A boy, which we already knew, and had the name ready: Isaac Asher. My husband realized he forgot the camera and I told him off. They didn’t allow photos of the surgery but they were okay once the baby got to the warmer. Neil tells me the baby was pretty bloody-looking and awful, though. He also peed on the way out. Everyone congratulated us, and the anesthesiologist wished us a Mazel Tov, which was sweet of her.

The pediatricians checked him and they brought him over briefly before taking him to the nursery for a proper exam. Since I was stuck in the OR anyway, and they said he’d be back when I went into recovery, I was okay with that. They measured him—8 lbs 6 oz, 19.5″. I grow nice big babies, what can I say? While he got his exam and bath, I got stitched up. In order to avoid the problems I had last time, the OB did a double layer suture with all internal stitches. It took a good amount of time–nearly an hour. By the time I was wheeled back into the LDR, Isaac was all done and waiting for me and I got to try nursing.

All in all, I was really happy with how it went. There were some problems post-op but it wasn’t anyone’s fault this time, and I’d like to remember them separately, so they’ll be in a separate post.

Because my BP stayed controlled, I didn’t deliver at 37 weeks. My OB will not schedule before 39 in healthy patients, in line with the research on early term babies. Schedule, you ask? Well… that was a dilemma. She would have allowed TOL. I don’t know at what point she would have gotten nervous—I suspect 41 weeks was the hard deadline. (I do know my practice routinely schedules induction/RCS for postdates between 41 and 42 weeks.) I did not entirely trust my BP to behave. On preeclampsia support groups, you hear from the bad cases: the preterm, the losses, the severe PE/HELLP/eclampsia, the NICU stays. My case is mild, by their standards. In the real world, I know too many cases of 40-41 week inductions for gestational hypertension or mild PE. Although my BP was generally very good, there was a little upward trend and some higher readings at home. I didn’t entirely trust my BP to stay good through 41 weeks.

On top of that, I had to factor in the following: I had an anterior placenta, causing a posterior baby that did not want to move. My cervix never dilated. I had no recorded contractions in 14 NSTs. Said NSTs were brutal, and I really didn’t relish fetal monitoring in labor (not optional as a VBAC with HTN!) I was not going into labor early. My guesstimate is that I would have gone closer to 41. If I had really thought I would go into labor between 39 and 40, I might have thought differently. Ultimately, I feared an emergency section most of all. I came to the realization that, even if it hadn’t been the worst case scenario, I had had a traumatic delivery and that in light of that it wasn’t irrational to prefer a planned delivery. So, I got myself booked in for a section at 39 weeks on the dot. The hope was that I would be out quickly because it was 2 days before Rosh Hashana, which I did not want to spend in the hospital.

Last Monday, I went to the OB for my 32 week appointment. I go in, my BP is 140/90. The nurse says, “Well, you were scheduled for an NST tomorrow” (news to me: I knew I was supposed to be starting them last week, but they hadn’t given me appointments) “so we’ll just do that now, then try your BP again.” We do the NST. It takes a little while to get baby on the monitor, and an ultrasound shows he’s transverse, but finally we do, and the test is reactive. OB does repeat BP.

162/110.

Uh oh.

Go straight to L&D, do not pass go, do not collect $200.

I get to L&D triage. The resident says I’ll probably be admitted for overnight observation and 24 hour urine collection. Then, she says she wants to do a cervical check and GBS swab, in case I deliver early. I ask if I need the GBS swab if I’m going to have an RCS and she says “probably not, but are you sure?” So we end up having a conversation about having an RCS. She was actually very nice and open minded about it. This happened several times over the course of the day—much less of an “you’re having another section” assumption than I was expecting. I did get a bit of an attitude from the LC about it (37 week RCS! Not the best scenario for breastfeeding success for anyone, much less me), though she got it. (They had me do my pre-delivery paperwork while I was there, and asked if I’d need an LC; I said yes, because I’d had a lot of problems with my first. So they sent her down to talk to me since I was there anyway.)

The rest of the day was as expected: lots of BP checks and peeing into the hat. My BP was flaky, but all below 140/90. I got some really low ones in bed, but that was no surprise. I suspected it was a false alarm and I was right. My 24 hour collection came back at 80, which was within a few mg of the one I’d done 2 weeks before. So I got to leave. I’m not upset though; last time, my OB did not pay attention, and it went south.

I’ve since had 2 more NSTs and both were reactive, although I have an anterior placenta, which is making the tests tricky position-wise. My BP has been okay. In fact, it’s been low today, really low, and I’m starting to wonder about labile pressure.

The OB was boring, although as I said, “boring is good.” My BP is holding steady and I have no complaints. The only moderately interesting thing was that she’d meant to ask me to do another 24 hour collection last visit, and had forgotten. So I did it overnight. It was perfect timing since I was coming back the next morning. The growth u/s was also fine. Baby is 3 1/2 lbs, putting it at the 60th percentile. That’s lower than before, but blood flow looked fine; they did a color doppler for the umbilical artery.

I’m spending all my time worrying. I told my OB, “I’m not worried yet; my BP started rising later last time, and statistically, you don’t often get it earlier as a repeat.” That wasn’t quite true. I am worried. I have no benchmarks from my first pregnancy, so I can never find reassurance. Everyone worries about IUGR, so I worry about that; but I also know I had a big baby the first time, and big babies with superimposed preeclampsia are more common than you’d think. Does this mean that having a nearly average baby is good? My BP has been steady. If there was a 2nd trimester dip, it was tiny. My official readings look like they dipped at 24 weeks, but they switched to letting me wait before getting a reading, and I started getting measurements more like what I got at home, so I don’t think it’s a real change.

I’m afraid to be hopeful. I feel like it will be better if I expect the worst again. I won’t be disappointed. I’ll feel like all this effort was justified. If I start thinking that I can dodge the bullet, it will be worse. If something is definitely wrong, or I have definite signs of heading that way, I can deliver the baby and know I did the right thing. If I seem to be fine, but deliver at 37 weeks rather than risk it, I’ll always have that what-if going through the back of my head.

I feel guilty for worrying. On the preeclampsia forums, there are women who delivered at 24 weeks. Women who lost their babies or spent weeks worrying in the NICU. If I didn’t have chronic hypertension, no one would even be concerned. I said this to a friend of mine (who delivered at 24 weeks with severe PE) and she said “It’s different, but it still stinks. It’s still a lousy disease.” It is, but I can’t help comparing myself to people who had it worse.

My problem is that I treat pregnancy as an annoying nuisance to be ignored. In my mind, if I feel fine, I am fine, and I can just tootle along as if I were not pregnant. I should have learned the truth the first time. It turns out I only applied the lesson to my blood pressure. So I go do crazy things like drive 400+ miles in a weekend at 28 weeks pregnant. Alone. And drive home in the middle of the night. And walk around NYC in 90F heat. And I don’t want to be the whiny pregnant lady, so I don’t take it easy, until I’ve blown up and am contracting.

So, after all that, I was exhausted. Thank god I did not get into an accident on I-78 on the way home (I did pull off twice to wake myself up, and got home at 3:15am!) For the topper, my BP yesterday afternoon was 137/87, which I do not like.

My blood pressure has been chugging along. Not terrible. I actually got a good reading at the OB’s yesterday, but I’m suspicious because it’s lower than I’ve been getting at home, and usually it’s the other way around. I also got confirmation of something I suspected might be true: She’s anticipating delivery at 37 weeks. There was a trial a couple of years ago called HYPITAT that looked at expectant management versus delivery for gestational hypertension or mild preeclampsia after 36 weeks. They concluded that the risks of expectant management were higher. Based on that, OBs have been delivering chronics at 37 weeks if their BP starts to rise—which it normally does. So, unless I get sick first, we’ll evaluate the situation at 36 weeks and pick a day. She said that by 34-35 weeks they’d probably have some idea if I’m likely to develop preeclampsia or not. If my blood pressure stays level, I might go to 38, but she didn’t sound optimistic about that; she said “If we get you to 37 weeks, that will be really good, and I’ll be happy with that.” With Aliza, my BP started rising around 32-33 weeks, and I started this pregnancy with a worse baseline (albeit better control). So I’m getting used to the idea of another 37 week section.

That’s about it. I had my glucose screen yesterday, and hopefully I passed. I don’t need GDM on top of HTN. I have a growth scan in 3 weeks, and will probably have another before I deliver, plus NSTs from 32 weeks.