Because I'm a labor & delivery nurse, does that mean I'm supposed to know what I'm doing with my own baby?

Thursday, June 26, 2008

Traveling with baby

We just put Baby Stewgler's west coast grandparents on a plane for home after a five day visit. We love playing tourist when they visit and this trip was no exception -- a Circle Line cruise around Manhattan, a walk across the Brooklyn Bridge (happy 125th BB!), a lovely afternoon in the NY Botanical Gardens in the Bronx. Traveling by boat, train & automobile with the bambina adds an extra little wrinkle, but is certainly not a reason to stay home and miss the fun. Here are a few things that made our daily junkets a little easier.

  • A good stroller: I did massive stroller research during my pregnancy and finally settled on the Micralite Toro. I'll be the first to admit that it isn't perfect (why does it take only one hand to fold it closed but takes two to unfold it? And why don't they tell you that on the website?), but it comes close. Mr. Stewgler is a major stroller hater and even he admitted that our travels around the city were aided by the Toro. Big air-filled wheels make it easy to get up over curbs & drivable over cobblestones and bumpy Brooklyn sidewalks. It's light enough to get it up and down subway stairs. And it's damn cool looking.
  • Formula "sticks": These pre-measured packets of formula make on-the-go bottle mixing a breeze. I'd pack the diaper bag with a couple of bottles filled with the correct amount of water and when we needed one it would only take a few seconds to add the formula powder. No fuss, no muss.
  • Skip-Hop Pronto diaper zone: It's just good to have all your diapering necessities well organized and well contained within your diaper bag. Added bonus to have a cool-looking pad to put between the little one's naked bum and, say, the bird poop encrusted benches at the botanical gardens.
  • Extra hands: Grandparents are the greatest!
For the record, I still hate the car seat.

Saturday, June 21, 2008

Ask Nurse Stewgler: The thing about birth plans

These days, the question you hear most as a pregnant woman is, "Have you written your birth plan?". Sure, folks still ask about your due date and strangers on the street will inquire about the gender of your unborn one, but those old school inquiries seem to take a back seat to the birth plan.

I'm sure my sense of this is skewed. I work at a busy Manhattan hospital where the well-heeled patients check their blackberries between contractions. They've planned every aspect of their lives to the Nth degree -- of course they'd turn up with a birth plan. As we gain more and more control over our fertility, we seek more and more to control the birth experience too. It all goes hand and hand, I guess.

I really appreciate the spirit in which the birth plan is intended. I feel strongly that if more people exerted demands over their health care, our system would serve us all better. It is dangerous to put yourself lock stock and barrel into the hands of your health care provider -- we should never abdicate that much control over our own bodies. A birth plan is evidence that this person has done research about what to expect from her hospital stay -- a great sign!

But here's what I've come to know about birth plans -- they almost always come to naught. The folks who arrive on L & D with a three page type-written list of all of the medical interventions they refuse to consider, seem to always end up in hysterics when the reality of birth starts to diverge from their plan. It's so sad to see those folks wasting emotion and energy lamenting the loss of their birth plan.

I tell people that the experience of childbirth is a lot like parenting. You can organize and plan all you want, but when the kid has a melt down in the middle of the perfect day you planned you'll just have to roll with the punches and work around it. Childbirth is the same way.

When I'm at work, I take birth plans seriously. I make time to read them and talk about them with the patients. I ask questions about the motivation behind each request or decision and I try, when necessary, to point out places where their requests run afoul of hospital policy or state mandates for patient care. Mostly though I try to prepare folks for possible forks in the road right from the start.

For example, a common statement on your average birth plan is this, "I want the baby placed immediately on my chest with as much skin to skin contact as possible." No problem. That's pretty much standard operating procedure -- even the seriously old school docs will put the baby directly on mom's chest. But, if in the midst of labor we find that there's meconium in the amniotic fluid, the baby will first be taken to the warmer first to have his airway suctioned out (if the baby aspirates meconium it can lead, in some cases, to pneumonia so we want to get as much out as possible). I think it helps to explain this early on so if it happens folks are prepared.

I think this is the best possible scenario -- an educated consumer and a health care provider having a dialog. If everyone considered their birth plan as nothing more than a conversation starter, we'd be OK. Things go wrong when folks expect that their birth plan is a set of demands etched in marble.

Before I became a L & D nurse I took part in a three day doula training course just to get some experience in the non-medical aspects of birth. On day two we broke into pairs to go through a birth preferences exercise. We were given about 20 cards -- each one had an option on either side of the card. They said things like hospital birth/home birth, pain medication/unmedicated birth, access to food & drink during labor/ice chips only during labor. There was even a card that said "Healthy mommy & baby" (there was nothing on the other side of that one).

The idea was that you would ask the pregnant woman to go through and turn each card to the side that reflected her preferences for the birth experience that she imagined. Once she'd made her choices, you'd ask her to flip five cards over to the other side. There were plenty of things that seemed like no big deal -- you could flip over five without "losing" much. Then, you'd ask her to flip over five more, and then three more after that. By the end she'd be left with her four or five absolute stone wall resolutions for her birth experience.

That's reality folks. Even if you're CERTAIN that you won't consider anything other than the details on your birth plan, you might change your mind when the going gets tough. Every person is different and every birth is different -- there's just no predicting how it's going to go.

So by all means, write your birth plan. Talk about it to strangers on the bus. Have the small of your back tattooed with "NO epidural". But when you do, please save yourself and your providers some grief by softening your language -- "I would prefer..." rather than "I refuse...". Once it's written, ask yourself if it sounds like a dictum that might court ire from your providers or a polite set of talking points that will inspire collaboration. Remember that the medical establishment is not out to thwart your ideals, they work hard to see that you are happy with your care. But in the end, they care only that mom and baby are healthy.

So remember that you can't control a force of nature. Be prepared to roll with the punches. Keep in mind that when it's over no one on the subway will ask how close your actual birth experience came to your birth plan. They will ask how you feel and they will coo over your gorgeous little one. And that, my friends, are the only two things that matter.

Wednesday, June 18, 2008

Ask Nurse Stewgler: No, you didn't pee your pants

I want to use this blog to offer insights from my job as a L&D nurse in addition to my job as a mom. Perhaps I'll add a weekly post to that effect. If you have a burning question for me, something you've ALWAYS wanted to know about pregnancy, labor, delivery, hospitals, etc. please let me know. Please be aware that the information or advice presented here is not intended as a substitute for medical care or information from your own provider.

Did my water just break?

Ahh, the eternal question and, you'd think, a simple question to answer. Why then are labor and delivery triage areas filled to the brim with women who think their water broke? Let's just say that, it rarely happens in life the way it happens in the movies.

First, let's talk about amniotic fluid. Amniotic fluid has two sources -- in the early months of your pregnancy your body produces the fluid and in the later months it created as a by product of the fetus' kidney function (meaning it's fetal urine). It is contained within a membranous sac inside your uterus -- this sac is called the "amnion" (hence the name).

The fluid is crucially important -- it cushions the fetus, cushions you against the kicks & punches of fetal movement, contributes to the growth and development of the fetus (it contains nutrients key to early development), and most importantly it aids in fetal lung development. As your fetus matures, he or she "breathes" in amniotic fluid which prepares the fetus' diaphragmatic muscles for the work of actual breathing upon birth. In addition, the fetus will ingest amniotic fluid -- you'll see the byproduct of this in the baby's early poops called meconium.

OK, so now that we know what we're dealing with, let's get back to the question at hand. Did your water break?

Let's set up an ideal scenario... you're 39.5 weeks pregnant, you've been contracting every five minutes for the last three hours, you're wearing waterproof pants while you bake a last minute batch of brownies to hand out to the nurses at the hospital (hey, I said ideal, OK)... when all of the sudden you get an unmistakable GUSH of fluid. It will feel warm, wet (duh) & perhaps slightly slimy. Get used to it because you'll be leaking fluid from now until you deliver.

Now what? OK, let's be realistic... the first thing you'll do is mop up the situation. Literally. Change your clothes, put on a pad (or three), call your partner to clean up any puddles, or change the sheets. As you clean up, you need to make note of one REALLY IMPORTANT detail. WHAT COLOR IS THE FLUID? Amniotic fluid might be totally clear, it might be blood tinged, it might be yellow or it might be green. It may smell briny, but it shouldn't be foul smelling.

Next, you need to call your provider. Your conversation is going to go something like this... You: "Hi doctor/midwife. Sorry to wake you. Uhh, I think my water just broke." Doctor/midwife: "OK. What color was the fluid?" Ok, Ok, so they might first ask you when it happened or whether you felt a gush or a trickle, but trust me they're going to want to know about the color.

Why do they care about the color? Primarily, they're trying to find out whether the baby has passed any meconium in utero. It's a fairly common occurrence -- especially in babies that are past their due date. Meconium in the amniotic fluid is sometimes an indication of stress on the fetus and may mean that your labor & delivery will be closely monitored (we can cover that in a future post). Be aware that meconium in the amniotic fluid can cause subtle color changes -- it's best to compare the color of the fluid against something white like toilet paper or a maxi-pad.

Your provider will also want to know if you see blood in the fluid. It's totally normal for "clear" fluid to have flecks of blood in it or to be very, very pale pink. If the fluid is dark pink or red your provider needs to know ASAP. It could be a sign of a placental abruption which is a medical emergency.

But what if you don't get a gush?

First, try to rule out peeing your pants. Does the fluid smell like urine? Is it yellow (but remember, this could be amniotic fluid stained with meconium, so don't be fooled)? Did you just sneeze or cough (stress incontinence is pretty common in late pregnancy because there's so much pressure on your bladder)? No, no, and no? Well, you may be in business.

If you have any question as to whether or not you're "ruptured", you should call your provider. They may ask you to come to the hospital or to their office to be evaluated. You may undergo a speculum exam during which they'll test a sample of the fluid with a nitrazine swab (the pH of amniotic fluid will turn the nitrazine paper/swab blue).

Because any break in your amnion could be an entry point for infection you should be careful to to put anything in your vagina if you suspect that your water is broken -- no sex, no tampons, no fingers, no douches and don't take a tub bath (a shower is OK). And because infection is a risk once your membranes have ruptured, your provider will likely want to deliver your baby within the next 24-48 hours.

Which brings me to my final point... ruptured membranes might happen because you've been in good labor for a while, but it might also happen before you ever experience a contraction. It might bring on contractions or make existing contractions WAY more intense. In any case, breaking your water means GAME ON.

So get those brownies out of the oven, you're having a baby.

Tuesday, June 17, 2008

One for the Road

We're going to be spending a couple of weeks on the beach this summer -- one at the Jersey shore with my family and one in SoCal with Mr. Stewgler's family. So we're packing up the surfboards and the sunscreen and heading for the sand. Sometimes the best thing about living in New York is seeing the skyline in your rear-view mirror.

These will be our first vacations with the bambina so there are a few things we need to work out. Sleeping arrangements have proven a cinch -- for Jersey we borrowed a pack-n-play & the Cali rental can provide a crib. We'll make room for the fancy stroller when we pack the car for NJ & we're hoping that one of the west coast relatives can loan us a stroller since we don't want to bring ours on the plane (we borrowed an umbrella stroller just in case). The biggest issue is proving to be all of the food paraphernalia.

In the grand pro/con list of bottle vs. breast feeding, the big con is bottle prep. Sure, "breast is best" but the real reason you should breast feed is because preparing bottles is a huge pain in the ass. You have to wash them and boil them and prepare boiled water to fill them with. Oh, and breast milk... it's free, whereas formula costs $25-30 a can (which lasts a week).

So far, we've had two scenarios when we've left town. 1. We've gone to visit my parents where there's this amazing thing called the dishwasher (and a grandmother) that does the washing and sterilizing for you. 2. We've gone to a wedding in the Catskills where we didn't have access to anything but a bed and a bathroom. For the former, we just took all of our bottle stuff along. For the latter, we bought pre-filled, no-refrigeration-needed bottles and the lousy nipples that fit on them.

I'm feeling like these beach vacations will test my bottle skills. In NYC, we own seven glass bottles (Dr. Brown's and Born Free) -- and we're constantly juggling the nipples, rings & vent parts that go with them. Yes we'll have a dishwasher in our beach rentals, but do I really want to cart all of this crap to California?

So here are my questions for all of the moms out there. How do you handle bottle feeding on the road? Any thoughts about Playtex nursers as a possible work-around?

Help!

Monday, June 16, 2008

Going Live

It seems my little caprice has been discovered. I've been quietly writing this blog while the baby naps, but I hadn't really worked up the guts to tell anyone about it. Now I come to find out that my college roommate has a blog too and in her first post she linked to mine! I'm still not sure how she found it -- I've always figured that my name was too common to google with any success -- but now that I'm out to her (Hey shug! How's Jackson Hole?) I figure I should be out to the rest of you.

So here it is... I have a blog. I'm going to try to make it more than just a "mommy blog" but I don't have much else going in my life right now so you'll have to forgive if these early posts are all baby all the time. I have some more interesting posts planned, but if you want to find out my ideas you'll just have to bookmark me & check back.

There's no place to sit!

Well, we've survived our first little parenting hiccough. Yesterday at about noon, Baby Stewgler had a bit of a blow out. I'm not sure how long she was sitting in a poo diaper -- I was busy trying on clothes that no longer fit me while she was (I thought) asleep. By the time it was all said and done, we'd made a mess of her, me, and, most notably, the bouncy chair.

Now I've taken some derision of late for the amount of time that my child spends in said chair. It seems that every time I send a photo to my girls, she's sitting in it. I could try to defend myself and point out that it's tough to hold her in my lap and snap a focused photo at the same time or mention that she really likes it or insist that it makes a spectacular backdrop, but I absorbed the jab and its accompanying grains of salt. It's true, she spends some serious QT in that chair.

Never was this more clear to me than the last 24 hours when we had no chair to put her in. Because we have no washer & dryer in our fifth floor walk up, I do a fair bit of hand washing in the bathroom sink. It's really no sweat -- the bouncy chair cover was clean in a jiffy, but because my forearm wrings don't quite measure up to a spin cycle and because we're in full summer mode with 80%+ humidity, the cover took its sweet time getting dry.

I have to admit, I didn't realize how crucial the bouncy chair was to my parenting style. It seems I depend on the chair to keep her safe, content and contained while I eat, shower, wash dishes, make cappuccinos, check my email, do the crossword, etc. Lest you think I'm a terrible mother, let me point out that the best thing about the chair is its portability -- I can use one foot to keep it bouncing while I wash dishes in the kitchen and she's within arms reach while I'm in the shower should her binky become dislodged. OK, I still sound like a terrible mother. For the record, I've never left her in it while I walked the dog or gotten my eyebrows waxed. Redeemed?

My point is that having no chair threw me a curve. The last 24 hours felt a lot like the first 24 hours (minus the hemorrhoids, of course) -- I had to figure out how to do everything all over again.

And while I was trying to come up with someplace to put her while I made a smoothie ("wanna watch your swallow mobile in your crib again? Oh boy, oh boy!") I started thinking about July 20th. That's the day that I'm going to wake to my alarm clock instead of my baby, put on my scrubs and walk out the door without her, not to return until after my 12 hour shift.

I'm worried that day will be less like a curve ball and more like a curve planet -- for me, for her dad, and for her. I know we're all going to figure it out and settle into that new reality eventually, but if the lack of a chair necessitated a complete reinvention how will we handle the lack of me?

Tuesday, June 10, 2008

What's working & what isn't

Now that we're ten weeks into this parenting adventure, I thought I'd reflect on what, of all the baby stuff we received/bought/inherited, has proven to be worth the space it's taking up in our apartment.

WORKING
  • Oeuf Baby Lounger: Baby Stewgler LOVES this thing. Turns out it's crucial to have someplace (other than the crib) to put the baby. Seriously, you don't want to have to hold 'em every minute. In shopping for a bouncy chair, we definitely prioritized the look of it and the size of its footprint. Yes, there are cheaper chairs (some of which bounce themselves), but this one is really well made, comfortable for the baby & it matches our design aesthetic. Bonus.
  • G Diapers: Without a washer and dryer, we were hesitant to use cloth diapers, but we also felt really guilty about disposables. G diapers are a great middle ground. G's have three parts -- a cloth exterior, a impenetrable snap-in liner, and a flushable/disposable/compostable/biodegradable absorbent core. We mostly use them at home (we use 7th generation disposables when we anticipate changes out in the world) where we can flush and reset with ease. Sure, we have the occasional blow out & you can't be faint of heart if you're going to have to hand-wash the liners in the sink (Dr. Braunner's peppermint soap is working well), but all in all we're totally sold.
  • Swaddlers: From the beginning, Baby IK has been sleeping in a swaddle. Mostly, swaddling helped to keep her moro reflex in check which has allowed her to sleep longer. Dr. Harvey Karp says that swaddling helps replicate the womb. In the beginning, the bambina was swaddled almost all the time, now she's just swaddled at night. They say she'll tell us when she'd had enough. We have lots of different swaddlers -- simple square blankets made with love by Aunt Maureen, the miracle blanket, Halo sleep sack swaddler, Swaddleme -- all of which work well. In our house, swaddling has helped to make our baby a good sleeper.
Not Working
  • Aden + Anais muslin swaddle wraps: In theory, these are great. Swaddling a baby in summer feels tantamount to torture, so the prospect of a gauzy swaddler sounds awesome. The problem is that these wraps are huge -- once you have the baby swaddled, they're wrapped in so many layers of muslin it might as well be a wool blanket. I recently cut one of the wraps in half which makes it slightly more effective. I think the design of these wraps fell prey to serving too many masters -- I'd rather have a well-sized muslin swaddle wrap than a too large wrap meant to swaddle, serve as sun cover, breast feeding cover, emergency crib sheet, etc. I wish I'd bought my own muslin at $2.99 a yard.
  • Graco SnugRide: Let me first say that I think this car seat is perfectly safe which all that matters in the end. My beef is with the handle -- moms NEVER have two hands to do anything so why would they design a car seat handle that takes two hands to adjust. There are two big, cheap-feeling, tough to engage "buttons" on each side of the handle and you need to push both of them at the same time in order to move the handle. Stupid. Totally stupid.
  • Similac 2 oz "nursers": We bought a case of these ready to feed bottles to take on a trip where we wouldn't have a place to clean & sterilize bottles. They served us well in that regard. The bummer is that the nipples seem to have a pretty fast flow. Baby Stewgler is normally a pretty chill eater -- with those nursers she was coughing and sputtering and drooling formula all over the place. As added insult, I discovered that the bottles are made of number 7 plastic which is reported to infuse liquids with bisphenol A -- an endocrine mimic which is particularly damaging to babies and pregnant women. Awesome.
All in all, we're doing pretty well. We kept a pretty tight lid on our registry which means that we don't have much that we're not using (I fear there are some outfits that IK will never get around to wearing, but that's OK). I'm proud of that. I know now that I could have brought her home from the hospital owning nothing more than a baby sling, a crib & bedding, some diapers, a breast feeding pillow, some bottles, some formula (even if you swear you'll never use it -- trust me, you never know), a swaddler & an outfit or two. Everything else is gravy.