the midwife`s journal <
15. when to intervene?
My role as midwife, 'with woman', continues through the week or more after the birth, as the woman takes up her commitment to nurture and nourish her child. It is a demanding time for the new parents. The euphoria of birth is supplemented with the round-the clock needs of the newcomer.
The baby looked skinny. She did not have the protective layer of fat that is usual in the full term baby. In a medical world she may have been categorised as "small for dates", or worse still, "intra-uterine growth retardation". I do not like using this language. Even the common usage of the word "normal" concerns me - what about a baby who has something different - "abnormal"?
As I examined the baby I explained to her parents why I felt it was crucial for her to begin effective feeding from the start. She did not have much stored energy to draw from. She was a well baby, and with good nourishment she would thrive.
During the first 24-hours she nursed reasonably well. Her parents rested and enjoyed her. She slept next to her mother in bed, and when they were up she was constantly in someone's arms. I do not recommend routine times for feeding well newborns. The complex interactions between mother and child that culminate in the establishment of effective breastfeeding are impaired when the mother has her eyes focused on the clock. She needs to use all her senses to know her child.
On the second day I observed a very quiet baby. Too quiet. I watched her nurse. She took the breast instinctively but seemed to lack energy and was soon asleep in her mother's arms. The question that came to my mind then was, do I recommend an intervention now, or wait and see. The baby was well. There was nothing about her colour, temperature, breathing, or any other physical sign that indicated illness. My judgment was not based on quantitative measures such as weight - it was a clinical judgment based on my experience and the baby's behaviour.
I try to understand breastfeeding from the baby's perspective first. This little one was saying to me
"I know the milk's there, and I know I want it. I just don't have the energy to work hard. It's so warm and comfortable in my mother's arms."
The baby needed milk - mother's milk. A teaspoon to collect the drops of colostrum is a simple device, taking the precious liquid gold directly to the baby's mouth. Then follows a sequence of events. The baby's tongue begins to lick; she opens her eyes and looks for more; she swallows and the energy is quickly available in her blood. Frequently a sleepy baby will wake and nurse effectively after a few drops of colostrum on a teaspoon. The mother's response is an increased confidence in her own ability to nourish her baby.
The mother needed help to improve her skill at expressing her milk. Each time her baby woke she offered her breast, and used the teaspoon get started if the baby's efforts were not quickly rewarded. She was happy to work this way, knowing that her baby was getting her milk.
By the third day the baby was brighter and nursing more effectively. The woman was expressing larger amounts of milk, and graduated from the teaspoon to a small glass, just the right size for her baby to lap the milk offered to her.
By the fourth day the mother told me that everything had changed. Baby was now nursing effectively under her own steam. There was no coaxing needed. The mother had a plentiful supply of milk, baby was waking, nursing strongly, and leaving plenty of evidence in her nappies that she was doing well.
The transition from nourishment in the womb to nourishment at the breast is a wonderful phenomenon. Most babies, given the right conditions, will achieve the transition successfully. It is an issue which has engaged the minds of our forebears down through history. In ancient times it was understood that the woman's destiny was to "give flesh" to the seed of the man, both before and after birth. Placental function was not understood. Leonardo daVinci (1452-1519) recorded the thinking of his time in one of his cross-sectional anatomical drawings. A duct is shown going from the woman's womb to her nipple, with a drop of milk coming from the nipple. It was known that during sexual intercourse milk would be spilled from the breast. This was explained by the existence of the hypothetical duct. The penis was thought to act as a piston, pushing the milk from the womb and out the nipple.
Milk ejection is now known to be under the influence of the hormone oxytocin, the same hormone that causes contraction of the uterus. The woman's role in "giving flesh", not only through her milk, but also in her contribution of genetic material and nourishment of the child in the womb, is even greater than the ancients understood. The complex balance of physiological and psychological; neuro-endocrine and immunological factors that work together in the breastfeeding process will never be mimicked. The woman and child who establish a breastfeeding partnership immediately after birth have a treasure that cannot be valued.
The woman who is receiving consistent advice from someone she has learnt to trust will understand the process. Intervention at this level does not indicate any failure on the part of the woman or the baby. It is a protective measure, ensuring health, rather than waiting for signs of illness such as dehydration or weight loss. I am privileged to be able to provide this type of care which is so very different from mainstream midwifery practice in this country.