Medication and Lactation

 
by Mary Curley, Clifton New Jersey, dedicated to my sister Ruth

I nearly weaned my baby at nine days old.

It was December 1999 and I waited, with some anxiety, as my due date approached.  The fact that I could have a Millennium Baby was uppermost in my mind as the excitement of Christmas gave way to worldwide euphoria surrounding the Millennium New Year.  People had all sorts of strange and wonderful plans made to mark this new year of a lifetime.  Obviously I wouldnıt be dashing across the world with them to celebrate midnight in twodifferent time-zones!  Nor indeed had I any desire to join my sister and her friend in New Yorkıs Times Square to watch the famous Waterford Crystal Ball descend.  I did, however, go with my sister into New York City during the day on New Yearsı Eve, to experience the buzz and anticipation of the occasion as the crowds gathered.  I retreated back to the relative calm of my home, like Cinderella, well before midnight.

With my first baby due any day, my main preoccupation was to avoid going into labor on New Yearıs Eve; I simply couldnıt imagine anything worse than having media cameras looking between my legs as I delivered the Millennium Baby!  For me this was an intimate, private occasion, very personal and not one to be shared with the world media in return for a lifetime supply of diapers or formula or any other reward for giving them a news story! 

Thankfully my wish was granted and my baby stayed curled up in the warmth and security of my body until after the Millennium celebrations were over.

I had moved to the US from Ireland the previous October, already six months pregnant and knew nothing of the American healthcare system.  I found myself on a very steep learning curve.  I had a lot to learn and had to learn it fast.  I was surprised and disappointed when I discovered that babies here were routinely delivered by doctors, and not by midwives and so, reluctantly I signed up with a regular obstetric/gynecology practice.

I read extensively during my pregnancy and knew that I wanted a natural birth, one that would be empowering and fulfilling.  The more I learned about the potential dangers of medical intervention in childbirth, the more adamant I was that I did not want the birth of my baby treated as a medical event. It had never occurred to me that I would be delivered by a doctor unless there was a problem, and felt sure that the very presence of a doctor during labor and delivery would, by its very nature, constitute a self-fulfilling prophesy.  Then one day, while reading an article in amagazine about doulas, I discovered that though unusual, it was possible to have my baby delivered here by a midwife.  And so I switched caregivers in my eight month, from an ob/gyn practice at a high-tech university medical center to a midwife at a birthing center.  Although I was concerned about changing caregivers so late into my pregnancy, I felt confident that I would have a more satisfying birth experience with my midwife.  She had a good track record of natural births and I could relate well to her and to her birthing philosophy.

I had the choice of delivering with her at the birthing center or under her care at the nearby hospital where she had privileges.  Much as I wanted to give birth at the birthing center or even at home, I decided to opt for a hospital birth because of a pre-existing medical condition.  Six years earlier, I had suffered deep vein thrombosis (DVT), a blood clot, in my leg after a long flight.  This was a serious, potentially life-threatening condition, which thankfully was resolved after three months on Warfarin, anti-coagulation treatment (tradename Coumadin in the US).   Blood tests carried out at the time failed to find any underlying reason for the DVT but I was advised that hormonal changes such as pregnancy or the contraceptive pill could put me at further risk in the future.  Therefore I felt more comfortable having doctors and medical facilities close at hand should a clotting problem arise at delivery or post-partum.

Even though I had opted for a hospital delivery I felt confident that, under the care of my midwife, I was not compromising my chances of having a positive birth experience, and I was still planning a natural unmedi-cated labor and delivery.  I had already decided that I wanted my baby to room-in with me and breastfeed on demand, having read about the amazing health and emotional benefits for the baby and the close mother-baby bond it fosters.  I hadnıt seen much breastfeeding within my circle of family and friends and didnıt have many role-models for the attachment-style parenting that I felt instinctively drawn towards.  It was mainly through reading that I discovered this style of mothering, mothering from the heart, which seemed so right to me.  My cousin in Ireland had given me her copy of La Leche Leagueıs The Womanly Art of Breastfeeding, and she herself was a wonderful role-model for me, having given birth at home and breastfed for a number of years.
 
Finally the moment arrived, time to put all the theory into practice.  I had a long but relatively easy labor, and a natural and joyful delivery with no complications; all I had hoped for.  I was not, at any time, offered pain relief medication nor did I ask for it.  In fact I was so immersed in the whole experience that I surprised myself by not even thinking about the pain.  My daughter Grace came into the world a healthy alert baby who nursed straight away.  Both baby and husband roomed-in with me at the hospital for the two nights.  We were off to a great start.  I was ecstatic, recovered well and was full of the joys of new motherhood breastfeeding.

A few days after coming home however, I started feeling a cramp-like pain in my right leg.  I assumed that it was a pulled or strained muscle, maybe from sitting awkwardly while nursing, but when the pain worsened I realized that it was more serious.  I called my midwife.  She was equally concerned and sent me to the hospital immediately where she arranged for a Doppler Study (similar to an ultra-sound) on my leg to check for a DVT.  My husband was at work but thankfully my sister Ruth was staying with me and accompanied me to the hospital.  Hospital rules didnıt allow Grace to be with me in the examining-room while they carried out the tests on my leg.  I hated having to be apart from her, but consoled myself with the knowledge that she was in the capable and loving arms of my sister in the waiting room.

I knew, somewhere in the dark recesses of my mind, that the pain in my leg could very possibly be a DVT, but I couldnıt admit as much to myself lest I make it come true.  Nothing, however, could have prepared me for that very news.  To my horror the test confirmed my worst suspicions; I had developed another DVT in the week post-partum.  I was admitted to the hospital there and then, feeling scared, bewildered and lost.  Ruth comforted me and helped with the baby.  Rather than have me admitted to a regular ward, my midwife arranged for me to be admitted to the labor and delivery ward (LDRP), which could accommodate both mother and baby.  That way Grace and I could stay together and continue nursing uninterrupted.  It was hospital policy that my baby could stay with me as long as there was another adult present to take responsibility for her as I was a patient.  So here I was back again in LDRP, coincidentally in the very same room where I had given birth to Grace only a week earlier.  This time the occasion was not such a happy one.

Then the nightmare began in earnest.  I was seen by a vascular surgeon.  He explained the seriousness of my condition: the DVT in my leg could, if left untreated, travel in my bloodstream to a more dangerous site, for example my brain, heart or lung, which could be fatal.  All I could think about was my beautiful baby daughter in my arms, and that I might not live to see her grow up.  My own mother had died suddenly when I was only eight years old. I was the oldest of six children, Ruth the youngest had just turned two, so the tragic possibility of leaving my baby motherless was very real to me. By some cruel twist of faith, was history repeating itself?  I could not
allow myself such morbid thoughts.

There were two alternative anti-coagulant treatments, the doctor said, Heparin by injection or Coumadin taken orally.  My first question was ³Can I continue to breastfeed?²  Definitely not on Coumadin, he said.  Regarding Heparin, he said that there had been no clinical trials carried out on nursing mothers taking Heparin, and that I would therefore be putting my baby at risk.  ³At risk of what² I asked, ³hemorrhage?²  ³Yes², he said.  My heart sank and I felt sick to my stomach.  I saw no option.  What mother would put her newborn baby at such risk?  The doctor advised that I start treatment immediately and give the baby formula.  With that, he left the
room.

I was all but resigned to what seemed like an inevitable course of action, to wean Grace abruptly and start medication that night.  I didnıt like the doctorıs advice, but I trusted him and believed that he knew best.  I was devastated.  I knew that nursing was important to me, but not until that moment did I realize how much. In only one week it had become for me an absolute and integral part of my mothering. It felt almost like a bereavement, the thought of weaning Grace. I cried and cried and could not believe that we would never nurse again.  I can still picture myself sitting there, holding her and looking at her, tears streaming down my face, loving her so much and wanting the best for her, furiously nursing her as if to get as much of my milk as possible into her this one last time.  I was grieving for all the lost goodness she would not receive.  I was grieving for our soon-to-be-lost nursing relationship.

Ruth was there, a tower of strength and clarity, supporting me as I
struggled in a hopeless fog.  She was horrified at the insensitivity of the doctor and was not at all convinced by his assessment of the situation.  She was not prepared to accept what he said.  She was angry, yet clear-sighted and determined.  We both felt the doctor had been dismissive of the nursing relationship. He showed no understanding of the numerous health and other benefits afforded by breastfeeding.  His risk-benefit analysis extended only as far as my need for medication.  He placed no intrinsic value on breastfeeding and saw no inherent risks in weaning Grace off the breast and on to formula.  It was simple and clear-cut to him ­ breast or bottle; it was all the same.

Something deep inside, call it motherıs intuition, prevented me from
starting the medication straight away.  I knew that if I weaned Grace it would be an almost irreversible decision.  I was not ready to do this.  Ruth and I began to explore other options.  True, I needed medication to treat the DVT; that was not optional. I could accept this.  What about Opumping and dumpingı my milk for the duration of the medication and then resuming breastfeeding?  But I would be on medication for at least three months, too long I thought to sustain my milk.  Anyway, even if I managed to do this, Grace would still be at the loss of her motherıs milk for those important three months and our nursing relationship would be severely disrupted.  So we ruled out that option.  Coumadin was definitely contraindicated for nursing mothers.  That, I could also accept.  But what about the Heparin ­ would that really put my baby at risk?  I called my pediatrician and left a detailed message for her stressing the urgency of the situation.  She didnıt return my call, however, plunging us deeper into the dark.

The more Ruth and I discussed it, the more angry and frustrated we became. We were determined not to leave any avenue unexplored but did not know where to turn.  If I was convinced that my medical condition absolutely required that I have treatment which would endanger my baby and that all options had been exhausted, then albeit reluctantly I would have weaned Grace.  But I felt that we didnıt have the full picture.  I was not in a position to make an informed choice about my health and that of my baby.  At no stage had my doctor suggested speaking to the hospital lactation consultant nor did he advise me to contact La Leche League. Ruth and I wracked our brains to find a solution, hoping for a miracle.  She felt that we should get a second opinion and seek further advice.  I asked to see the lactation consultant at the hospital and also left a message for the hospital pharmacist to contact me.

My husband Gerard had joined us at the hospital by this time.  In the midst of our explanations and deliberations, the nurse came in with the first dose of my medication as directed by my doctor.  I refused the drug, explaining my reservations and told her that I was awaiting a second opinion before starting any treatment that could interfere with my breastfeeding.  She was kind and understanding, and suggested that she might have some information for me.  She provided pages photocopied from a breastfeeding reference book. Although no clinical trials had been carried out on nursing mothers, Heparin was not considered a high-risk medication during lactation. This was our first glimmer of hope at the end of a long, long emotionally exhausting day. I decided not to start my medication that night, postponing a final decision until the next day when I would have a chance to discuss it with the lactation consultant and the hospital pharmacist.  This was a serious and very difficult decision for me, a huge leap of faith.  Here I was, with a potentially life-threatening condition, ignoring the advice of my doctor and not taking the prescribed medication.

The following day a miracle unfolded!  I cried with relief as the advice from both the lactation consultant and the pharmacist confirmed the information given to us by the nurse.  Although there had not been any actual clinical trials carried out on nursing moms, women on Heparin had nursed safely.  Apparently the molecular size of Heparin makes it unlikely that it would cross into motherıs milk.  Even if some of it did get into the milk, the pharmacist explained, it would be destroyed by the baby herself during digestion because for Heparin to take effect, it must be injected subcutaneously.  I could safely inject myself with the prescribed Heparin, secure in the knowledge that it was unlikely to get into my breastmilk.  I was doubly reassured by the fact that any of the medication that did somehow get through would be destroyed by Graceıs own digestive system.  What a revelation!  What a relief!

All throughout my indecision the previous day my midwife had advised me to trust in myself.  She assured me that in following my mothering instinct I would make the right decision for myself and for my baby.  Sure enough, surrounded now by helpful, understanding and knowledgeable people, I was at last in a position to make an informed decision about my health and that of my baby.  After much soul-searching and with the support of my husband and my sister, I started on the Heparin treatment and continued to breastfeed my baby.  I was discharged from the hospital the following day and remained on Heparin for three months, after which time I received a clean bill of health from the doctor.

Grace is a happy, healthy and lively toddler who, two and a half years later, still enjoys the benefits and the pleasures of nursing with her eight-month old sister Eleanor.

I have since learned that my story is not unusual.  Many doctors are only too willing to prescribe weaning as a quick and easy solution in such situations, with no thought for the distress caused to mother and baby, and no consideration for the health, nutritional and emotional benefits denied to the baby who is weaned unnecessarily.  I look back with sadness and disbelief when I think how disempowered and helpless I felt, how easily I could have accepted in good faith the doctorıs advice and how close I came to weaning Grace abruptly at the tender and untimely age of nine days.  I think about all we might have lost, the health and nutritional benefits, the enhanced immunity and the emotional closeness afforded by nursing.

I look back also over the past two and a half years and am grateful for the relaxing and calming effects of prolactin, the Omothering hormoneı produced during breastfeeding or as Dr. Sears aptly calls it the Operseverance hormoneı.  I call it the Ohappy hormoneı and donıt know what I would have done without it during some of the more challenging moments of motherhood! I will forever be thankful that I had the strength and courage to make the decision to continue breastfeeding Grace.  It has enriched our relationship beyond imagination and I am sure it has played a role in the kind and loving relationship I see developing between her and her baby sister.  Our beautiful nursing threesome has made my life all the richer.  Without it, I would never have known the joys of hearing a little voice say ³No close the nummies, Mommy² or ³I share the nummies, Mommy; that one is Eleanorıs and that one is Gracieıs²!  And I wonder how else I would comfort my upset toddler when she comes to me crying and says ³Nummies make it better Mommy.² 

BREASTFEED

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