Oh my! Life with a newborn is wonderful. Fletcher is already displaying a lovely personality and lively intelligence, seen in glimpses in the short hours in which he is awake and the fleeting smiles that cross his face on the twilight edge of sleep. (Gassy grimace "smiles" are different.) He makes earnest attempts to communicate, through eye contact and the simplest and most pure signs and gestures: for instance, he roots all the time, for his knuckles, my pinky finger, the pacifier, nipples, and for food, but if he is HUNGRY, he makes pointed eye contact and then opens his mouth wide, like a baby bird. He copies facial expressions -- sort of -- although he has patience only for sequences of three or four of them. He clearly loves and trusts his father and mother. And he is strong -- raising his head from Day Two, although he cannot maintain it, and becoming Tiny Fists-O-Fury when upset or gassy.
Guess what upsets Fletcher? My breasts.
He won't nurse, for various reasons. When he was born, he was lethargic from Magnesium Sulfate and morphine, hypoxia, and a precipitous blood pressure drop. He was "sleepy" and the instant the nipple went into his mouth, he fell asleep. Tickling or chilling him during nursing to try to keep him awake only (predictably?) annoyed him further.
He clearly dislikes having a lot of breast tissue in his face along with the nipple, but there's not much I can do about that -- I am both fat and busty, and I have a lot of breast tissue. The "breast sandwich" is too fat for his little mouth, and my nipples are too big for him. And after being injured by the well-meant pinching of the lactation consultants and my own desperate attempts to compress my size Fs into size As for the baby, I have been wrestling with engorgement that makes this problem worse, much worse: the nipple is perched on a taut, swollen areola that cannot be "sandwiched."
And he hates to be confined (except in a swaddle, which is most DEFINITELY not nursing attire in his book) and doesn't like to be "positioned" tummy to tummy with me (or any variation thereof, in which he has to lie still and stop swinging fists and feet). He doesn't open his mouth wide enough to latch, ever, and might be tongue-tied... but at this stage of the game I would not consent to elective surgery (however minor) to correct it.
But he was jaundiced and we were in a major hurry to get some nutrition in him to flush the bilirubin out of his system. So we fed him expressed colostrum, by finger feeding and through a bottle nipple, with the assistance and blessing of the lactation consultants. He is now nipple-confused and just gnaws the bottle nipples instead of sucking on them -- though he does suck my pinky and the pacifier, if he can get his tongue properly depressed to do so.
The only position in which Fletcher appeared to enjoy the process of unproductively mauling my nipple, licking off the droplets I hand-expressed to tempt him at least, was oddly gymnastically equivalent to the reverse-cowgirl (or at least the 69) of nursing: too contrived, lacking in intimacy, and simply not as pleasurable as it is adventurous. I can lie on my side with the baby's tummy toward my face and his head toward my breast, and instead of arching, screaming, and pummeling me with his brutal little fists and seizing handfuls of areolae with his sharply kitten-clawed fingers, or falling asleep, he simply gums my nipple and whimpers. But when they tried to teach me to do this in the hospital, I was in agony from my incision, and I am not sure that it's the answer now, either. I mean, nursing at the breast instead of simply lying together skin-to-skin and feeding him satisfactorily from a bottle is a matter of my convenience: for social reasons, I cannot exactly strip, lie down 69-fashion with the baby, and try to force him to suckle instead of gnaw in a "mothers' room" at Babies-R-Us -- let alone at my chair in a restaurant!
So. I've been exclusively pumping breastmilk for the little guy. And, when necessary due to engorgement or blockage or when encouraged by nurses in order to help push out bilirubin, a supplemental bottle of formula every other day or so.
I've researched nursing through every website and book I can lay hands on, and am mightily annoyed. All of them assume that you will read the books before starting and NOT as a matter of troubleshooting, and all of them assume that if you just stick with it everything will be magical and will work out perfectly and unicorns will fart rainbows on every street corner. They make dire predictions that if you ever, ever give a baby formula, you have condemned him/her to a life of obesity and diabetes, amid other complaints. They tell you not to "give in." They assume that doggedness is all it will take to nurse a baby. And I am here to tell you, it doesn't always work out that way.
Also, there's a lot of disinformation out there. Nice and well-meaning people with lots of professional experience will give some of it to you. They probably do a lot of good for people without serious problems, but for those of us who have some stubborn obstacles, the advice itself can cause suffering.
Here are the little things about expressing breastmilk that I've learned so far.
1. DON'T let pumping or hand expression cause you pain. If the pump hurts you, you may have too small a flange for your nipple, or too sharp an edge in your flange: use lanolin to grease the flange edge if you need or file it down with a fine emery board before you wash it next. Or you may have the suction turned up too high. Just -- don't. Be gentle and kind and loving to your breasts.
2. DON'T worry. If you are stressed, you will give less milk (that session.) Take the time to relax, breathe deeply, think happy thoughts, get a massage or get your back scratched, get comfortable, have someone hold the baby, have your significant other massage your breasts (NEVER toward the nipple, always away! and massage up to the collarbones and out to the edge of the armpits, you have glands everywhere), use hot compresses or take a warm shower if you like. Kick your relatives out, even if you would let them watch you nurse: pinching your breasts or being hooked up to the machine is not shameful, but it is qualitatively different. You will be amazed how much this affects your milk production.
3. About quantities: all the books will tell you that so long as your baby is peeing or pooping the requisite number of times and appears to be thriving, you have enough milk. This is probably true; all babies are different. And yet... if you're like me, you want to know what would be ideal production. You will start out producing a milliliter or two a session of expressed colostrum, the sticky yellow stuff that is so great for babies and which comes in before your milk. That amount will increase until transitional milk comes in (much wetter and whiter). By the end of the first week of the baby's life, you will probably be producing at least half an ounce to an ounce of milk a session. By the end of six weeks, when your milk is done transitioning and your supply becomes more or less stable if maintained, you'll be producing something like 25 ounces a day.
4. Pump every 2 1/2 to 3 hours during the day and every 3 to 4 hours at night, for 12 to 15 minutes a session. This is tough to balance if you get tender: you'll need to stop if you are making yourself sore and aren't producing much milk, but you will want to express a goodly quantity every session to "order" the milk you want for the next session (you get back what you remove from the breast.) Don't crank up the pump strength. Don't pump more frequently. Don't pump forever in a session. Painless and efficient is what you want.
5. Use an ice-pack after pumping if you are sore. Don't use it too close to the next session, as a cold boob is not an optimal milker. Use a warm compress to loosen things up again if desired.
6. Try to get ahead of the baby's needs. If baby is crying, it will stimulate your letdown, sure, but it'll raise your stress. See #2 above. Have someone entertain the baby if possible while you focus on pumping.
7. Don't focus too hard on pumping. Feel free to relax & meditate, fantasize, scheme, watch TV, read, whatever. I catnap because oxytocin makes me a zombie.
8. WEAR A BRA. Not a tight bra that leaves lines and compressions on your skin, because that will impact the glands and could cause mastitis or engorgement. A nicely-fitting, soft, stretchy sports bra.
9. While you pump, use gentle compression on the engorged glands in your breast to increase milk flow. You'll be shocked at how well this works. GENTLE is the watchword here -- and you do not want to squeeze-and-pull toward the nipple, just to press the milk sinuses that are reluctant to release their bounty.
10. Don't squish the flanges into your flesh so hard that they create compression areas. The ideal is to hold the flanges gently onto your skin in a "natural" position. This ideal is ridiculous, because there is nothing comfortable about leaning forward with your hands tucked under your knockers and trying to hold on hard-plastic cups that will spill milk down to your navel if you jostle them at all, but it's just that -- an ideal. Shoot for it. And learn to live with the spills.
If I think of more, I'll add them. But there you go.