Pumping Tips for the Military Mom

This past weekend was the first time going to the field since my daughter was born in February.  Army regulations prevent units from having new moms go on overnight trips until your little one is over four months old. So as of June 13, I was on the list to head out to the field.  This weekends training schedule was packed, including bussing across the state and being the Officer in Charge (OIC) on the weapons qualification range.

Even without being a new mom, even for the second time, being the OIC of a range is an important responsibility that takes a lot of planning, coordination, management, and execution.  There are a lot of moving parts that go into making the range a success and accomplishing the mission.  But I also had another mission: pumping and saving enough milk for my baby girl.

I looked to one of my favorite resources on the subject: Breastfeeding in Combat Boots.  Robyn Roche Paul is the go-to resource when it comes to knowing about the tips and tricks for successfully breastfeeding in the military.  She has been a breastfeeding advocate since she herself became a mother while serving in the Navy, and has been an International Board Certified Lactation Consultant (IBCLC) since 2006.

My husband was able to find a plug in cooler at a garage sale a couple of months ago, and I originally planned on taking it with to store my milk in.  But after a test run last weekend, we discovered that it just wasn’t staying cold enough and it wasn’t going to the best choice for the logistics of taking it from our sleeping area to the range and back again. So then I started looking into taking some dry ice in a small picnic cooler.  I found a distributor nearby and they were really informative about how to use it – but they advised that I would need to check with the bus company that would be transporting us to verify that they would allow it on the bus.  Since the buses are contracted, I would need to talk to the actual bus driver that I would have on the day of and that just wasn’t information that I was able to track down.

So, my section NCOIC helped me to verify that they cooks for the unit would have ice on hand throughout the training exercise.  She chuckled a bit about it, but her daughters are actually my age and breastfeeding mothers themselves.  The morning of departure, I packed up a bag of ice from my own freezer and tucked it into my cooler. I also made sure I had a couple of special things in my pump bag to make sure that I would have smooth sailing all weekend.

  1. Freemie  – These collection cups for my breast pump were a HUGE game changer.  I’m able to use them with my Medela pump as well as with their own model as well!  They tuck right into my bra so that I can pump discretely whenever, and wherever I can.  I just put them in place, and then I just pull my tan t-shirt back down and pull my ACU blouse back together so that you can hardly tell I’m pumping. The noise of my pump humming next to me is the only thing that gave me away a couple of times! I even pumped in the control tower of the range!  They are absolutely worth the investment.
  2. Battery Pack – Medela has a battery pack that is compatible with their Pump in Style pump and this was amazing for pumping on the bus to and from our training.  It was a four hour bus ride each way, and it’s not always possible to pump right before boarding based on what is going on.  But with the battery pack I could pump anywhere that I needed to.
  3. Power Adapter – I also made sure to tuck a power adapter into my bag just in case I needed to pump while in a vehicle I would be able to with ease.  I didn’t use it this weekend, but it has come in handy before and I definitely recommend every pumping mom have one in her bag!
  4. Pacifier Wipes – There are some fancy wipes you can get for your pump parts for quick cleaning on the go. But when I checked out the ingredients compared to the equally fancy but much cheaper pacifier wipes available, they were very similar.  So when the best I can do is a quick wipe down this is what I use.  You don’t want your milk sitting in your pump parts out in the heat in the field, it’ll cause bacteria to grow.
  5. The Basics – These are things I always have on hand including my breastmilk storage bags, permanent marker, and extra tubing.

I am very fortunate to be in a unit with many people who are supportive of me and other mothers in the unit that are on this pumping journey.  I was able to pump on the bus on the way to our training base, in the barracks, at the range, and on the way back as well.  There were some hiccups of course, but these have to be taken with a little grace and press on to not only accomplish my mission to nourish my daughter but also to accomplish the unit mission.

I missed a pumping session due to a required certification course with Range Control, and it made me anxious at the time and impatient to get to a place that was at least semi-private to pump.  I didn’t feel comfortable pumping in the van on the way back to the barracks because it was a packed full 12 passenger van but I just had to tell myself that I was already late pumping anyways and the extra ten minutes it would take to get there wasn’t going to make a huge difference.  When I got there, I was able to sit down and have a moment of quiet and pump.

The morning of the range, I woke up to pump and the milk started backing up into the tubing!! AHH!  It made me panic for a split second, but then I got my wits about me and disconnected the tubing before the milk reached the pump.  After calming down from my oh-my-gosh-my-pump-almost-just-got-milk-in-it moment.. I just took my pump cups and the tubing to the latrine, washed everything and started again.  And it was fine!

The Non Commissioned Officer in Charge (NCOIC) on the range with me was really supportive.  He had zero issues with my pumping in the tower, saying something to the effect of “Of course, it’s just natural!” After hearing so many stories of other Soldiers having unsupportive environments, it was a sigh of relief to just be able to do what I needed to do and take care of business.

Other tips:

  • At breakfast and dinner each day I replaced the ice for my cooler and it worked out really well. But we were eating in a DFAC which made it a lot easier.  But our food service section told me that even if they had been cooking out of the MKT they could have helped me with ice.  Don’t be afraid of simply asking for what you need.  You might be surprised how supportive people can be with just a simple request!
  • I ended up moving my pump from the normal pump bag into my assault pack so that it was easier to take with wherever I needed to go.  It helps decreasing the I’m-carrying-a-breastpump-everywhere feeling too.  Just another Soldier carrying around a normal assault pack.
  • I used a pillow over the pump in the barracks after lights out and before wakeup to keep it from making too much noise and waking up the other Soldiers.
  • I wore tank tops under my tan t-shirt to make sure that when I was getting my pump stuff set to go I wasn’t showing my stomach. That might not bother other people but I like to stay as covered up as possible especially at work, and it is also a good-will gesture to put others at ease who might be around when you need to pump.
  • Stay flexible.  You might not always be able to pump in ideal conditions.  You might end up pumping in places you’d never expect, with people around.

The Army doesn’t have a regulation to protect the rights of breastfeeding mothers like the other services, so you have to be pro-active.  Instead of focusing on what the Army doesn’t spell out in writing, we can focus on the flexibility that we can have with it.  I’ve found a lot of success with being honest about what I need to accomplish my goals and frankly, not making it sound like a big deal.  I don’t ask permission to pump; I let people know that I need to go take care of something and I’ll be with them in about 15-20 minutes. If I have a meeting scheduled at the time that I normally pump, then I pump earlier or wait until after if I know for sure that it’ll be a short one.  The more natural we make it seem, the less it will phase others and the more pumping can be normalized.

The End of Maternity Leave 

Today is my last day home with my family before I go back to the office.  

I can hardly believe how fast the time has gone and that Tomorrow I will be returning to work – armed with a new breast pump and the faint hope that my brain will function. 

I am blessed that I have been able to spend ten weeks at home with my new little one, my toddler, and my husband. The U.S. Military gives new moms six weeks of paid maternity leave. After the end of the six weeks, I used a combination of regular vacation time, and 13 days of convalescence leave after my Thyroidectomy. 

The time has been a bit surreal in many ways. There’s so many things that I was able to do that would normally never happen. Like wearing colored nail polish for 8 weeks straight (I’m only allowed clear polish when in uniform). Sleeping in and snuggling with my kids on weekdays. Taking our time to get ready for the day. Going to the Chiropractor as a family. Running errands in the middle of the day. And exploring the city more than ever before, including trips to the Zoo and Children’s Museum too. 

As I sit here, listening to my baby girl breathing as she sleeps on my chest, it is hard to believe that it’s over. My days have been filled with such joy! And soon I’ll only be able to spend half as much time with my little ones again. 

I am so thankful that my husband is a stay at home parent. I can’t imagine how emotional I would be if tomorrow I had to take the kids to a daycare facility. We are blessed to have one of us at home, and he does an amazing job, but sometimes I wish I could be the one to do it. For a variety of reasons, it has made more sense for my husband to stay home. But I fear that my kids will somehow be upset about that decision someday. That they’ll feel angry that I chose to work instead of taking care of them. I think a lot of working Moms face this fear.

How do I explain to a child all of the very logical reasons why it makes more sense for Mommy to work? When at the same time my heart aches to be able to give them exactly what they want?

I don’t think there’s a good answer to this. But for now, I will work hard and give them the best life that I can so that they are taken care of and feel loved. I will try hard to treasure every moment we have together to make it through the times when we are apart. And someday I hope that they understand that we’ve done the best that we can for them. 

But for just this moment I’m going to soak in this baby snuggle. 

Ten Tips for Surgery as a Breastfeeding Mama

Having surgery while you’re breastfeeding your little one may not be ideal, but sometimes can’t be avoided. I just had surgery a few days ago for Thyroid Cancer, and I wish I had known some of these ahead of time! This was my first surgery besides my emergency cesarean, and I didn’t know what to expect. 

In case this is your first time too, here’s a brief timeline of what happened. First, we checked in and waited in the Family Lounge. When they called me back, I went to a small triage area where they took my vitals and had me change out of my clothes and into a hospital gown. From there, I said goodbye to my husband and was taken to the pre-operative preparation area. This is where I spoke with the Anesthesiologist and the Surgeon. Next was the surgery itself. After the surgery, I was in the Post-Anesthesia Care Unit. And finally, to the recovery area where I saw my husband again. 

So here are my ten tips to navigate all of that as a breastfeeding mother: 

1. Start a stash early. If you know about your surgery in advance, start pumping and saving milk up ahead of time. I used a Milky Milk Saver during the first couple of weeks post partum to catch my extra milk to save. We were able to use that milk for the two days I was away from my daughter.  Pumping once a day can also help to build a stash as well. 

 2. Have some help. My surgery was a two day endeavor. My Mother in Law came to help with both the baby and the toddler so that my husband could be with me as much as possible the day of surgery and day of discharge. If that isn’t an option, reach out to your friends and community. You can also look at Care.com or Sittercity to find someone to help. 

3. Let your doctor know. I was able to speak with my surgeon during my pre-op appointment regarding breastfeeding and pumping. We discussed what kind of anesthesia they usually use and asked her to put a note in my file requesting a breast pump in my recovery room. 

4. Make a mermaid bra. This was a tip from the amazingly kind nurse when I was getting ready in the triage area. I was nervous about my milk leaking during the surgery, but I could not wear my undergarments into the operating room due to sanitation reasons. We took four pieces of medical tape and taped my disposable nursing pads on instead.   The anesthesiologist was fine with this and it put my self conscious mind to rest. 

4. Bring your own pump. Even if you’ve talked to your surgeon ahead of time about getting one at the hospital, bring your own too. I packed mine in a small bag inside of my hospital bag. I was able to pump about an hour before my surgery in the triage room, and then gave it to my husband. I had the nurse write a note in my chart that they should send for it again immediately after surgery- while I was still in the post-anesthesia care unit. 

5. Disposable underwear and a pad. If your surgery is very soon after giving birth and you’re still experiencing Lochia, or even if it’s later on and you have some lingering incontinance, don’t be afraid to ask for some of those nice stretchy disposable undies and pads.  They won’t allow personal undergarments in the OR, but they can give you some temporary ones. Your nurses might even chuckle and say something about it being the easiest request they’ve had all day.

6. Request a pump as soon as you arrive in recovery. I must have been annoying in my persistence, but I’m glad of it. My hospital pump didn’t arrive until about four hours after my surgery. They had to get it from the maternity ward in another building. I used my personal pump twice during that time. Having the hospital pump was a lot more convenient for overnight for a few reasons: it was on rollers so I didn’t have to hold all the attachments and the machine on my lap whilst getting situated, it was much more efficient so I’m sure I pumped more than I would have with my normal pump, and it’s much quieter which I’m sure room mates in the recovery room appreciate. 

7. To dump or not to dump. You’ll hear varying opinions on this depending on who you ask – especially from the surgeon, the anesthesiologist, and the nurses. I decided to only dump the milk that I pumped immediately after surgery – while I was still in the post-anesthesia care unit.  I needed assistance from the nurse to attach my pump and get started so I felt there was probably still too much medication in my system to safely keep it. However, I kept all subsequent pumps because I was not on anything stronger than what they give to cesarean section mums. Make the best decision for you and your family. Kellymom.com has some great information regarding anesthesia and breastfeeding. 

8. Don’t stress the ounces. Pump when you can and don’t worry about whether you’re keeping up with demand. Post surgery your true focus should be on healing – your baby needs you healthy and strong! Any milk you get is a blessing and stressing about whether it’s enough could steal your joy. Set an alarm to pump every 2-3 hours as a reminder and then try to relax.  

9. Bring supplies. Make sure that you bring your other breastfeeding supplies with you as well. I had with me milk bags, a sharpie, and extra nursing pads. It made it much easier to store the milk and label all of them. Don’t rely on the hospital to have enough pump bottles to store everything you pump. 

10. Nurses are there to help. If you need help rinsing and washing the pump parts, ask! If you need a cooler with ice to keep it cold, ask! Nurses are great problem solvers and can help to make it easier on you to accomplish your goals. The call button is there for a reason.

I hope that you don’t have to use these tips, but if you do, I hope that they help your experience go smoothly!

Birth Story: Ellie

Birth Story: Ellie

Today, I get to share with you my own VBAC birth story!  It’s already been a few weeks since Ellie arrived, and I am finally able to sit down and write this and it still seems surreal to me!  If you’ve been following my blog, you know that over the past three years I have been doing a lot to prepare for our second baby – even before we knew that they would be here!

My first baby arrived through a traumatic emergency cesarean section after a long labor in 2012.  He presented in an asynclitic posterior position and despite the OB trying to manually turn him twice during the pushing phase – he would not budge.  During the attempts to turn him, meconium stained fluid was released, his fetal heart rate plummeted and we were rushed to an operating room.  I experienced a panic attack during the surgery and my son was rushed to the NICU due to inhaling the fluid and meconium.  We were reunited again more than 7 hours later, an exhausted mama and baby.  Recovery was very hard physical, emotionally and mentally.

The following days, weeks, months I started to heal.  I started to realize that it was okay to not be okay with how my son was born.  And once I acknowledged my own trauma of his birth I was able to truly start healing.  I felt like my body had been broken and I needed to figure out how to fix it.  I started to reach out to other mothers who had similar experiences to get more support for how I was feeling.  And just as I had seen medical staff for my physical healing, I started working on my emotional and mental healing as well – combining PTSD counseling from the surgery with physical activity and took up running.  Every mile that I ran started to prove to me that I was not broken – that I am strong and capable. I even ran my first full marathon in January of 2014!

In the Spring of 2014 my husband and I finally agreed that we were ready to expand our family, and that I had healed from our previous birth to try again.  Little did we know that it wouldn’t take long to get a positive pregnancy test!

All things considered my second pregnancy was fairly uneventful.  I didn’t have any pregnancy related complications.  I was diagnosed with Thyroid Cancer during the first trimester however, and that did make it more interesting but it didn’t change a lot regarding our pregnancy.  I really liked my providers and they have a great reputation for VBAC success with over 70% of TOLACs resulting in VBAC.  I also hired a Monitrice as a labor assistant so that we would have someone with us throughout labor to assist with positions, pain management, and when the midwife couldn’t be in the room with us.  I stayed active and healthy throughout the pregnancy; running until I was 34 weeks and continuing to walk until 38.  I saw a chiropractor weekly to help get baby into a good position by using the Webster Technique.  I think all of these factors combined really helped to get us ready!

My due date was 8 February 2015 and as the date came and went my anticipation built.  Several friends due around the same time (and after me!) had their babies and I was eager to have our baby too! That last week we tried nearly every old wives tale out there to try and convince our little one that it was time to make their debut!  Eggplant parmesan, fresh pineapple, sex, walking, acupressure massage, pedicures, evening primrose oil, pumping, spicy thai food and I’m sure there’s more that I tried and even tried twice. This kiddo was just not ready!

I had an appointment on Thursday when I was 40+4 and agreed to finally have a cervical check.  I was already at 3 cm and 70% effaced!  The midwife did a membrane sweep to see if we could maybe get labor going within the next 12 hours or so.  Since I had already been experiencing contractions every night for over a week that didn’t stick around, I was willing to risk going into prodromal labor.  I went home hopeful that it would be just what the baby needed, and waited.  And waited.  I texted my Monitrice around 9pm and she suggested I go to bed saying, “if it is going to work it will work! You’ll need your rest!” I woke up to go to the bathroom around 1:30 am on Friday and nothing was going on still.  I chatted with my sister on Facebook, lamenting that the baby would apparently never emerge. and then went back to bed.

Contractions woke me around 5:30 am on Friday, just a few hours after complaining to my Sister. I started timing them and they were about 5 minutes apart already but only 30 seconds or so long. I sent a text to my Monitrice, Ellen, at 6:30 am and got in the shower.  I woke up my husband after the shower and let him know that the contractions weren’t letting up and I was fairly sure that this was the real deal.  I messaged Ellen again and let her know that I was going to eat some breakfast and keep her posted if they got more intense.  By 8:00 am I was starting to think that maybe I should have Ellen here and I called her.  She stayed on the phone with me for 15 minutes and at the end she said it might be a better idea to meet at the hospital rather than have her come to the house first – it was starting to snow out and it was the beginning of rush hour traffic on a Friday!

We headed towards the hospital and arrived there around 9 am. In triage they had me change, did some monitoring, took some blood, inserted my Hep-Lock and the Midwife on call, Meredith, came to check me. I was so thankful that she was the Midwife on duty! She had been so reassuring during our appointments and she immediately put me at ease. I was already at 5 cm and 80% effaced.  By this time I think the contractions were 2-3 min apart and more than a minute long.  I was starting to rely more on my Hypnobabies words and having counter pressure on my hips.  Once a room opened up they wheeled me there – I didn’t think I could possibly walk through these contractions.  On the way there I had to get the nurse to stop the wheelchair for one!

We got to the delivery room around 10am and that is when it all starts to blend together.  I remember them bringing the birthing ball and using it to lean over the bed while Jeremiah, my husband, and Ellen did counter pressure on my hips.  Then I was kneeling on the bed facing the wall.  Jeremiah says that worked great because they could adjust the head of the bed for me and still give me counter pressure during contractions. Ellen and my husband were great at reminding me to keep my voice low during contractions, and that helped to make me feel more in control of the pain.

I started to transition around 11am and they checked me again; sure enough I was at 8 cm!  The intensity of this time surprised me, and having Jeremiah by my side encouraging me was priceless. He even told me that they were starting to prepare the infant warming table – I was going to do this!!  He even prayed with me for strength and comfort.  Not long after this I started to have the urge to push, but Meredith and Ellen let me know how important it was to wait until I was at 10 so that I wouldn’t swell and make it harder to push when the time came.  They had me blow my breath out like blowing out a candle through contractions to help resist pushing, it took a lot of focus and encouragement. They were having a hard time getting a heart beat from the baby, so they had me turn around on the bed so that I was laying on my left side. They found a great heart rate and checked me again.. and said I could push!! I was so relieved! It was 11:20 am.

I hooked my arm through one knee and Ellen helped to brace the other.  Jeremiah held my hand and helped coach me through pushing, relaying to me what Ellen and Meredith were saying about slowing down, tucking my chin, staying focused and what was happening.  We prayed together again, thanking God for everything and asking for more strength.  The nurses brought a mirror out so that I could see what was going on – I took one look and was done with that! Ha! The need to push was so intense that it was hard to resist and slow down so that the baby didn’t come too fast. It wasn’t long until our precious baby emerged and as they helped me bring her to my chest, my husband announced that our little girl was here at last! 11:37 am! Only 17 minutes of pushing!IMG_7489

She was beautiful.  I could hardly believe it was real! I had done it! She was here!  The three of us reveled in the moment, soaking in the moment that we got to meet each other.  She latched right away and we got to spend some time doing skin to skin as Meredith repaired a small tear and helped with delivering the placenta. After an hour of family time, the nurse took Ellie’s measurements while I started to get a bit cleaned up.  Meredith and Ellen joked about us being able to leave the next day since everything went so smoothly!

IMG_7484

I started to notice some bleeding as we were getting ready to go to the recovery wing.  I told the nurse and she checked me before we left the delivery room and then called ahead to have an OB meet us at the recovery room to double check the bleeding. I was still feeling a lot of pressure and pain, which surprised me, but I had a hard time describing it to anyone so I wasn’t sure if it was normal or not.  When the OB came to our room he was also followed by a small swarm of nurses with different carts and trays.  He said that they needed to check me for a hemorrhage and not to worry.  Lets just say that even though he was calm and collected, the influx of staff and the uptick of concern in the room made me anxious.  Thankfully, Ellie was sleeping peacefully after her eventful morning.

Before the OB started to check for the hemorrhage, they gave me pain medication through the hep-lock that was placed while I had been in triage earlier that morning.  I was so thankful that I hadn’t fought back on the hospital policy that required them for VBAC patients! Jeremiah took my hand and comforted me as the OB checked and found more than 800 mL of blood and tissue that had to be removed. It was a very painful procedure, but the OB was able to remove everything that needed to be and ensured that there was no active bleeding. Thankfully I did not need a blood transfusion, but they were going to keep a close eye on me for 48 hours to make sure that there was no more bleeding.  They also double checked with an ultrasound machine that there was no additional tissue or anything remaining.

After a roller coaster of a day, we were finally able to relax as a family!  We started calling our families and letting them know that Ellie Grace had arrived safely and that we were doing well. And I finally got to eat!  Pancakes, bacon, eggs and a big glass of orange juice delivered right to my room for an afternoon snack.  It was already after 4:00pm!

IMG_7493

Yes, it was so good I am glad I took a picture!

I am so thankful and blessed from this journey. Ellie is amazing, and Noah is a great big brother to her already.  I know that many VBAC moms say that their births are healing and in many ways it was.   During my pregnancy there were so many moments when I still doubted myself, my body, and God’s plan for us.  When I crossed the finish line of my marathon last year I had finally had a moment where I felt like my body could handle anything and that I wasn’t broken anymore.  Ellie’s arrival was the reaffirmation of that moment, and that as long as I trusted God I could do anything.

Ex 14

Distribution and or reproduction of the story or photos not permitted without the written consent of the author.  If you would like to share your VBAC story with our readers, please send it to combatbootmama@gmail.com

Packing our Bags

With only two weeks until our due date, I’ve finally gotten around to packing for our hospital VBAC!

I honestly can’t remember what I packed last time, and I’m not sure if I used a lot of it.  We were in the hospital for over a week then, and I know that hubby had to go home and get more clothes and things after a couple of days.

This time, I want to make sure that I’m not packing too much since I know the hospital really does provide almost everything we will need for the couple of days that we should be there.

Here’s my list that I’m starting from.

Small purse insert {what I transfer from purse to purse anyways}

  • Photo ID, debit card, etc.
  • Military ID (Insurance Card)
  • Chapstick
  • Lotion
  • Hair ties
  • Gum

Mama’s Bag

  • Labor essentials zip-top bag:  Essential oil bottles, energy gels, headband, chapstick.
  • Toiletries Zip Lock: Travel sized shampoo, conditioner, body wash, cold cream, toothpaste, toothbrush.
  • Labor gown
  • Robe
  • 2 Comfy outfits (yoga pants, nursing tank, T-Shirt, socks)
  • Nursing pajamas
  • Nook and charger
  • Slippers
  • Visual Birth Plan
  • Blessingway cards and necklace, prayer cards.

Grab and Go

  • Camera and charger
  • iPhone charger
  • Makeup bag
  • Hair needs – comb, curling gel, blow dryer & diffuser

Diaper Bag

  • Gender Neutral going home and picture outfit (long sleeve white onesie, overalls, socks, mittens)
  • Swaddle blanket
  • Name reveal hats {can hardly wait to show you!}
  • Diaper rash cream

Junk in the Trunk

  • Infant car seat and weather cover (since we have a small car and already have another car seat in there too, and I plan on sitting in the back seat on the way to the hospital we will install it on day two before we leave)
  • Warm baby blanket
  • Boppy/Nursing Pillow
  • Garbage bag and an old towel – just in case we need to cover the seat of the car if my water breaks at home.

So far, it’s all sitting there waiting.. well, most of it!  We will see if it’s enough or too much soon.  What are some things that you couldn’t live without in the hospital?

~Mama

CombatBootMama

Blessingway

This past week I went to my local ICAN meeting, as I have monthly for the past year.  The ladies there have been a fantastic group that have helped me in so many ways.  They are supportive and knowledgable about VBAC and the local medical community in ways that have really helped me prepare for our upcoming birth.  This month they also did a blessing way for me!

 

hospital bag

I’ve topped off my hospital bag with eleven amazing notes filled with affirmations and encouragement as I go through this birth and a necklace to remind me of their words when I am in the midst of my birthing time!

Thank you so much to everyone who has been there through this time of preparation.  We are only a couple of weeks away from our estimated due date!

~Mama

CombatBootMama

 

ICAN   The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).

Birth Plan Series: Fetal Monitoring

The next topic that I really wanted to dig into for our birth plan was Fetal Monitoring. It’s come up a few times this pregnancy at some of my appointments, and the policy at my hospital is that all VBAC patients have continuous Electronic Fetal Monitoring during their time at Labor and Delivery. As I started to look into the research about fetal monitoring, it became clear that this is a HUGE topic! So, if you have the time to get through this I think you’ll learn a lot and be able to make a great informed choice for your own birth plan too.

My main concerns regarding continuous fetal monitoring during labor includes the accuracy of the monitoring and the affect it may have on my ability to stay mobile during labor. In this post, I’m going to go through a few different topics including the types of monitoring used, the various heart rate patterns that they are watching for during monitoring, and how that relates to VBAC specifically.

Types of Monitoring

There are two types of fetal monitoring used: Electronic Fetal Monitoring (EFM) and also Manual Auscultation. EFM is much more common, and enables providers to measure the response of the baby to contractions. It does this using two receivers, one for the fetal heart rate and one for measuring the strength on contractions. EFM has become much more popular since the 1980s, with original hope being that they could decrease the incidence of Cerebral Palsy. Although EFM is used in over 85% of hospital births, the rate of CP has not changed since WWII.

Manual Auscultation is when providers use a handheld device to listed to the fetal heartbeat while feeling for contractions using their hands. This type of fetal monitoring is most commonly used during care provided by a midwife, and usually more common in home birth and birthing center situations. There is no continuous monitoring when this is the method used.

What are they looking for?

A normal fetal heartbeat varies between 110 and 160 beats per minute, and potential problems with the fetus can be signaled by a heart rate that doesn’t vary, is too high, or too low. According to ACOG, there are three levels of classification for the print-outs, or tracings, generated by the EFM. Category 1 FHR Tracings are normal and no specific action is required. Category 2 tracings are considered indeterminate and evaluation, surveillance and possibly other tests should be used to determine if there is a problem. Category 3 tracings are abnormal and this may require additional actions like providing oxygen, changing positions, discontinuing labor stimulation (Pitocin), or treating maternal hypotension. If the providers aren’t able to get the tracings to return to normal, ACOG recommends that the baby be delivered as soon as possible.

So, who determines what category the tracings are? Your providers. This opens the door to a large variety of interpretations. In fact, according to a press release from ACOG, “The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.”1 ACOG recommends that women who have high-risk conditions such as preeclampsia, type 1 diabetes, or suspected fetal growth restriction (IUGR) be monitored continuously during labor.

Fetal Heart Rate during VBAC

I really want to focus more on how this impacts mothers who are going through a VBAC birth. Understanding how providers use these tracings to monitor VBAC patients can give us some insight into why they have policies in place that require continuous EFM for those patients. When speaking to my provider, they said that fetal distress is often the first sign of Uterine Rupture, and that is why they have their policy.

“In a larger study, Leung et al. analyzed the FHR and uterine contraction pattern immediately prior to 78 cases of uterine rupture. Prolonged deceleration was defined as a FHR less than 90 beats per minute that exceeded 1 minute without return to baseline. Prolonged deceleration (alone or proceeded by either severe late or variable decelerations) occurred in 71% (n = 55/78) of the cases of uterine rupture. In addition, prolonged deceleration occurred in 100% (n = 36/36) of the FHR tracings in which total fetal extrusion occurred. If more than one type of periodic deceleration, in addition to a prolonged deceleration was present, only the most ominous pattern was recorded. Late decelerations were considered most ominous, followed by variable and early deceleration. Although late decelerations were more common preceding the prolonged deceleration that heralded uterine rupture, this finding may be an artifact of the study methodology.”2

I know that a lot of that is some very technical language, so now lets explore what some of those heart rate patterns mean.

Fetal Heart Rate Patterns

  1. Fetal Tachycardia, defined as a baseline heart rate greater than 160 bpm and is considered a nonreassuring pattern. Between 160 and 180 bpm it is considered mild and over 180 bpm is considered severe. Over 100 bpm is usually due to fetal tachyarrhythmia or congenital anomalies. Some causes of fetal tachycardia include maternal fever, hyperthyroidism, maternal or fetal anemia, Chorioamnionitis, and prematurity. Fetal tachycardia may be a sign of increased fetal stress when it persists for 10 minutes or longer, but it is usually not associated with severe fetal distress unless decreased variability or another abnormality is present.3
  2. Fetal Bradycardia is defined as a baseline heart rate less than 120 bpm with 100-120 bpm range not associated with fetal acidosis. It is common in post-date gestations and in fetuses with occiput posterior or transverse presentations. A FHR below 100 bpm is usually associated with babies with congenital heart abnormalities. Moderate bradycardia of 80 to 100 bpm is a nonreassuring pattern. Severe prolonged bradycardia of less than 80 bpm that lasts for three minutes or longer is an ominous finding indicating severe hypoxia and is often a terminal event. Causes of severe bradycardia include prolonged cord compression, cord prolapse, tetanic uterine contractions, paracervical block, epidural and spinal anesthesia, maternal seizures, rapid descent, and vigorous vaginal examination.

Both Tachycardia and Bradycardia are considered longer term patterns to watch for. There are some short term or periodic FHR changes that should also be noted.

  1. Accelerations are usually associated with fetal movement, vaginal exams, contractions, umbilical vein compression, fetal scalp stimulation or external acoustic stimulation. They are considered a sign of fetal well-being, and are the basis of the nonstress test (NST) that many providers recommend to women who are past their due date. The presence of at least two accelerations, each lasting for 15 or more seconds above baseline and peaking at 15 or more bpm, in a 20-minute period is considered a reactive NST, which is a good thing.
  2. Early Decelerations have a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Meaning that the heart rate will decrease at the start of the contraction, and then return to baseline after the contraction. Early decelerations are reassuring, and not an indication of fetal distress, but they need to be identified to avoid confusion with other nonreassuring decelerations.
  3. Late Decelerations are caused by uterine contractions and are associated with uteroplacental insufficiency, which means that there is a decrease in uterine blood flow or there is a placental dysfunction. Some causes include postdate gestation, preeclampsia, chorinic hypertension and diabetes mellitus. A late deceleration starts at or after the peak of a contraction and the heart rate doesn’t return to baseline until after the contraction ends. According to the Association of American Family Physicians (AAFP), all late decelerations are considered Category 3 situations and a pattern of them is nonreassuring.
  4. Variable Decelerations. These are shown on the FHR tracings in “U”, “V” or “W” pattern and may not have a constant relationship with the uterine contractions. They are common in patients who have experienced premature rupture of membranes (PROM) and decreased amniotic fluid volume. They are caused by compression of the umbilical cord. Variable Decelerations can be complicated, “Variable decelerations may be classified according to their depth and duration as mild, when the depth is above 80 bpm and the duration is less than 30 seconds; moderate, when the depth is between 70 and 80 bpm and the duration is between 30 and 60 seconds; and severe, when the depth is below 70 bpm and the duration is longer than 60 seconds. Variable decelerations are generally associated with a favorable outcome. However, a persistent variable deceleration pattern, if not corrected, may lead to acidosis and fetal distress and therefore is nonreassuring.”3
  5. Sinusoidal heart rate patterns are associated with high rates of fetal morbidity and mortality, and is considered a Category 3 FHR pattern. It indicates severe fetal anemia, which can happen in cases of Rh disease or severe hypoxia. On the FHR tracings it looks like a regular, smooth, undulating wave that happens two to five times per minute and has a range of 5-15 bpm. It is also characterized by a stable baseline heart rate between 120 to 160 bpm, and doesn’t have variability between the beats.

How to Decide

Now that I know more about the different types of heart rates that they can see using the EFM and what they can indicate, I understand more why my hospital would require this for VBAC patients. However, my main concerns with continuous fetal monitoring haven’t changed. How can I be sure that the providers are accurately reading the FHR tracings? I have to have trust in those that are there and that they have the experience and knowledge to interpret them. How can I preserve my ability to stay mobile during labor? I am going to request that they use a wireless model of the EFM so that I can be comfortable while being monitored.

During my 35 week appointment, I talked to my midwife about my concerns and we talked in detail about how they ensure that multiple people are looking over the tracings before initiating the decision to have a cesarean section and that they work hard to try other options before resorting to surgery. She also explained how they have installed wireless receptors for their monitors throughout the birth center so that whether I am in my room or walking the halls they will be able to find me if they need me and I will still be able to have the mobility that I really want.

Although it’s not ideal to me to have continuous monitoring, I think that it will be something that I can work with. If during my labor I change my mind, we will cross that bridge when we get there. Did you have continuous monitoring during your labor? Were you able to have a wireless version? What was your experience like? I’d love to hear from other mamas about their experience!

 

~Mama

CombatBootMama

 

  1. American College of Obstetricians and Gynecologists, June 22, 2009. (31 December 2014) (http://www.acog.org/About-ACOG/News-Room/News-Releases/2009/ACOG-Refines-Fetal-Heart-Rate-Monitoring-Guidelines
  2. O’Brien-Abel, Nancy, RNC, MN. “Uterine Rupture During VBAC Trial of Labor: Risk Factors and Fetal Response” (31 December 2014) http://www.medscape.com/viewarticle/458963_5
  3. Sweha, Hacker and Nuovo. Association of American Family Physicians. “Interpretation of the Electronic Fetal Heart Rate During Labor” (31 December 2014) http://www.aafp.org/afp/1999/0501/p2487.html