by Emily Oster
Count per Day
Time
Left
Right
Dirty
Wet
4/12/2011
1
1:53:00
10
10
1
1
4/12/2011
2
3:50:00
20
10
1
1
4/12/2011
4
7:45:00
15
1
1
4/12/2011
5
10:00:00
10
1
1
4/12/2011
6
12:10:00
15
18
4/12/2011
8
16:55:00
8
11
1
1
4/12/2011
9
17:55:00
15
6
1
1
4/12/2011
10
20:04:00
16
31
1
1
You’ll notice that there are some more precise entries for breastfeeding times and some less so. The less precise entries are mine. Indeed, in some notes about this period that Jesse made for posterity, he indicated, “Dad set up a really elaborate data-entry system to log feeding and pooping. Mom wasn’t really as good as Dad at keeping track of minutes. She liked to round to more even numbers.”
Please remember, we are two economists married to each other. There is no hope for us.
At the two-week visit, we showed our spreadsheet to our pediatrician. She told us to cut it out.
Of course, we were amateurs at this relative to some other parents. My friends Hilary and John developed a complete statistical model, with graphs, of the relationship between eating and sleep length.
For people who love data, there is a seduction to seeing the numbers there in black and white. You can look for patterns—on one day, the baby slept for seven hours. Why was that? Was it the twenty-three minutes of nursing before? Should you try exactly that length of time again?
There are some (minimal) reasons to collect data. Keeping track of when the baby is eating can be valuable early on since it’s easy to forget when they last ate. There are some nice apps that let you record from which breast they ate last. I know what you’re thinking: How could I forget that? Trust me, you will. I used a system with a safety pin, which I moved from one side of my shirt to the other to tell me which breast to start with next. Not recommended; I frequently stabbed myself.
In the event that your infant is struggling to gain weight, keeping track of how often and how much they are eating (and, in some extreme cases, weighing them before and after feeding) can be very valuable. But for most babies, this is unlikely to be necessary or useful.
As the baby gets a bit older, keeping track of when the baby eats may help form a schedule. But in the first weeks, a feeding schedule is a bit of a pipe dream. If you want to collect data and make pretty graphs, go for it. But remember that this is the illusion of control, not actual control.
GERM EXPOSURE
There is a broad theory called the hygiene hypothesis, which states (I am paraphrasing here) that the increase in occurrences of allergies and other autoimmune illnesses over time is a result of decreased germ exposure in childhood, and that exposure to more microbes and germs as a child can help their immune system properly identify and not overreact to perceived pathogens.13 While we don’t have conclusive proof that this is true, there is some evidence backing the theory in the form of laboratory studies of particular cells and comparisons across cultures in rates of various diseases. This suggests that as your child ages—say, into toddlerhood and beyond—it is not necessarily a good idea to wipe down everything with hand sanitizer or bring your own disposable placemats to restaurants. Your kid probably shouldn’t lick the floor at the airport, as mine have occasionally done, but going a bit more in the exposure direction may be sensible.
For these reasons, many doctors are reasonably lax about children’s germ exposure after infancy. But virtually all doctors will suggest you try to avoid exposure to illness in the baby’s first couple of months. One reason for this is simply that the smaller the child, the more vulnerable they are to serious complications. But a second reason is that for very young infants—especially those younger than twenty-eight days—medical protocols suggest much more aggressive interventions in response to illness.
What does this mean? Basically, if your otherwise well-seeming six-month-old gets a fever—even a pretty high one—and you go to the doctor, they’ll probably look them over, tell you they have a virus, and send you home with instructions to give them Tylenol and fluids. In fact, many doctors’ offices will tell you not to bring this child in at all unless you are very concerned.
In contrast, if your two-week-old has even a low fever, you’ll need to take them to the hospital, where they’ll be subjected to lab tests—likely including a lumbar puncture (spinal tap)—given antibiotics, and admitted as an inpatient. With very young babies, doctors have a harder time distinguishing between high- and low-risk fevers. Babies in this group are somewhat more susceptible to bacterial infections, including meningitis, which is extremely serious. Somewhere between 3 and 20 percent of infants under a month old who come to the doctor with a fever have a bacterial infection.14 These are mostly urinary tract infections, but they must be treated, and reasonably quickly.
The combination of this higher risk of and difficulty detecting infection means that aggressive intervention is an appropriate approach, but most babies with fevers are actually fine.
When a slightly older infant—between twenty-eight days and two or three months—presents with a fever, there is more ambiguity about treatment. Some doctors will still perform a routine spinal tap, although there is less evidence that this is beneficial.15 The procedure for managing infants in this age range (and younger) is many-stepped and varied.
Two of the key points here are whether the baby appears sick (this sounds crazy—of course they appear sick; they have a fever—but if you are a pediatrician, this distinction apparently makes sense) and whether there is an obvious viral exposure. If you come in with a forty-five-day-old baby who has a cold and a low-grade fever but seems otherwise fine, and bring along the baby’s two-year-old sibling who has a cold from day care, the doctor is likely to react differently than if you come in with the same baby with no sibling, and the baby is listless.
How does this all relate to the question of germ exposure?
The big downside of being exposed to germs—or specifically, to sick kids—during these early weeks is the possibility of setti
ng off this chain of interventions. If your infant does get sick, these procedures make sense, but if they just caught a cold from being pawed by a germy two-year-old, you’ll be doing a lot of interventions for no reason. It’s therefore better to keep the germy two-year-old away from the newborn, if at all possible.
Once your baby is over three months, and especially after they’ve had the first set of vaccines, treatment of a fever is closer to what you’d expect with an older child—basically, give them some Tylenol, keep them hydrated, and wait for it to go away. At this point, the downside of germ exposure is simply a sick kid, not a cascade of invasive testing.
The Bottom Line
Swaddling has been shown to reduce crying and improve sleep. It is important to swaddle in a way that allows the baby to move its legs and hips.
Colic is defined as excessive crying. It is self-limiting, meaning it will stop eventually. Changing formula or maternal diet, treatment with a probiotic, or both have shown some positive impacts.
Collecting data on your baby is fun! But not necessary or especially useful.
Exposing your infant to germs early on risks their getting sick, and the interventions for a feverish infant are aggressive and typically include a spinal tap. Limiting germ exposure may be a good idea, even if just to avoid these interventions.
3
Trust Me, Take the Mesh Underwear
When I was pregnant with Penelope, Jesse and I went to a childbirth class at the hospital. Toward the end of the day, they handed around a bag of stuff that you’d be given after birth. There were ice packs and huge menstrual pads and these really enormous mesh underwear.
“These are the greatest!” enthused the person running the class. “You’ll definitely want to take some home with you.” I took a closer look. They were like parachutes. I mean, there is no question that my butt grew along with the rest of me, but would I seriously be wearing these? It was enough to make me reconsider the childbirth decision, but at that point it was a bit late.
It turns out that the mesh underwear—which, yes, you should take with you—is so large because it has to hold all the other stuff the hospital gives you. First you put on the underwear, then add a giant menstrual pad or four, and finally a layer of ice packs. It’s a makeshift ice diaper.
There are a lot of baby books (like this one) that tell you what will happen with your baby. And there are a lot of pregnancy books that detail what happens to you while you are pregnant. But the world is oddly lacking in discussions of what happens, physically, to Mom after the baby arrives. Before the baby, you’re a vessel to be cherished and protected. After the baby, you’re a lactation-oriented baby accessory.
This omission is problematic, since it fails to inform women about what to expect after you’re expecting. Physical recovery from childbirth is not always straightforward, and even in the best of circumstances, it’s messy. Hence, the ice diaper.
In this chapter, I talk a bit about what you can expect for your body in the first days and weeks after you’ve given birth. I should clarify that the discussion here covers a typical recovery. Things can go wrong in ways beyond this, which is why it is crucial to tell your doctor if you are concerned about anything. The lack of discussion of what to expect in terms of your post-childbirth body can make it seem like anything you’re experiencing is fine, but it’s not. There is no shame in asking.
(I should add a caution here, for which you can thank my friend Tricia: if you have already been through this and you do not want to relive the gory details, skip to the next chapter.)
IN THE DELIVERY ROOM
The baby has arrived. The delivery is over. The placenta is out. If the birth—either vaginal or by caesarean section—went as expected, they’ll likely let you hold the baby and perhaps encourage you to try to nurse.
In the meantime, the doctor will be working on repairing things.
If you’ve had a caesarean, your doctor will stitch up the incision and dress the wound. This is typically a straightforward process, and similar from woman to woman. With a vaginal birth, there is more variation. During a vaginal birth it is very common to have vaginal tearing. This most frequently involves the perineum—the area between the vagina and anus—but you can also have tearing in the direction of the clitoris.
The degree of this tearing varies widely across women. Some women do not tear (although most women do a bit, at least with their first baby). If you do tear, the degree is ranked from first to fourth degree. A first-degree laceration is minor tearing, which heals well on its own with no stitches. Second degree means there is more involvement of the perineal muscles, but the tear doesn’t extend to the anus. Third- and fourth-degree tears extend all the way from the vagina to the anus but differ in how deep they go, with fourth-degree tears extending into the rectum. Third- and fourth-degree tears must be repaired with stitches, which will dissolve on their own after a few weeks.
Most tears are on the minor side, but approximately 1 to 5 percent of women will have more serious third- and fourth-degree tears.1 More severe tearing is more common with instrument-assisted delivery (that is, delivery with either forceps or a vacuum). There is some evidence that warm compresses on the perineum during the pushing stage of labor can prevent very severe tears.
Depending on the degree of tearing, the repair can take quite a while. If you’ve had an epidural, you should not feel the stitching. If you did not have an epidural, it’s common for the doctor to use a local anesthetic.
The other thing that will happen in the delivery room and continue over the next few hours is abdominal massage. Over the first hours after birth, the uterus should contract toward its pre-pregnancy size. If this doesn’t happen, there is an increased risk of bleeding. Uterine, or “fundal,” massage has been shown to assist this process and lower the risk of bleeding. A strong nurse will come around occasionally and push hard on your stomach. This is uncomfortable at a minimum. (To call this a “massage” is an insult to even the worst massage therapist.) With Finn, the nurse who did this told me, “I’m not the nurse people like to see.” If you’ve had a caesarean, it can be extremely painful. The good news is that you shouldn’t need abdominal massage after the first twelve to twenty-four hours.
IN THE RECOVERY ROOM AND BEYOND
When things are fixed up, you’ll head off to the recovery room to begin trying to get back to normal (except now you have a baby). Of course, you’re not quite the old you.
Bleeding
Regardless of how you gave birth, for the first couple of days afterward, you will bleed a lot. Before I had Penelope, I was under the impression that this bleeding was due to trauma; this isn’t the case (or, at least, you will bleed even without trauma). In fact, it is the lining of the uterus departing.
For the first day or two, this bleeding—in particular, the clotted blood—can be a little scary. You’ll sit down to pee or get up out of the bed and there will be an enormous blood clot in the toilet or on the pad. The doctors will tell you to watch out for clots “fist size or larger” (other doctors will use fruit metaphors—a plum- or small orange–size clot, they want to know about). By extension, this means that clots smaller than that—but not much smaller—are common. Passing these isn’t typically painful, but it is jarring.
You can bleed too much—maternal hemorrhage is a possible postbirth complication. Since you know you should bleed some, it can be hard to know how much is too much. If you’re not sure, ask. If you see a clot and think, Is that the size of a fist, or just a bit smaller?, don’t wait around measuring it for yourself—buzz the nurse.
The passing of clots will die down after a couple of days, but you’ll keep bleeding—first like a heavy period, then a lighter period—for weeks. Once you’re home, the bleeding should decrease over time. If, all of a sudden, you start bleeding a lot again, especially if the blood is bright red, call your doctor immediately.
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br /> Peeing and Pooping
Many women get a catheter (a tube in the urethra to collect pee) during birth—you’ll get this for sure if you have a caesarean, and very likely if you have an epidural. This will be removed in the first few hours afterward, and it will be time to try to pee and poop on your own.
The experience here begins to diverge depending on what kind of birth you had.
If you had a vaginal birth, it will hurt to pee. Even if you had a very “easy” experience, your vagina will still be kind of banged up, and there will be some stinging. It’s worse if you are dehydrated, which makes the urine more concentrated. At many hospitals, they’ll give you a squeeze bottle of water, the idea being that you squeeze water on while you pee so the urine is diluted and not as painful. This works okay, although—here’s a pro tip—definitely make sure you do not use extremely cold water.
It will also likely hurt to poop. This depends, again, on how traumatic your birth experience was. It is common to give women stool softeners to improve the first postbirth bowel movement. It may be a couple of days before you actually have that first bowel movement, which is good. Also, this may not be as bad as you think. And anyway, you have to do it.
If you have had a caesarean, these problems are different. First, you may struggle with holding pee at all while you wait for your bladder to “wake up” after surgery, and the catheter may be left in place longer. Whether peeing will hurt depends on the circumstances of your labor and delivery. If you were in labor for a long time before the surgery, you may still have discomfort and swelling that makes urination uncomfortable. With a scheduled C-section, this may not happen.
After a caesarean, doctors generally want you to either poop or at least pass some gas before you leave the hospital; this is to ensure that you can have a bowel movement after what is basically major abdominal surgery. It is not unusual for it to take several days for this to happen. In service of this, you’ll get stool softeners. In the absence of vaginal trauma, the actual act may not be that uncomfortable. Sitting down, however, can be painful due to your incision.
