Day 10: No free rides

Today was one heck of a day. I'm not sure if it is good or bad that my high point of today was changing my little girl's diaper for the very first time. It's impressive how much of something that gross can come out of a baby just over 2lbs. I was given a 2 min time limit and I'd like to think I made my time.

Dr. Hitesh wasn't in until Monday so no taking care of business there, but there was drama across the way at the NICU. It did start off well, and I had an awesome time this morning at bath time taking pics and tons of video. We'll start with finding Mr. Vivek all discombobulated at the bottom ofhis crib with his hat, as usual, cast off to the side.

First up for bathtime was Princess Tara. She splays herself out and waves her limbs around frenetically, but doesn't seem to cry or distress like Vivek does. I think she likes a good portion of bathtime actually. I took two excellent action shots of our princess.

Here is a video of Tara's spongebath adventures:

Vivek on the other hand during bathtime makes adorable squeaks of protest:

Post bath time Miss Tara is quite alert, but Vivek wanted to go back to bed after a quick snack.

But soon after bathtime problems arose. I could tell my little chipmunks were hungry because they were pushing their little tongues out and restless, making sucking and smacking noises.

But the problem was by 9:15, 15 min after feeding time there was no breastmilk.the nurse had told me. I offer to go to Manju's room to see what the hold up is. Several things become apparent:

1. Manju has no pump of her own because the hand pump is shared between her and the other surrogate. I learned later they alternate every two hours who pumps and it is sterilized in between. This gives them four hour gaps and more rest and enables the two of them to produce enough milk...usually. I quickly decide to bring my hand pump at the hotel that I had bought for plane travel and give it to Manju so this won't hold them up anymore.

2. Manju keeps talking in Gujarati expecting me to understand her, and I never want her on my team at charades. She does point to her chest and say something that makes me think she doesn't have enough. I ask about the 2nd surrogate and she points upstairs. I am ticked because I wonder what Nita has to do that is more important than pumping milk for my babies.

I explain the problem to the nurses and Suvarna, the most amazing nurse in the world who is getting a huge tip when we leave, happens to have a 6 mos old baby and assures me that she will provide milk herself if needed to add to whatever Nita brings. I go to the hotel and sterilize my hand pump.

When I return at the next feeding it is apparent some more discussion has occurred, but I'm not sure what. Suvarna tries to tell me something about it when I hand her the pump, but due to the thick accent I have some trouble understanding it. Suddenly both surrogates show up, and I realized Suvarna was trying to tell me she was about to play hardball and take matters into her own hands...literally. She had made my low production surrogate come down so that she could assist her and pump her herself to make sure it was done correctly. She got almost enough milk for both babies but was a few mL shy. Manju did not seem all that happy about being manhandled, but I would like to have seen her more concerned about the welfare of my tiny hungry babies than her modesty.

The other surrogate had a long discussion in front of me with another nurse Anju who speaks some English but not much, and I could tell it was a lively one. The other surrogate Nita had struck me as a little pushy and I had been wary of her. I become increasingly nervous about the content of that conversation as I held my son for the next hour. When Dr. Kothiala comes in later as I'm concluding kangaroo care with Vivek, she compliments my singing and asks me about it. Turns out her CD broke but she had been playing classical music in the NICU based on her music therapy research.

I not so gracefully segueway the conversation into the drama that had been going on with the surrogates and twice delayed feedings due to poor supply. A pow-wow occurs where Suvarna and Anju fill Dr. Kothiala on what had gone on and I finally find out the truth.

Nita is my hero. The reason she had been upstairs was that she was going to all the other surrogates trying to get enough milk for my babies! I am almost certain that this was not the first time she has done this to cover for Manju. She also explained that Manju had been "losing interest" in producing milk for my babies. Don't get me started on how angry that makes me. Either work hard to produce or go home to Ahmedabad, but there are no free rides here. You'll get no sympathy from me because I pump every 3 hrs day and night for the one mL I produce, and she gets a liesurely four hours with meals delivered and no babies to see.  I am not a rich woman and this is not a surrority house. (Punny right!?)

Nita also had a surrogate in mind who would be interested in taking over for Manju so she can go home to her family. I make sure Suvarna and Dr. Kothiala know that I am not paying for someone who is not dedicated and productive in providing for my babies. Dr. Kothiala says I should go to see Dr. Patel's assistant and insist that Manju be cut off and sent home, and today or tomorrow morning they will resolve getting another surrogate to pump for me. Her assitant was very professional and confident and spoke superior English, and I felt instantly at ease. Dr. Kothiala assured me she would also contact Dr. Patel about the matter post haste.

In talking to Dr Kothiala during the whole wet nurse drama, I learn some other good info. In about two weeks we will start using my preemie formula (Similac Neosure) that I brought. She uses breastmilk only until gestational week 32, which should be the end of this month. She does that to avoid NEC (necrolyzing colitis I spoke about in a previous post) but the breastmilk is not as calorie dense and they don't put on weight and grow as fast as they do when you add formula to the mix. She is using some fortifier but explained she has maxed out on that for now. She will also try bottles and breastfeeding at the switchover point because the sucking burns so many calories, she would rather have them on a calorie dense regimen to ensure continual weight gain. I also learn that preemies at this stage in her experience take 3 weeks to gain back birthweight, so all my concerns about Vivek dissipate as he is getting close.

After all the drama I decided I needed to get away for a while and go for a jaunt about town for lunch. I dropped by to see my new friends from NY, and told them I was headed to Subway and they joined me. It was a hilarious ride in a Tuk-tuk. Seeing a guy the size of a middle linebacker cram into one is comical, and when you add two women and the driver...  It's not all that impressive to locals though cause I have seen about 7 folks crammed into one, and even more children on their way to or from school. The sandwiches and cookie were yummy and the second best meal I've had here so far. The place is as tightly in line with the Subway standard operating procedures and appearance as humanly possible in India, and the only main difference aside from localized menu selections were one side is vegetarian and the other isn't. It is a little further away, but worth the trip.

Tomorrow we do Alpha for lunch and will bring some back for my friend with her twins at the hotel, so I'm excited that I'll eat well tomorrow too and help them out again. But mostly, I'm excited for bathtime. And maybe now with having earned trust changing diapers I can look forward to another one tomorrow. How soon will it be before I no longer look forward to changing a dirty diaper, I don't know...

Marmet Technique

Thanks to a tip on a Yahoo group for support for adoptive lactation, I figured out that righty is very responsive to manual hand expression of breastmilk and now far out produces lefty, who still prefers the pump. Below are some instructions I found online on the Marmet hand expression technique.

How to Manually Express Breastmilk - The Marmet Technique

Draining the Milk Reservoirs
1. Position the thumb (above the nipple) and first two fingers (below the nipple) about 1” to 1–1/2” from the nipple, though not necessarily at the outer edges of the areola. Use this measurement as a guide, since breasts and areolas vary in size from one woman to another. Be sure the hand forms the letter “C” and the finger pads are at 6 and 12 o’clock in line with the nipple. Note the fingers are positioned so that the milk reservoirs lie beneath them.

• Avoid cupping the breast

2. Push straight into the chest wall

• Avoid spreading the fingers apart.
• For large breasts, first lift and then push into the chest wall

3. Roll thumb and fingers forward at the same time. This rolling motion compresses and empties milk reservoirs without injuring sensitive breast tissue.
Note the position of thumb and fingernails during the finish roll as shown in the illustration.

4. Repeat rhythmically to completely drain reservoirs.
• Position, push, roll...
• Position, push, roll...

5. Rotate the thumb and fingers to milk other reservoirs, using both hands on each breast.

 Avoid These Motions
1. Do not squeeze the breast, as this can cause bruising.

2. Sliding hands over the breast may cause painful skin burns.

3. Avoid pulling the nipple which may result in tissue damage.

Marmet Technique copyright 1978, revised 1979, 1981 and 1988. Used with permission of Chele Marmet and the Lactation Institute, 1616 Ventura Blvd., Suite 223, Encino, California 91436

Anand NICU Veteran's Advice

Last year during our first attempt, and wonderful couple named Jeff and Michelle befriended us. They were so helpful and reassuring, and gave us some of their leftover food in addition to great advice and reassurance before they left. I was pretty nervous about the egg extraction, but seeing her quick recovery helped me calm down. They wound up being successful on that first try and they had a daughter, who was born at 30 weeks. She found me on Facebook, and upon hearing about our early arrivals she sent me a huge email that eased my mind greatly and prepared me for the NICU in Anand. I have to share the highlights with the blogosphere in the hopes it helps someone else as well to know what to expect.

"We were there for 8 or 9 weeks, I can't remember now but it felt like forever.  Hopefully your babies have gone to Dr. Anita's hospital.  Hers is the best from what we heard.  Dr. Anita is really good, she seemed to be the best Dr over there and her hospital is where you want preemies to go because she has the most experience.  Her hospital is real close to the Rama.  You can go see your babies at any time and we usually went over there about 3 times a day."

"The NICU is small and not the cleanest and I don't think it had air conditioning, they usually had fans on when we were there.  They will make you wash your hands and then use this blue sterile cleansing stuff and then put on some blue or green scrubs to see the babies.  The nurses will fuss at you if your hair is down, so make sure you pin it up or they give you grief."

"When your babies get a couple weeks old, tell Dr. Anita that you want to do 'Kangaroo Care' and the nurses will put the baby on your chest which is really good for bonding and it helps your baby hear your heartbeat and is really good for the babies.  They are funny about men being in the NICU and they used to tell my husband that he had to go out in the hallway when the doctors came in to check on the babies....it's almost like they're back in the 1920's or something."

"There are 2 nurses that speak English....Sandia and Suvarna.  Suvarna may still be only working part time but Sandia is full time.  They can explain everything to you each day but most of the other nurses don't speak English.  Dr. Anita speaks great English but there are 2 other Doctors and their English is very limited. Sandia was our favorite....she's a little nurse...really tiny.  She lives right across from the Rama, so if you ever need her, she can come over to the Rama and help you out.  She checked on our baby every day once we got her out of the NICU. "

"We would go see Dr. Anita everyday in her office to get updates on our daughter.  The best time to meet her was at 7 pm because most of the crowd in the waiting room is gone then.  If you go see her around 11 am, there's a massive crowd in the waiting room.  Ask her tons of questions."

"I think my husband told me that it ended up costing us about $50/day for our daughter to be in the NICU...  If your babies go to Dr. Burien's hospital, I've heard that he charges twice what Dr. Anita charges.  Also...Dr. Burien was Dr. Anita's student.  The hospital would ask for a deposit of about 20,000 rupees every couple of weeks...I think that was $400."

"If your surrogate is pumping milk for you, Hitesh told us that our surrogate would do it for a month (since our daughter was born so early) and that we'd just have to pay for the milk.  Well, we later found out that you have to pay for the surrogate's room at Dr. Anita's hospital and that was pretty expensive.  We had to pay $600 for the surrogate to stay at the hospital for a month plus I think it was $100 for the breast milk.  We just weren't expecting the room that our surrogate stayed in to cost so much....Also, the surrogate will tell you that she wants extra food while she's there pumping milk.  Ours wanted mangos and apples and some other fruit (can't remember) and walnuts.  My husband had to look all over to find the apples since they're shipped in by truck so that was a pain.  Some of the other Indian couples there told me that we 'had' to give our surrogate extra money each day and that we should give her at least $20 a week.  This is not true, so don't believe anyone if they tell you this.  Dr. Anita told us that certain fruit is good for milk production so we just got the fruit that she told us to get.  We weren't expecting to have to go around and buy food....we wanted to concentrate on our baby....so it was a pain to find this out when we got over there.  If you have any problems with your surrogate giving milk or refusing to....then tell Hitesh and he'll get it taken care of."

"Also, the nurses will expect a "tip" when you leave the hospital to come home."

"Uday is a huge help with getting around.  If you have him pick you up from the hospital, ask him to bring you a sterilizer so that you won't have to buy one.  He can also bring you a baby bed and a mosquito net, so ask him for one so you don't have to buy one.  Uday also can do all the running around for the police report info."

"You will see LOTS of nannies in the Rama and they'll be watching you like hawks.  They all will want you to hire them.  From what we heard, Dieksha is the best.  She has experience with preemies and she speaks English.  Her sister is Gungha and she is much younger and doesn't really speak English but she's pretty good with preemies too.  If you guys have to get a nanny, I'd probably try to get Dieksha because everyone seems to think she's the best.  We didn't get a nanny because as soon as we got our daughter out of the NICU, we immediately flew to Mumbai and then back and were gone real fast."

"Uday made everything happen for us real quick.  We didn't bring much cash with us for the trip over but my husband went to the ATM at least once a day and got cash out so that we'd have enough to pay everyone. There is an ATM right under the Rama on the first floor and it let us take out $200 a day, so we did that all the time."   

"If you have a pediatrician picked out in Texas or a neonatologist in Texas, keep their email or phone # handy since you'll probably want to ask them questions.  If you know anyone who is a Doctor in the states....keep their # handy.  We had trouble getting US doctors to talk to us in India because they said it was 'too much of a liability' for them to give us advice while we were in India....so you may want to talk to a US doctor now before you leave and see what advice they can give you."

Thank you so much to Michelle for all her helpful advice and information!