“Pumped” in JAMA

I was at our block education the other day when one of my male co residents asked me, “Did you read the JAMA reflection piece from Sept 11?” (answer to this is always no, my JAMA sits on my kitchen table where it’s main purpose in life is to be an excellent spider squisher). When I said I hadn’t, he took his issue out of his backpack and gave it to me.

If you haven’t seen it, the article is called Pumped by Dr. Charlotte Grinberg. (Article here). It is a fantastic reflection on pumping during intern year and like most reflections on pumping I identified with it so much. I almost cried when *spoiler alert* her freezer broke and she lost her stash. And cheered at the final couple of paragraphs.

I am so happy to see this in JAMA. My coresident told me - “I read it and thought of you guys”. I’d lately been fielding comments like “I wish I got a twenty minute break in my clinic schedule!” so it was great to hear something more affirming. I suppose my male coresidents are less likely to be reading blog posts on mothersinmedicine.com so I’m hopeful this will bring more discussion and more advocacy to pumping residents among the non pumpers among us.

Re: my own pumping journey - baby is 11 months and we have almost made it to a full year of exclusive breast milk due to the combination of ridiculous pumping sessions, learning to advocate for myself, a lot a lot of luck, and a pretty supportive work environment. Cant wait to celebrate his one year journey by temporarily retiring the Spectra. 

Adventures in Pumping II: The rotating resident

Here is my past few months in pumping chronicled by rotation. As the weeks went by, I turned from a shy awkward pumper to a frank “I’ll do it wherever just get me a plug in” resident.

Ortho: show up to clinic struggling with clinic bag in one hand and pump in the other. Young ortho PA that I am scheduled with has kids, gets it, and finds me a private office for the day.

Cardiology: lots of older male physicians, and scheduled with a new one every half day. Rather than explain the pumping every single half day, I pump on the way to and from work and simply say I need to leave half an hour early to make my q4h schedule. I don’t say why, they shrug and say sure. I tell the younger female cardiologists I need to pump and they “remember those days” and are full of support.

Hospice: in a car with my wheelie backpack going to multiple hospice sites. At one point, I am stuck far from my pump as I misjudged how long the trip would take me and as my mentor for the day is sharing a deeply emotional story as we are ending or day together, all I can think is “gottapumpgottapunpgottapump”. Also had a mentor that went to NP school in the pre-double electric breast pump days and not-so-fondly remembers hand expressing during breaks. I’m so glad we’ve come far from that.

Night float: Sitting in my call room calling specialists with the little “whirr whirr” in the background. Eye the pagers carefully, just daring them to go off with a Code Blue while I am plugged in.

In between, check Facebook. That Willow pump that keeps haunting my news feed with ads looks wayyyy too good to be true. But cheering on the days to an better breast pump.

Psych: checking into an attending’s office for a half day. He has a no show, so I casually mention I need to pump sometime in the next two hours. Ten minute tour through the offices ensues, ending with me pumping in his private office and him waiting outside in his own lobby.

Clinic: having much more in depth conversations with my patients about pumping, supplementing, etc. Run downstairs every 3-4 hours past all the patients in the lobby past  to the pump room, stopping to briefly complain to the care coordinator about how pumping sucks literally and figuratively as we both have babies within a few weeks of each other. She made it a year with her first so we are cheering each other on.

Conference: presenting a poster at a conference at a large office building. Find the pump room of dreams including sink, long counter, multiuser pump, fridge, large comfy chair. Immediately send an email to my office manager outlining this in case we ever have extra money lying around when we design our next clinic. The pump room is in use when I need it in the afternoon, so I am directed to a Breastfeeding Pod (called a Mamava) that looks like one of those party photo booths. Crawled inside, feeling slightly seasick but very private and secluded in my little cocoon.

OB: I pick up an OB shift for a resident out sick. I sit in the pump room in peace wishing I could figure out how my Spectra parts could attach to the multi user hospital Medea  pump. I get to work with the nurses who helped deliver Baby, show them pictures, and they let me eat from their potluck spread.

I mainly wanted to write this all down so I can remember both the ridiculousness and support when we’re finally ready to shelve the pump. Hopefully someday I can say “I remember when I had to haul my pump around with lots of parts from place to place in a huuuuuuge bag! You have it so much easier now!” Until then, pump and I will continue to hit the road.

Kicks

Mau Man and the Chronicles of a Low Birth Weight Mama

BIRTH:

In early March, I became a mama for the second time. We have nicknamed our new little one Mau Man. Our home birth didn’t feel all magical like the pictures I see on the Internet but maybe after continued exposure to oxytocin while nursing I’ll change my story and in a few years I’ll tell you all about how magical it was (feel free to call me out on it!). It was intense and brief (he came within 3 hours but it felt like days). Similar to our natural hospital birth with our first Zo, the details are hazy and I feel traumatized. Did a human just burst forth from my body? Yup! He did. Did I feel like I would give up. Heck yeah, I felt like throwing in the towel a few times, but I didn’t. Was I scared. You bet I was! Did I feel powerful afterward? You know what, I sure did! And super tired too, just like with Zo. I feel like no matter where you deliver, birth takes over you, it takes hold of your being and you just have to submit to the intensity of the process.

LOW BIRTH WEIGHT, THE CONTEXT: Now we find ourselves with our newest little one who is healthy in every single way except he was tiny at birth. 2360 grams (or 5 pounds 3 ounces). Under the low birth weight cut off of 2500 grams. I have read countless studies of how Black women like myself, regardless of socioeconomic status, are at a higher risk of pregnancy complications, maternal and fetal mortality, preterm labor and low birth weight. At my Baby Sprinkle a few months ago, a group of my closest friends and I spent considerable time discussing this topic. Pretty morbid but we are all Black doctors, educators, and health care professionals. But somehow I thought, I would be insulated, I would be spared. I took my vitamins, exercised, meditated, saw a chiropractor twice a week. With all of the complications and losses friends and patients have had I realize that low birth weight is manageable but it still hurts. After our own loss last year, I realize that regardless of how small he was I get to hold him and touch him and smell him and snuggle him and nurse him and I will do everything in my power to get his weight up.

LOW BIRTH WEIGHT, THE COMPLICATIONS: Flash forward to Day of Life 3. His weight loss was more than what our Pediatrician and I liked and he was at risk of hypoglycemia and dehydration. He had a good latch but he just couldn’t muster up enough energy to transfer milk out of my breasts fast enough to grow. I had to start nursing and feeding him every 1.5 hours and start pumping several times a day to provide expressed milk to supplement him with. We worked with an amazing local Lactation Consultant friend first at our home and then in her office and started using a Supplemental Nursing System or SNS. This is a little tube that you attach to a syringe to feed babies at the breast or using a finger to help train them. This helps prevent nipple confusion by delaying the introduction of a bottle. Day of Life 4 was a blur with a ton of feeding and pumping. Day of Life 5 - he had begun to gain weight and his parents were exhausted. We were allowed to space him out to every 2 hour feeds. Day of Life 9 back to birth weight. Day of life 18 weight up to 6 pounds.

And this is where we find ourselves: Nurse and reposition the SNS 10 times. Pump. O finger feeds with SNS in the early evening so that I can sleep for a few hours (this is priceless! Many thanks to Lactation and our old school Pediatrician who made this a key part of our process). Smile. Cry. Have a melt down feeling guilty that I couldn’t make him fatter. Listen to a podcast. Take a lactation supplement. Play with Zo for a few minutes. Tell Zo to be gentle and not climb on me while I’m nursing. Get a pep talk from the hubby. Repeat.

I’ll keep you posted and can’t wait until I can throw this SNS out. I pray for the day he is exclusively breast fed and that breastfeeding soothes him.

My world at night: our 30mL  syringe, the SNS premature baby feeding tube, my 2 pumps - my Spectra electric pump for daytime pumping and my NatureBond silicone manual suction pump for easy night time pumping - I pop it on the alternate breast while nursing/SNS feeding. 

REFERENCES:

Adverse birth outcomes in African American women: the social context of persistent reproductive disadvantage. https://www.ncbi.nlm.nih.gov/pubmed/21213184

Black Women Disproportionately Suffer Complications of Pregnancy and Childbirth. Let’s Talk About It. https://www.propublica.org/article/black-women-disproportionately-suffer-complications-of-pregnancy-and-childbirth-lets-talk-about-it

Racial Discrimination and Adverse Birth Outcomes: An Integrative Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5206968/

What’s Killing America’s Black Infants? Racism is fueling a national health crisis. https://www.thenation.com/article/whats-killing-americas-black-infants/

The Year in a Word Cloud

Because I Hated Every Second of Breastfeeding

Genmedmom here.

There have been many times when I have struggled to empathize with the patient. There are certain healthcare issues, and certain patients, that I have found consistently frustrating over the years.

I've written about this, and been pretty well chastised by readers. I don't mind, because I know that 99% of physicians have their kryptonite issues, and just don't talk about it. I'll take the heat for being honest.

My kryptonite issue has been obesity. I admit, that for many a patient encounter, I've sat there and counseled (for the millionth time) on diet, and exercise, and priorities, and wondered to myself: Why can't you do this? Why can't you just lose weight?

I know that sounds terrible. Heck, it IS terrible. My bias is based on my own experience: I gained sixty pounds in my first pregnancy, and fifty in my second. The weight didn't come off postpartum, and I found myself obese. BMI 30. I dedicated what precious little time I had as a working mom to eating healthy and exercising, and I lost it all. It took two years. It was hard. There were ups and downs. I've written endlessly about it here, and here, and here....

Of course I know that it is totally and utterly unfair to think "Well, if I could do it, why can't you?" but truth is, that's a pretty natural way to think, and many of us think like that.

So I've been making a conscientious effort to do better, to let go of the bias, and the frustration, and meet people where they are, no matter what the medical issue is.

But it was only when I was sitting with a lovely young patient of mine who was upset, grieving, actually, that she had been unable to breastfeed her infant, that I had a real breakthrough.

This poor woman had had a complicated pregnancy and delivery. Nothing had gone the way she had planned. But she held on and held it together, because she knew that if her baby survived, she would do everything right. She would take THE BEST care of this baby. She was determined to breastfeed for a full year. It had never occurred to her that that might not happen.

There were problems with the latch, with the milk supply, with pain, with baby's growth. Still, she was determined. She got the hospital lactation consultant and a private lactation consultant and every breastfeeding book on Amazon and drank Fenugreek tea et cetera, et cetera... for weeks.

But one day when she had spent an hour and a half with the industrial-grade pump and got only about a teaspoon of breastmilk, with her nipples raw and bleeding, with her infant screaming, starving, with the pediatrician's concerns about his growth, with her consultants saying "Just push through! Keep trying!" for the gazillionth time but without any other real suggestions, and without any progress, she broke down.

She gave up.

So the baby got formula. And did fine. And grew. And she thought this burden was lifted from her.

Until the judgments came.

She was part of a social circle that especially valued breastfeeding. Friends and family would comment, say, "Don't you know breast milk is best?" or "Well, if you had only tried X, I bet it would have worked" or "If you had only HUNG ON a little bit longer" or "Those doctors pushed you towards formula, those doctors always push the formula, you shouldn't have listened" et cetera, et cetera.

It got to the point that she hid bottles and formula, or avoided socializing altogether. She felt like a freak, a failure. She worried what awful consequences there might be for her baby. She waited for some severe illness to befell her son, and for someone to blame it on her.

Oh, my heart went out to her.

Flashback. I was pregnant with Babyboy (now five and a half years old). I had a three-page birth plan outlining my natural vaginal delivery. I had a doula. I had Ina May's books on childbirth and Nancy Mohrbacher's books on breastfeeding. I had secured a highly-rated lactation consultant and booked a consult with her BEFORE the baby was born. I bought Medela breastmilk bags and a plastic organizer for the freezer. I arranged a breastfeeding room in my office.

But there were complications. The delivery- that's a story for another day. Emergency C-section for deep transverse arrest. Bradycardia. Meconium. Mayhem. I was discharged with a hematocrit of 22.

Babyboy was fine, but I grieved the loss of my dream birth. I was determined to get breastfeeding right: I wanted to breastfeed for a full year.

But. There were problems with the latch, with the milk supply, with pain, with baby's growth. I was still determined. I got the hospital lactation consultant and a private lactation consultant and every breastfeeding book on Amazon and drank Fenugreek tea et cetera, et cetera.

Miraculously, I was able to breastfeed for a full three months.

But, I hated every single second of it.

When it got close to feeding time, I would inwardly cringe. With his latch, I would outwardly gasp, and clench my teeth in pain. The doula and the lactation consultants gave up on me. It was a nurse practitioner at Babyboy's pediatrician's office who suggested APNO (All-purpose-nipple-ointment), and it was an OB/GYN who prescribed it for me. The APNO cream helped a bit, and it got me through the three months, though nothing really helped.

Inevitably, what would come to mind with EVERY feeding were images:

Of glass-shard covered twine being pulled out of my breasts through my nipples.

Of someone pouring acid over my areolae.

Of my baby with little piranha teeth and malevolent intentions.

Oh, I hated it, and I hated myself for hating it. Wasn't breastfeeding supposed to be this wonderful bonding experience? I would rock and cry, literally cry, while stroking my baby's forehead and begging forgiveness, because I could not WAIT for this to be over.

So when it came time to go back to work, I started on a combined oral contraceptive and took Benadryl, and let that milk supply dry right up. Worked like a charm. I was done. It was such a relief.

When I told my colleagues I would not be needing that breastfeeding room, I got some eyebrow raises, but no one questioned. Many of them had made similar decisions for different reasons.

Most of my friends were understanding (very different social circle from my patient-mom) and for that I was very grateful. As a matter of fact, people came out of the woodwork with their own breastfeeding difficulty stories. I was not only NOT the only person who had struggled, I was not the only person who hadn't enjoyed it, and I was not the only person who had guilt about that.

Yes, there were a few "judgy" moments. People I didn't know well, and luckily didn't give a rat's ass about. A lady at book club gathering, a friend of a friend.

But my patient, my poor patient. Her "support network" was annihilating her. I was outraged on her behalf. I wanted to reassure her.

So I shared my own story with her, and we discussed ways to manage the hurtful comments and avoid the negative people.

For doctors, sharing our own stories and feelings about medical issues with patients is a tricky thing. Sometimes it's appropriate, sometimes it's not, and sometimes it's a mixed bag. In this case, the patient expressed relief and gratitude. She had been initially expecting me to judge her, too, she said. She was so glad to have found validation, reassurance and open discussion instead.

That's when I had my breakthrough: The patient had been expecting me to judge her, and had instead found validation and reassurance.

Wow. THAT is what I need to bring to EVERY patient encounter. Validation, reassurance, open discussion. Because that is what I would want for me, as well. It's what I want to be able to provide for everyone, especially my patients.

Pump hero

I needed to meet with a team to grade their students and had set up a time to meet them in their team room. This is one of the best team rooms we have in the hospital. It's spacious, with a wall of computer stations on either side, and windows lining the opposite wall from the door, filling the room with natural light. When I'm bringing the third-year students around to their team rooms after orientation, I always deliver this team's students last since it's kind of like closing the curtain between first class and coach.

I walked into the room and saw a medicine intern with her back to me, working at her computer. At the other wall, the senior resident was reading some papers before him. They greeted me as I sat down with my folders and took out my forms for grading.

"I hope you don't mind, but I'll be pumping while we do this." In the sudden quiet, I heard the telltale rhythmic sounds that I knew so well. She was pumping. Right there. In the team room. I didn't notice earlier, but she apparently had a hands-free set-up going, and was typing away, doing her notes. I glanced back at the senior resident, nonplussed. This was routine business.

I was filled with...joy. Admiration. So impressed.

"I think it is so awesome that you pump in the team room!" (Could I have?)

"I've lost all modesty after 9 months," she said with a smile.

We graded. She finished pumping, cleaned up, stored the milk, and I could not stop smiling.

The Last Bu-bu

WE DID IT!!!  When I started breast feeding I was determined and optimistic!  But, as I persisted I got discouraged more times than I could remember.  There were latching problems, cracked nipples, thrush and the pumping!  PUMPING SUCKS!!!!  I celebrated when we hit the one year mark and I stopped pumping.  My plan was to allow my baby girl to self wean.  Well, she wasn't interested.  I stopped pumping but kept making LOTS of milk, so we persisted with morning and nighttime feeds.  When my baby girl was a year and a half I left the lab and went back to surgical residency hours.  My initial stint on transplant kept me at work around the clock and I felt for sure that my milk would dry up.  Miraculously it didn't and "bu-bu" time became a special time with me and my baby girl in the midst of all the chaos.  Well, the time has finally come.  Baby girl is losing interest, I've basically stopped making milk and my baby girl is a smart, amazing, beautiful big toddler now.  She hasn't had bu-bu in a week.  I put her to sleep by telling her princess stories or stories about my "doc-tur house" while she lays her head on my chest.  I'm a bit sad our "bu-bu" time is over but amazing grateful for the two and a half years we had of this amazing connection.  I'm incredibly proud of our accomplishment that survived even the insanity of residency and as always I am crazy in love with my beautiful child.  I can't wait for all the new memories we will make together.

Now off to pick some strawberries!  Happy Saturday!

A tired American - an angry rant

Ok, so this is risky, and I’m likely to attract plenty of debate but here I go.

First, why am I writing about this?  Because I took an oath to be a healer.  To me this means tolerance, justice, acceptance in order to achieve a greater good, in order to promote a healthy society.  So, I am just a little irritated today as I look at my country which appears to be at odds with itself.  My anger started while listening to NPR on the drive to work this morning and hearing about all of the discussion resulting from the TIME magazine cover of a model-like mom breastfeeding her three year old standing on a chair.  Criticisms flying everywhere about extended breastfeeding and self-important moms. There is the typical sexualization of breastfeeding with lots of reference to the attractiveness of the mom on the cover, and the usual “if they can ask for it” type comments.  (side note: newborns ask for it too - its called crying!!)  So funny, that anyone who decides to formula feed their infant gets nearly stoned for not going the “breast is best” route.  Then we flip it around and hate on the moms who keep breastfeeding.  I realize I’m using the proverbial “we.”  If this doesn’t apply to “you,” then feel free to ignore.  But for all the rest of us: Lets STOP THIS!  Mothers are always criticizing mothers - breastfeed or not breastfeed, work or stay at home, work a lot or a little, nanny or daycare or grandma, etc, etc.  Even Fizzy’s post last week, illustrated how quickly we jump to judgement.  As clinicians we do know the literature and the evidence, but the first step in being able to do no harm is gaining the TRUST and RESPECT of our patients, and in order to do this there needs to be more tolerance and listening.

Anyway, I’m just all revved up.  I live in the Amendment 1 state.  Justice, tolerance.  I won’t say anymore than that.  Our political system is full of polar opposites, butting heads and refusing to compromise.  We’re arguing over reproductive rights of women... AGAIN!  WHAT IS GOING ON!!!

Can’t we all just get along?

When breastmilk isn't best

That's right, I said it. Breastmilk isn't always best.

I always considered myself to have a very healthy attitude about breastfeeding. I set a goal for myself to do it for a year, but was willing to occasionally supplement with formula. And when women tell me they want to breastfeed, I try to offer practical tips, including telling them not to stress if it doesn't work out.

But recently, I've realized that my attitude about breastfeeding is far from healthy.

Ways you know you have an unhealthy breastmilk obsession:

--You have passed up a chance to do something actually enjoyable in order to pump

--Your baby is 6+ months and you are still pumping

--...even though it means you leave work later and see your baby less

--Your freezer contains more milk than food

--You have fed your baby breastmilk that might have been going stale instead of fresh formula

--You make breastmilk bottles with less milk than you think your baby will drink so none of it will get "wasted"

--You feel sad/angry when the baby doesn't drink all the milk in a bottle because it is "wasted"

--You have given up sleep to pump

--You have given up sleep to keep your baby from getting a single bottle of formula

--You think formula smells bad

--When your baby does get formula, you feel guilty

--Even though you pretend not to, you secretly judge other women who don't breastfeed for at least a full year

Is this healthy? Is it necessarily in my baby's best interests? I'd say it's often very clearly against my baby's interests, actually.

The way I finally realized this might be a problem was that recently I had an issue with my pump equipment. I found some old crud on the... yellow thing the milk filters through (OK, I don't know what any of the equipment is called). I washed it daily but apparently didn't completely dismantle it properly. I worried that all the milk I had pumped was tainted. Two months worth, about 300 ounces. And I started to panic.

I started to plan: No more skipping pumping sessions. Maybe start pumping again on weekends. Somehow I had to replenish all that lost milk.

That's when I realized that I was being completely ridiculous. My baby is almost a year old and the winter is over... so what if she got a couple of months of formula? Would that really be so harmful? Would it be harmful AT ALL? In fact, might it even be better to give fresh pumped milk and formula, rather than all frozen milk?

(By the way, the above is a great reason never to use donated breast milk that isn't well screened.)

Anyway, I emailed my pediatrician's office and they said I didn't have to throw out all that milk. But part of me still thinks I should, just to cut the chains (and be safe). I haven't decided yet, but I've decided I'll be okay with it either way.

Multi-tasking

Today was one of those insanely busy days, the kind that I had never come close to encountering prior to having my first child. On top of my regular clinical duties, I had additional responsibilities that had been "saved" for me since I couldn't do them while (inconveniently) out on maternity leave. The end result was that I ran around like a headless chicken trying to round with my housestaff, see consults, see clinic patients, fit in two pumping sessions, and deal with some seriously crazy patient scenarios, straight out of Grey's Anatomy.

Today, multi-tasking was the only way I could survive. I seriously had almost no time to sit still, I barely ate lunch (two hours after I initially heated it in the microwave), and always, always took the stairs.

My most peaceful moments were, coincidentally, while pumping. At least then I had no choice but sit in my office and internet surf or read my email (probably against OSHA regulations to walk around the corridors while pumping).

Of course, during my second pumping session, I actually paged the resident I was working with on consults to discuss our patients, you know, seriously multi-tasking. I made no excuses for the background whirring noise. "I'm pumping," I announced unceremoniously at the beginning. There was no time to be modest.

(I knew she was a mother; I certainly wouldn't have said this if she were a man.)

She chuckled. "I've so been there."

Which is why I love working with housestaff who are mothers themselves. There's an unspoken understanding.

They get it.

Herbal Suspect

I first learned about the potential dangers of taking herbal supplements in medical school. The point was driven home by a patient with rhabdomyolysis. Another with acute liver toxicity. Many an attending warned us to ask about supplements or instilled the fear that anything could make it's way into an herbal pill, and thus their usage should be actively discouraged.

I frowned at the lack of strong evidence supporting their usage. I have to admit that I grouped those who used herbs (and usually it was multiple offenses) as a little bit out there. You know, a crunchier sort, not grounded in science or rigor.

My mother, as luck would have it, would fall into that group. She is all about the holistic and the natural. Her evidence has always been in the form of testimonials and N=1 logic. A friend cures constipation with mega doses of Vitamin C? She's on it. Her cousin's babysitter ate flaxseed once and had more energy? Done. A friend of a friend of a friend of a friend (who is wife to a physician!!!!) swears by walking on her hands to cure the hiccups? She asks for how long. I've often wondered how half my genes are from her.

I, on the other hand, harbor a healthy fear of supplements, with herbs topping the list. They frighten me because they can very well be biologically active in non-perfectly-elucidated ways. Perhaps it's the complete lack of control in terms of production, dosing, effect, and potency that scare the OCD scientist inside me. Then, there's the fear of hidden toxicity. Who knows what could happen? A couple of years ago, I would have never thought I would ever try taking herbal supplements. No way.

Yet, when I started stressing about returning to work and pumping enough to keep my newborn son fed exclusively on breastmilk a few months ago, I read with interest about fenugreek and Mother's Milk Tea. Really? Increase milk production? Mine more liquid gold with every pump? Of course, I didn't look into possible negative side effects at all; I didn't even care. If it meant being able to nurse longer, I would consider trying it. Fear of the unknown and the unaccounted for never entered the equation.

I decided to try Mother's Milk Tea. The ingredients include fennel seed, anise seed, coriander seed, spearmint leaf, lemongrass leaf, lemon verbena leaf, althea root, blessed thistle herb, and fenugreek seed. Listing out those ingredients makes me feel like a witch mixing a potion in a cauldron in my backyard.

I drank my first cup excitedly, thinking about how much more milk I'd produce that day. It tasted slightly bitter and medicinal, certainly nothing I would voluntarily choose to drink if given the option. Over the next few days, I diligently brewed my herbal concotion and did notice an increase in how much I pumped if I drank two or more cups a day. Maybe.

So, now, it's been a little over the month, and I have often wondered aloud why Costco doesn't carry Mother's Milk Tea by the crateload. For my child, I've recklessly turned from a science-based pragmatist into a herbal-tea-chugging junkie who's just looking for her next fix.

Which makes me think about how much motherhood (and the compulsiveness to be a "good mother") has changed me.

Also, if I grow a third eye, you'll know why.