My archives might be a little outdated especially the older blogs. My links above are all new and current.

I have only positive things to say about Permission to Mother, an autobiographical account of a thoughtful mother and clinician who courageously writes from her heart, soul, brain, and personal experience; who is open to change in her views and opinions and is not guided by the safety of rules of any group or the status quo; she is guided by love and openness to the experiences life brings her and her family. Her process benefits her and those around her and those who read her words. And to add to that, the writing style and story telling ability here make it a very enjoyable read speckled with both the humor and seriousness of life. ~Laura Keegan RN FNP, author of Breastfeeding with Comfort and Joy

Readers enjoy your feedback and Reviews (82!) on amazon. Kindle Version Available!

Please Join me on Facebook at Punger Family Medicine.

Monday, March 31, 2008

March Blog Summary

Here is my end of the month summary of posts and some updates:

Grandpa Update
A Tribute to Grandpa
Jewish Mourning
Grandpa is having a Military Memorial coming up next week. I need to come up with an inscription for the plaque.

Family Practice Board Recertification
Bipolar, Breastfeeding, and Board Exam
I have not studied much for the board exam. But I find I am using a lot of mental energy thinking about it. I have not addressed my sons bedwetting (posted in February) at all. I think you're suppose to be a "stable" household to approach bedwetting treatment. William is plugging along and doing well in his Language Arts and Science classes at Florida Virtual School. I need to stay disciplined to keep him on goal. Some of the extra-curricular activities (karate and Hebrew) have been cancelled this week for public school spring break and my evenings are really grateful to have a breather. Scott is making big strides in reading. We are using Hooked on Phonics that I purchased 10 years ago.

Conference Exhibit for Permission to Mother
Local Moms Save the Date!
I need to place an order for books to bring to the conference. I ordered and recieved some posters, postcards, business cards to use. I am so thankful my mother and fitncrafty sister volunteered to make a display board for to use at these activities. A big load off my mind! I have one more activity possibly in October and then I can call it a full schedule.

Order of the Published Posts
I have learned a lot about blogging this month, I set up google reader. I finally figured out that.

Dear Bernadette,
The Rest of the Photos From Scott's Birth
Children's Noise is Music to my EARS
Natural Alternatives to Tampons and Pads I learned how to bump my posts!
Formula for Orphans I am so glad to see the birth of this Foundation!
skin-to-skin vs. bottle propping
How to spell Breastfeeding? Note-- Bedwetting is one word.
Another reason to have a midwife...


Permission to Mother Distribution

I am appreciative that I have a flexible "job" and still can come home at lunch to see the boys, although they usually don't care if I come home or not during the day. I'm appreciative that I have a "job" doing what I love and it allows time for all this extra-curricular activities, not to mention book activities.

On top of it all, I am still maintaining my sugar-free. It's been 6 months. With a schedule like that, you'd think I'd need a ton of sugar. The only sugar I may have been exposed to is inhaling the "fumes" when I open a gatorade powdered mix to make for the boys or a contaminated knife goes through my food. (ei, sugar is not banned from my house, only my body. I do my best to avoid the knives, wipe the counter well, etc...)

I have one question remaining in my mind. When am I going to take a vacation? Or just a little break. That board exam really dents my summer. I am blaming it all on that exam.

Permission to Mother Library Distribution

Libraries:

This week Indian River Community College notified me that they accepted my donated copy of PTM to be shelved at the SLW branch. Place a hold here.

Another copy has been donated to FAU Library.

Three copies have been donated to the Saint Lucie County Library System (Fort Pierce, Morningside, Lakewood Park). Place a hold:

When I get to Martin County and Indian River County , I will leave a copy for those libraries. I request inter-library loans often, so you can to if you need to.

Of course, the local LLL library and local midwife libraries.

Perhaps I'll update this library list as it grows.

Wednesday, March 26, 2008

Another reason to have a midwife...

Today I was signing off consult notes I get from the specialists. This is from a GYN:

We had a long discussion today. 78 yo female with a history of breast cancer satus / post partial hysterectomy 2 weeks ago for what was thought to be a benign lesion came back from path as malignant. Her breast cancer was treated with ... ... ... and complicated by... ... ...

Now I am recommending a repeat total hysterectomy to remove the tumor, but we should wait till she has healed from this surgery and seek the opinion of a radiation oncologist. I'd like to start radiation now, but its likely a RO won't start till after the second surgery and the concerns about chemotherapy are ... ... ... on and on it went.

Wait! When I birth, I want someone focused on me and babies and breastfeeding and wellness. I don't want someone distracted and specializing on disease and illness and complicated surgery making decisions. This lady deserves a great specialist, like she obviously has, who is weighing and discussing all the options. This is what a gyn is trained to do. A gyn also delivers baby according by today's standard of care. But I want a provider who specializes in me and my baby and my wellness. That specialist is my independent midwife, who is only trained in birth and wellness, along with my own personal self-responsibility. I do not need a surgeon and cancer specialist when I am pregnant.

(No, I am not P.)

How to spell Breastfeeding?

Breastfeeding, breastfed, etc... is all one word. You see me close it, but your spell check separates it. That's probably confusing. Professionals in the field close the space and if you want to look authoritative, it's best to close it, too.

At first the spelling confused me, too. I do believe that one day soon, "breastfeed" will be added to the dictionary, especially as more people use the word.

When I am being published, I have to specify to the editor to keep the space closed. I often look at articles in the paper about breastfeeding. If the space is present, it makes me think twice if the author is someone in the field or just a journalist. I put less weight on the article when I see the space.

On the same note, I close the space on these words: homeschool, homebirth, postpartum, breastmilk. My spell checker does not like me.

Monday, March 24, 2008

skin-to-skin vs. bottle propping

I've been wanting to collect "educational" photos like this that illustrate no skin-to-skin contact during a feed. I hated to see this baby being fed like this. Babies nurse for more than hunger. They need skin-to-skin when they feed for optimal development.

At least there is a human on the other end of the bottle and it's not totally propped, but I was watching the mother and baby and this bottle would have been propped if there was something to prop it on. Carrying this baby around in a sling would have made me feel so much better. It would have provided the skin-to-skin while bottlefeeding.

If you are going to deliver liquid to a baby in a bottle, can you please hold and touch the baby? Bottlefeeding does not mean you have to prop. Propping is dangerous. It may lead to choking and it is a type of abandonment. There should always be human touch when it comes to feeding a baby.

Deciding not to breastfeed is one issue, propping and lack of skin-t0-skin is another issue. No baby wants a double whammy.

Sunday, March 23, 2008

Natural Alternatives to Tampons and Pads


10% of first order of three or more lunapads
at Twofloridadocs.com (coupon code 10luna)
exp 4/08


I’ve been totally natural for over four years! I first heard of natural products over nine years ago on natural family living internet forums. I don’t know what took me so long to switch. Perhaps, not knowing anyone personally who used natural menstrual products kept me procrastinating. Finally, when the constant use of disposable postpartum pads left me irritated, I switched. I already decided to cloth diaper my third son so he wouldn’t rash, and it finally made sense to use natural menstrual products myself. I have had no more outside irritation or vaginal dryness since switching.

I like the softness and comfort of Lunapads. I like the choice of prints. They feminine prints make me feel proud to be a woman during a time when popular culture says, "gross." I like the option of the extra soft organic pads. I like having my familiar and personal supply of various size pads and liners to meet the needs of my cycle. I know the right size is always there. They real work. I don’t have to go to the drug store for personal products anymore. (And I don’t have to guess what “new and improved” means in terms of absorbency.) They don’t fall apart in my purse. My Lunapads are always fresh and clean. I don’t have to be concerned about how many years a found tampon or pad in my draw, purse, or suitcase has been carried around.

My funny husband seems to know my cycle. Every twenty-eight days, "Let’s take the boat out, swim etc…" Committed to natural, that’s when I began using the Divacup for our outings and travel. I like the flexibility of internal and external natural products to meet my moods and needs.

Now being in the style of medical work that I do, I tend to attract women who have discontinued using, one-time-use products for a variety of reasons: financial, environmentally friendly, comfort, medical. I am not such a loner. Many women get rashes, infection, and irritation from disposable products. Lunapads has a website and now I am one of their distributors for pads and divacups.

I will not go back to disposable products. I wish I knew of them when I was a teen and could have benefited from natural products over the majority of my menstrual years. I feel good about using Lunapads and the Divacup.

If I had daughters they would use these products, too. But its really cool that my boys have an awareness that natural is normal and they don't know about the artifical options.

Originally posted 11/29/07

Saturday, March 22, 2008

Children's Noise is Music to my EARS

I took my two oldest to Shabbat services last night. It was a special Purim celebration. The Temple has had a guest Cantor who has brought so much talent, humor and warmth to the Temple. David, my 4 yo stayed home with Dad. I'd love to have my whole family go to what should be an activity for the whole family, but I do need to get something out of being there without chasing and controling a preschooler. I found the evening to be enjoyable.

The Cantor led a special Tot Shabbat on Saturday morning at 9 before the regularly scheduled service. Tot Shabbot is for David. Its kind of like Kindermusic but with all Jewish songs appropriate for the season and holidays. David refuses to sing the songs. He's a little shy and a little unsocialized (you, know the homeschool-thing ;)).

The song is:
I got the Shabbat feeling in my head...
I got the Shabbat feeling in my ears..
I go the Shabbat feeling in my eyes...

The verse changes to learn parts of the body said in Hebrew.

Finally Scott chimes in quietly...

I go the Shabbat feeling in my Butt.... (this is a real proud moment for me--not)

David loved this verse and finally sings it as loud as he can.

I am the mother of boys and this is reality. They feed off of each other and find a lot of humor in toilet talk. At least they learned the song.

We made it through Tot Shabbat without being kicked out and I decided to stay for the regular service with the guest Cantor with all 3 of the boys!

I sat next to a dad with several kids. He only brought one daughter this morning. His youngest son, who is also named David (the same age as my David) drowned a few months ago. My heart aches. When I saw the other David and his mom and siblings, even though I didn't verbalize it, I felt unity having all our young kids in service amongst elders. (Mine of course, are much, much more noisy).

Back to this morning. Mine lasted an unusually long time behaving and being quiet. Finally the restlessness became noise. Heads turn, the sh, sh, shing begins from the seniors. One even said to Scott to be quiet.

I wish she would come directly to me. This would be my reply:

I would give ANYTHING to have the TWO Davids laughing and running and even SCREAMING during service. Children's noise is music to my ears. I can't imagine the pain the other David's mother feels. I am crying as I write this. I wonder if anyone else in the Temple is grateful that us mothers of young restless boys bring them and if the seniors who want a QUIET temple really want a quiet Temple.

Saturday, March 15, 2008

The Rest of the Photos From Scott's Birth

Since I was digging out photos from birth #2 for the post below, I thought I'd scan the rest of my "birth" photos.... and as you see there are no labor and birth photos. Remember, I still had PTSD prior to this birth. Although my photography was improving in other areas and my sister was available to take photos, I thought to myself, "I do not NEED photos of myself with an IV, monitors, strap down, barfing, and near dead." I did not think labor could be a beautiful event, so there was no need to have photos of my labor and birth to reinforce negative memories.


I wanted birth to be different, but I could not really imagine that I would be able to labor any other way. And as it turned out, I stayed home to labor and never had had anything strapped on me, I didn't barf, I stayed in my own clothes, and I stayed in control.


In retrospect, my labor was worth photographing. I'd have my good memories in photographs and also then you would have my images to see how my doula helped me stay focused and in control and not just my little stories.
It's amazing the difference one birth can have on you. My sister and I both had SLR cameras, why did I just have the Polaroid loaded?????????????? I love seeing how William gazes at Scott. I hate seeing myself in a hospital gown. I hate the feeling of how unempowering wearing a hospital gown for birth is. I hate that my son was on this warming table and not in MY arms.


My next birth had about 4 cameras!

________

I haven't forgotten the vaccine posts. I have outlines and notes almost ready to go. I just don't find vaccines as interesting as birth and breastfeeding. If I have anything about birth and breastfeeding to say, it's always going to come first.

Friday, March 14, 2008

Dear Bernadette,

The author of the book is called the author
The editor is called my editor
The cover designer is my cover designer
The one who writes the foreword is my foreword _________...

...there is no special name for the foreword writer. There should be.

When I first thought about who should write the foreword for Permission to Mother, I was on the wrong track and thinking about finding someone internationally known in the field.

My editor suggested asking an *interesting* mother, like one with 12 kids born at home and actively involved with natural mothering movement.

How obvious! But even more importantly when my books story includes a culmination of our friendship, spirit, and camaraderie, it became clearer to ask you. It's great to have an editor to offer a fresh perspective after being lost in the endless "what's-next tasks." You're so busy I would have never bothered you, if it wasn't for her push.

I can imagine it's no easy task to be put on the spot and write a foreword for a book that is only available on computer screen (at that point in time and still going through revisions). I was so grateful and appreciative to receive and read that foreword. I feel like it completed my book.

This is how I autographed your personal copy of Permission to Mother:

Dear Bernadette,

Thanks for being there for Scott's birth and then through the years helping me process the events(good and bad), emotions, and feelings of all my pregnancies and birth and postpartum. Thanks for bringing your unyielding faith in birth to Scott's birth, sharing your belief in a hands-off birth with me, and believing that I can progress in labor without intervention.

Thank you for insisting that I put my stories in writing, despite my initial resistance to not want to. Thanks for your confidence in my writing skills before I had confidence in my abilities.

You were the mother of 10/doula and I was the not-very-confident pregnant mom of 1/physician. Now, you have 12 and I have 3, you're also an RN and I became an IBCLC. I've enjoyed working on our mutual goals through all the writing, editing, and photography. Thank you for writing a beautiful and perfect foreword for my book. Thank you for being a part of my journey.

Love always,

Denise

PS If I find a photo of us from Scott's birth it's going here* Well, I found one.
There's me, compliant in a hospital bed after a birth with Scott and my doula. I usually don't have issues with how I look in photos, but I do have issues with this photo of me.

I felt much, much better than I looked!








PSS I am also impressed that your church has an option for for a "cloth diaper" shower to replace a disposable diaper shower. This I learned today.

Tuesday, March 11, 2008

Order of the Published Posts

Dear Sarah,

When we were discussing daycare, you verbalized (wrote) how your most current post that started as a draft and saved as a draft showed up on your published blog in the order that you started the draft and not in the order the blog post was published. (Hence, visitors might not see new content below old content.)

That's a mouthful. I hope that makes sense to everyone.

I had a chance tonight to find out how to start a draft when the thought is there, but get it published at the top of the blog even if you don't finish it for months.

At the bottom of blogger, look for post options. Click on it. When you get ready to publish your (old) draft, simply update the date and time, and your published post will show up at the top of the blog.

I feel like I accomplished something. :)

Monday, March 10, 2008

Conference Exhibit for Permission to Mother

I am planning on attending the Florida Lactation Consultant Conference April 11th and 12th in Lake Mary, Florida at the Marriott. I've been to previous conferences held by FLCA and it is one of my favorites.

This will also be the first conference exhibit for Permission to Mother. I am excited to have this chance to show the book off in person!

I am donating two books to the conference raffle and one book to the organization's member library. If anyone is interesting in bulk conference pricing let me know. I am working on bulk pricing and and a conference special price.

If you are interested in attending there is still time to register. You do not need to be a professional in lactation to attend. It is a casual, friendly and very informative meeting. The exhibit hall is also friendly.

My mother, who is a Central Florida Realtor and lives close to Lake Mary, will help me man the exhibit, because I really plan on learning something in the lectures. :) I'm looking forward to having her support for this event!

Sunday, March 9, 2008

Bipolar, Breastfeeding, and Board Exam

Continuing from the previous post. There is always a few questions on the Family Practice Board Exam about Bipolar, Lithium and Breastfeeding. The "correct" answer would be the choice making the association that breastfeeding and Lithium are incompatible. It's a no wonder than that physicians tell their bipolar clients that they can't breastfeed; its what they've learned.

Now do you think, I tell Bipolar clients they can't breastfeed? First of all, an individual assessment is important. "Bipolar" is used loosely and people use the term meaning a whole range of different scenarios. When I first learned of bipolar it meant Manic/Depressive--going from psychotic highs (mania) to psychotic lows (severe depression). I hear it being used more casually to mean anyone who has ups and downs. So the first thing I would do is determine if its really Bipolar and consider what medications are used for treatment.

For "real" bipolar then I would consider the possible use of the safest medications and make recommendations to the treating psychiatrist. If not possible to change medications or minimize dosage and the mother will truly be on Lithium and antipsychotics, I can monitor the mother and baby closely by physical exam, by blood test, by breastmilk drug levels. I did something like that for Sarah when she needed Iodine for her thyroid. Why put a baby on formula automatically when we know formula has definite risks vs. a ttheoretical risk from a low exposure of medication. Breast is always best.

If the mother is psychotic she would be a risk to her baby and that would be a contraindication to breastfeeding.

As far as the casual uses of calling someone bipolar, there is so many scenarios. In the worst case I would do the same monitoring as above. In cases not so extreme, I can probably work out breastfeeding.

It is important for a woman with bipolar to find someone specializing or interested in breastfeeding medicine. Getting a referral through the Academy of Breastfeeding Medicine or La Leche League Medical Associates is a start. I know that some members will provide highly individual care, but there are also associates who are very conservative or may be associates new to all this.

I would also include a vitamin and nutritional assessment to determine if there is a treatable underlying cause for the psychiatric symptoms. Depression has been proven to be associated with B vitamins and folate deficiencies.

Family Practice Board Recertification

My Family Medicine recertification exam in coming up, August 1, 2008. My husband and I are both taking the test in Maitland, Florida. We both took the initial exam and have been recertified after seven years and it's coming up on eight years now. I am bored studying for my board exam. This is the first year it will be all computerized. I want to read a few a review questions everyday. Real life seems to be getting in the way of this goal. Its been a few weeks since I've opened a book. As anyone knows who has taken a professional exam in any discipline, the information we need to review does not seem to apply to our real life professions. The discussions, sometimes, are just flat out wrong. I disagree with nearly almost every discussion following the question.

Here is an example. It is common to have a question about the cause of acne on FP exams. The test question wants you to associate acne with the causative bacteria. Chocolate would be a wrong answer. The discussion clearly states that acne is not caused by sweets and treats. Now in real life I had an adult acne problem. I found out I was sensitive to sugar. I eliminate sugar and my skin clears up. Its frustrating to invest time into "learning test questions" and "wrong and useless information."

Do you want to even know what I think of the obstetrics and the handful of breastfeeding questions in my review books? GRrrrrr.

Friday, March 7, 2008

Jewish Mourning

I just haven't felt like writing anything, but that is normal after a loss of anyone in family. I see grieving survivors in my office often having a lot of trouble getting back to their life. Its not necessarily suppose to be easy, but so few people have any coping mechanism for death.

Judaism has many guidelines for death. In a nut shell and very simplistically--No life support. After death the body is suppose to remain in the presence of family as to not be tampered with. Buried as quickly as possible. The family actually digs the dirt and covers the casket with dirt. No cremation. No embalming (ei., dust to dust). No make-up. No viewing (which relieves me greatly, what a terrible and disrespectful thing to do to someone's body). Lighting a shiva candle after a funeral, wearing a black ribbon. Sitting shiva, receiving visitors who are only concerned with the welfare of the survivors and good memories of the deceased. Visitors not making demands on the survivors.

Sounds hard to carry out all that. My family doesn't do all that. My family is not religious. But... I feel good knowing that I understand the rituals and can have some control over lighting a candle and wearing a ribbon. Perhaps I'll come up with other rituals that are meaningful. It gives me control knowing what the rituals are and that I can perhaps understand in my mind why we don't do thing s that way or perhaps never understand but accept.

The shiva candle, a week long candle, burned for someone in your immediate family is symbolic of the time we should focus on our spirituality. It is not a time of going to parties and joy. It does not matter if you got along with or fought with, hated or loved, it is still family and whether or not you like it, we have a flood of feelings and emotions and they need to be faced. I can see how Jewish mourning brings survivors together to remember the good, to strengthen the ties between the survivors. Funerals and mourning are, in a way for survivors to deal and cope... and then gradually move on in appropriate timing. It's a way for us to confront reality and not hide behind our busy life. Its the Jewish ritual that makes most sense to me. You'll know when my Shiva candle burns out. Unless its urgent and related to feeding my family, my thoughts are where they should be.

Monday, March 3, 2008

A Tribute to Grandpa

Death is usually thought of as something sad and terrible. Something that is so final has a way to make us put our mortality into a new perspective. When one dies who is 94 years old, it's also amazing to think about the gift of life and longevity. Grandpa was gifted with longevity as is the Jewish people. What cultures or religions have survived as long as Judaism? The passing of a grandparent makes me think with pride about my heritage, eventhough Grandpa was secular. He did marry within Judaism, but I never heard him talk about going to Temple or celebrating Jewish Holidays. We are not sure he celebrated becoming a Bar Mitzvah. It's interesting some of the questions that come up after one dies.

Judaism has a very methodical way of mourning the loss of family. Like other Jewish life cycle events, I find very little space or appreciation for most life cycle rituals from the outside. With grieving, modern culture demands you be back at work in 24 hours. It's viewed as a sign of strength to be back and functioning. Judaism has a strict week-long mourning process. Even in my own house it is hard to create any space to reflect. No wonder people have so much trouble with grief--there is hardly time to process the death, our own mortality and spirituality before going on to handle the public on their terms.

Grandpa lived a strong and independent life. He was not formally educated, but very smart. He would have loved to be a college graduate and not just dress in my robe for the camera. My younger cousins are physicians, but my Grandpa says he was the first MD in the family...get it...Meyer Deutsch...he was full of humor and corny jokes. He hates that I homeschool. Shamed that he never got a degree and worked to support himself at a very early age, he doesn't understand how much I admire self-education.... which is what he was, self-educated. No one in my family seems to recall who his parents were. Was he left orphaned? It would account for us not knowing much about his early days or his parents names and lack of history we have on him. He read the New York Times Daily for a million years. He missed reading my published book, by just a few days. He was a purse maker... or better called a craftsman. He was handy and meticulous around the house and loved showing off all his gadgets. He could play the harmonica. He was proud to have Greatgrandchildren.

Grandpa will not have a Jewish burial and funeral service (its just the way the situation is and far too complicated for me to fully understand). That makes me sad. My own mourning space will bring him Jewish honors. I am grateful for the black ribbon the Rabbi placed on me and my mother to bring us some space. His ashes (oh, so not Jewish), will be buried in a national military ceremony.... when the military gets to it (not with Jewish urgency). Grandpa is a veteran of World War II. I do think he would like being buried there. He was not one to ever utter a preference or discuss the world to come.

I am sure he would be happy, even if he could never express it in words, that I can take my own initiative to bring spirituality to his passing. I lit a Shiva candle for him last night and read the Mourner's Kaddish. Reading it in Hebrew, like we do at the Temple brings me a sense of community and continuity, but I found it difficult to read the Mourner's Kaddish at home with my Mother and Boys in English without tears. The meaning is penetrating. It is a reminder that the spirit is stronger than death and Grandpa's influence on me shall live.

Grandpa Update


My Grandpa, Meyer Deutsch, passed peacefully around 4:40 on Friday, February 29, 2007, Adar 1, 24, 5768 on the Jewish Calander. He was 94, with a sharp mind, and lived independently until Jan 12 when he broke the second hip and went to the hospital. He recovered from his first hip surgery exceptionally well. While in rehab (if you can call it that) this time, he developed pressure sores from being immobile. The sores led to infection. His friend Stanley, who stayed with him at Hospice at JFK, said that Grandpa said, "Good Bye, Stanley" as he took his last breath. He knew.
This photo of him when he first met my Step-Grandmother.

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