Postpartum Visits Revisited: Yes I said yes I will yes.

My attention was drawn this morning to an excellent, straight-to-the-points post entitled "How to Be the Best Postpartum Visitor in 15 Minutes Or Less". It is spot-on. By way of introduction, she says:

This visit is NOT about you. It is not about the parents hosting you and putting on a cup of tea so you can sit and visit and hold the baby. Think about how you would feel if you had either had surgery or ran a triathlon. What would you want people to do for you? This visit is about blessing the parents and making their life a little bit easier. Your prize is getting a quick peek at the cute new human.

Quite. I can't tell you how many moms are expected to play hostess to their visitors while they're still undergoing major healing, and possibly even more significantly, adjusting to the seismic shift that has just taken place in their lives. Postpartum visits need to be made in loving service TO the mother and new family. Here's her list of criteria for the perfect visit:

1. Bring a healthy meal. Include a salad or fresh vegetables. Only use disposable dishes. There is nothing more annoying than

a) having to wash more dishes when you have a new baby

and

b) having to try to return dishes to all sorts of random people when you have a new baby

2. In addition to your meal, bring cut up veggies and fruit, unsalted trail mix or nuts, or other such healthy snacks for daytime munching for mom to eat while she's nursing.

3. Go into the kitchen and spend 5 minutes clearing off a counter, washing a sink-full of dishes, loading the dishwasher etc. Don't ask permission, just do it. Then set the table for their dinner.

4. Before you leave your house, put some paper towels and some powdered bathroom cleaner like Commet or Ajax in a baggie. Stick it in your purse. While you are at the house, go and use the washroom...and while in there do a three minute bathroom shine-up, using your paper towels and cleaner.

5. Coo over the baby, but wash your hands before touching it.

6. If they want to eat right then, heat the food up and put it on the table, give everybody kisses and then leave.

7. Take the garbage out when you go.

Awesome, right? Even if your visits are professional (as a doula or lactation consultant or some other solicited service) there's still wisdom in the core message.

This post reminded me of a post I did on the same a while back, "The Answer is Always Yes", from which I excise one final point to add to the basically perfect list above.

I have one final suggestion. This is something to tell her in response to the inquiries of other friends and relatives who will want to visit. Almost invariably, when people arrange to come calling on a new family, they ask "Is there anything I can bring you? Pick up at the store? Anything?" THE ANSWER IS ALWAYS "YES". ALWAYS! This goes back to the learning-to-ask-for-help thing. It is SO HARD for us to get this lesson, and stop trying to prove we are superwomen who can do everything all by ourselves immediately after delivering the placenta, but there's no time like the postpartum period to start feeling comfortable with it. Have her keep a notepad by the phone, or in a very handy place if she relies on her cell. This notepad would be a great inexpensive gift, especially if a pen is attached so she doesn't have to look for one over and over. She can then keep a running list of things that she and the household need, just jotting them down as she goes. Orange juice, witch hazel, baby wipes, red raspberry leaf tea, onions, sanitary pads, flax meal, Rescue Remedy, dark chocolate, burp cloths, fresh fruit, a new thermometer, WHATEVER. If the list is literally empty, and she can't think of *anything* else - ASK FOR TOILET PAPER. It can always be added to the household stash. Make her repeat it with you: "The answer is always 'Yes'!"

It's more of an exhortation to the new mother, but friends and loved ones who are aware of this idea can encourage her in their phone calls prior to the visit, and help her to say embrace the yes.



Confession: I myself have been guilty of not bringing food in disposable containers. Yes, they're less environmentally friendly, but using them once in a blue moon (of the babymoon variety) is pretty benign, and there are also disposable products made of recycled materials one can use - check out Whole Foods or other similar businesses. I hereby apologize to anyone I put in the position of chasing me down to return a casserole dish!

My Babymoon Bake: A perfect first meal for a new mama!

Many of you know I have another blogging life - the food blog I share with my mom, Fab Frugal Food! Today, worlds collide.

Along with breastfeeding support, giving tips on infant care, and light housecleaning, one of the most popular functions of a postpartum doula is, happily for me, meal preparation! I love this part of my job almost as much as holding sweet little bundles in order to give mama a break.

Relatives and friends like to bring over casserole-style dishes, which are highly practical as they can be frozen, stored efficiently, and are easily reheated - they can, however, be a bit on the heavy side. I have a few favorite recipes for new families, with an emphasis on nutrition and digestibility, but I recently tinkered around and figured out what might be the ultimate meal for a new mama. A midwife in Jennifer Block's book "Pushed: The Painful Truth About Childbirth and Modern Maternity Care" described the postpartum meal that she always prepares for her clients as being nourishing, quickly absorbed, high in iron and in fiber; it's typically based in greens and brown rice, then sweet potatoes, or any other favored vegetable. My version includes spinach (though you could use fresh kale or chard), brown rice and tomatoes. You could omit the tofu and use more cheese; I would just caution you to keep it minimal, as constipating foods can be especially difficult in the early postpartum days.

For the sweet potato component, I simply toss some sweet potato slices in olive oil, garlic powder, smoked paprika and a touch of salt, then bake them on a cookie sheet at the same time the spinach-tomato casserole goes in. Finally, I'm sharing a recipe that was NOT mine originally (though I tweaked it), some lactation cookies; shared once before on this blog, but hey - so worth sharing again. These treats include several galactagogues. Bring these three items over to any new mama - satisfaction guaranteed.

SPINACH, TOMATO, TOFU & BROWN RICE BAKE

2 cups brown rice (I prefer short grain)
1/2 teaspoon salt
1 10 ounce box frozen chopped spinach
3 tablespoons olive oil
1 medium onion, chopped
1 red bell pepper, chopped
4 cloves garlic, minced
14 ounces firm tofu, frozen, then defrosted and squeezed thoroughly dry
28 ounce can crushed tomatoes
1 tablespoon dried basil, or about 1/4 cup fresh, if you have it on hand
1 teaspoon dried oregano
1/2 cup Parmesan cheese or, for a vegan option, 1/4 cup nutritional yeast

SWEET POTATO ROUNDS

2-3 sweet potatoes, sliced about 1/4 inch thick
2 tablespoons olive oil
1 tablespoon garlic powder
2 teaspoons smoked paprika
1 teaspoon salt

Step one is easily done while you prepare the rest. Combine rice with 4 cups water and a dash of salt in a large pot and bring to a boil, then reduce to a low simmer, cover, and cook for 45-50 minutes. Remove from heat when done (try not to peek until at least 45 minutes have elapsed), fluff with a fork and set aside.

Preheat the oven to 375 and add the prepared sweet potato slices, if making, as soon as it comes to temperature. Set the timer for 20 minutes and start checking them then; you'll want them to get to golden brown on the bottom before you flip them (just once). We're going for overlap with the casserole, or they may be finished at the same time. Either way works.

As the rice cooks, do the rest of your prep, including defrosting the spinach if it hasn't been done yet, then removing the excess moisture by wringing it in a dishtowel or pressing it through a fine-mesh sieve. Ready? Okay, now we heat the olive oil over medium-high in a large saute pan, then add the onion. Saute for 3-4 minutes, until starting to soften, then add red pepper and cook another 4-5 minutes, then in goes the garlic for another minute or so. Add the defrosted, squeezed tofu - you'll want to crumble it right into the pan; the consistency will be a bit like ground meat. Saute it with the vegetables and oil for a few minutes. Add the crushed tomato, bring to a simmer and then let it cook for 5-10 minutes over low, stirring occasionally, until liquid has reduced a bit. Add spices, spinach, and about half the cheese, stir well.

Now spread the rice out in the bottom of a 9x12 glass or ceramic baking pan (sprayed with a touch of nonstick, just to be safe), then layer the spinach, tomato, tofu mixture over it. Sprinkle remaining Parmesan on top and bake for about 2o minutes (using which ever rack isn't occupied by the sweet potatoes, which at this point might need to be flipped to brown on the other side, then rotated to the other rack anyway).

When both are finished, get going on the cookies, if you haven't started already/eaten your way through the dough.

LACTATION COOKIES

1 cup butter (or palm shortening)
1 cup sugar
1 cup brown sugar
4 tablespoons water
2 tablespoons flaxseed meal
2 eggs or Ener-G egg replacer
1 teaspoon vanilla extract
2 cups all-purpose flour OR flour of your choice
1 teaspoon baking soda
1 teaspoon salt
1 tablespoon ground fenugreek
3 cups thick cut oats
1 cup chocolate chips
2 tablespoons brewer's yeast

Prepare a baking sheet with parchment paper or a silpat liner.

Mix the flaxseed meal into warm water with fork, set aside 3-5 minutes. Cream butter or palm shortening and sugar. Add eggs or prepared egg replacement. Stir flaxseed mix into butter/shortening mix and add vanilla, blend well.

Sift together all dry ingredients except oats and chocolate chips. Stir wet ingredients into dry, then stir in the oats and the chocolate chips. Drop by heaping spoonful onto on baking sheet and bake 8-12 minutes.

These are easy to healthify if you want to make them vegan and/or avoid white flour or refined sugar: just substitute a gluten-free or a whole grain flour, and use brown rice, pure maple syrup, or a substitute of your choice in place of the sugars. As denoted, palm shortening can replace the butter and Ener-G egg replacer for the eggs.

[This will be my first "cross-posting" - I'm sharing this post on Fab Frugal Food as well!]

-- posted by Anne

The answer is always "YES!" (Or, how to help a struggling new mom.)

How best to be of service to a new mother often comes up in conversation when you're me, both online and out in the real world. I received this email from a concerned relative of a new mom, so by way of example, I thought I'd share this correspondence, with permission and edited to remove personal information.

I'm hoping you may be able to help me out. My niece just delivered her first child, by C-section, 5 weeks premature. The baby may come home today. My niece is also prone to depression, has been for a long time, and I can hear it creeping back into her. She wants to go back on her meds because she realizes whats happening but of course is worried because she is breastfeeding. Her mother (my sister) is wonderful. She's very practical, almost to a fault. Not that there's anything wrong with practical advice, but I think my niece is going to need more supportive real-time help. I've told her if she needs me just call, I'll take the day off, leave early and if it's the middle of the night, call and we can talk it through together. What else can I do?

First, what a wondeful auntie you are for wanting to help! Assuming you live close enough that visits aren't a HUGE commute, I would offer four basic suggestions (the latter three of which work even if it is a distance). First off:

1. I would consult her about what times of day are best for her to receive visitors, and then I would simply plan to visit her regularly (with notice prior to your arrival, of course). I would not wait for your niece to ask for help - because she may never feel like she can really ask, no matter how sincere your offer of "anytime, day or night" really was. There is a tremendous amount of pressure to become self-sufficient as a new mom, and moms can feel like they're failing if they need to ask for help, no matter how much they need it.

The visits can involve some practical, simple help, like doing the dishes or folding some laundry - things that can make a big difference in a new mama's day (at every visit, I try to always leave the sink free of dishes and the laundry finished or at least in progress). Sometimes just watching the baby while she takes a shower is all she might need to feel renewed. Other days she might have to cry on your shoulder for a while, get some advice on newborn care, then take a long walk while you prepare some food for her (bringing homemade frozen meals is ALWAYS a boon). And some days, just chatting and laughing over tea will make her feel human again.

Point being, the companionship itself is as important as help with tasks , breastfeeding support, etc. Isolation is such a huge factor in postpartum depression, and if she is already prone to depression, you guys (her family) really need to help her watch out for this. Having those regular visits to look forward to, especially in the early days when new moms feel like they're barely treading water, can help her feel like she always has a lifesaver being thrown her way. My friend Patty came over once a week, and though I would have loved help more often, knowing that I had that support to look forward to helped anchor me all week long.

If it's possible for you to visit, let's say, M-W-F (just for example) for a while, and then taper off after you see how she's doing, I think those regular visits would be the best possible thing! I can see how it would also be beneficial to have the visits from you EVEN IF her mom is already there a lot. I am *sure* her mom loves her like nothing else in the world, and vice versa, but sometimes having your mom there can be . . . well, I don't want to say oppressive (though that could be true in some cases), but there might be some extra pressure or other relationship baggage (even minor stuff) that can be hard for a new mom, if that's her only support. I'm not saying her mom isn't helpful, because I'm sure she is, but it can be really refreshing to have someone besides your mom to help. (I hope that made sense.)

2. (You knew this was coming!) One other thing to *consider*, especially if regular visits from you yourself aren't logistically feasible, is, of course, hiring a postpartum doula for her for a while. :o) In addition to being able to provide the above, she does have specialized training, and can sometimes offer a bit more in the way of breastfeeding support, should that become an issue (though very serious problems would be referred to an IBCLC).

To locate a postpartum doula, if you don't know of any, there are a few options - here are a few to get you started:

• This is DONA's site, the largest of the networks to date
  
• And there's this site, though it's relatively new and might not have extensive listings yet: Doulas.com
• If you're coming up short, just try Googling "postpartum doulas" + "relevant city/area".

3. Just a quick but important note on the meds: There are actually a LOT of medications, including antidepressants, that are perfectly fine with breastfeeding - more than some doctors know unless they specialize in it! The thing to do is find out what her medications are, and then find someone with the Thomas Hale guide to breastfeeding and medication (a.k.a. lactational pharmacology) to look them up - I would try calling local lactation consultants. In the rare cases where the medication IS inadvisable with nursing, alternate medications that may be just as effective are recommended. So if her doctor has told her she can't take her medication while breastfeeding, this might be incorrect - it is worth a look! Plus, you can henceforth impress your friends by saying "lactational pharmacology". It's like flashing a Mensa card.

4. I have one final suggestion. This is something to tell her in response to the inquiries of other friends and relatives who will want to visit. Almost invariably, when people arrange to come calling on a new family, they ask "Is there anything I can bring you? Pick up at the store? Anything?"

THE ANSWER IS ALWAYS "YES".

ALWAYS!

This goes back to the learning-to-ask-for-help thing. It is SO HARD for us to get this lesson, and stop trying to prove we are superwomen who can do everything all by ourselves immediately after delivering the placenta, but there's no time like the postpartum period to start feeling comfortable with it.

Have her keep a notepad by the phone, or in a very handy place if she relies on her cell. This notepad would be a great inexpensive gift, especially if a pen is attached so she doesn't have to look for one over and over. She can then keep a running list of things that she and the household need, just jotting them down as she goes. Orange juice, witch hazel, baby wipes, red raspberry leaf tea, onions, sanitary pads, flax meal, Rescue Remedy, dark chocolate, burp cloths, fresh fruit, a new thermometer, WHATEVER. If the list is literally empty, and she can't think of *anything* else - ASK FOR TOILET PAPER. It can always be added to the household stash.

Make her repeat it with you: "The answer is always 'Yes'!"


To help drive the message home, I share with you some "Yes" visuals I found via Google Image search.

The Third Day

The other day I shared the news about the home birth of friend/distant relative. Today, another online friend (an online one from afar) is having a tough first week postpartum, and it reminded me of my own beginnings. There was so much that was wonderful - and so much that was not just grueling, but frankly, terrifying. For many moms, the Third Day is the day of reckoning. Hormonally, you're undergoing the biggest changes you will ever undergo in your life apart from puberty and menopause, and both of those take place over the course of years, not days or even just hours. Going from being pregnant to not being pregnant, and then from not-lactating to lactating . . . And then there's the sleep deprivation, and the overwhelming reality of one's responsibility as a mom hits you - well, sometimes it's just not very pretty. If you're reading this, you've probably been there.

Here's my crash course boot camp story, in a nutshell:

Day 3 into 4 was the time of staring into the abyss for me. OH, but I was an absolute wreck. I had only slept a few scattered hours total since the birth, my hemorrhoids were terribly inflamed, making it impossible to get comfortable in any position, but especially sitting, my milk had just come in and I was hugely engorged with what felt like rocks in my boobs and ARMPITS and had no idea whether it was normal, I was freaking out about Lily's umbilical cord getting funky, and worst of all it was becoming clear that she was having trouble latching, though I had no idea just how epic this would turn out to be (but that is entirely another story).



I felt completely buried by my endless task list. In addition to just caring for a brand-new precious baby, I had to make sure to 1. learn to use the breast pump, 2. take both of our temperatures regularly, 3. make sure I was getting enough fluids, 4. do fundal massage to help my uterus keep contracting down, 5. keep replenishing my witch hazel and comfrey pads in the freezer to soothe my bottom, 6. do lots of skin-to-skin contact with her, 7. swaddle her, 8. feel confused about which of the former two I should be doing at any given moment, 9. put her in the sun periodically to help with her mild jaundice (and at one point I was CONVINCED I had done so for a few minutes too long and given my newborn a sunburn and was despondent), 10. figure out how to use my Maya Wrap, when thanks to the extremely confusing DVD I couldn't even get it threaded . . . And all of this was on top of nursing difficulties. Yeah, I was a little overwhelmed.


I remember sitting at the computer at 6 am with cabbage leaves stuffed into my bra, tears rolling down my face, posting a pitiful thread on Mothering.com's forums asking for help. I had never felt so pathetic. I remember sobbing hysterically - and I do mean hysterically - when Lily wet her diaper while lying on a heating pad - it leaked (I hadn't gotten the hang of using the waterproof covers yet) and I was suddenly convinced that she could have been electrocuted and it was all my fault. I remember on day 4, having not ventured out of the house since I was in labor, Aaron convincing me to take a walk during a time when Lily was asleep. I wasn't up for a long walk, but he begged me to please, at least get some air, just for 5 minutes. Clearly he could see that I was becoming seriously unhinged. So I agreed to walk to the mailbox. I ambled out the front door, dazed, and then realized I had walked out there with my shirt COMPLETELY unbuttoned and hanging open, in the state I'd been walking around the house in. Thank goodness no neighbors were around to see, and it did give me the first laugh I'd had.

I never saw why a postpartum doula would be such a big help before I had that day, and then I totally got it.

(Note the breast pump tubing.)

Can you relate? Share your own Days of Reckoning?

Love at first latch

Gloria Lemay just posted a great piece about the importance of skin-to-skin contact after birth, and how it relates to the First Nursing Session. We know it is important to establish nursing soon after birth, but HOW soon? Is it possible to push it too much? Let's assume mom and baby have not been separated, which is the central issue. Does the first latch have to be within the first 5-10 minutes, or is there a greater window of time to work with? An excerpt, quoting IBCLC Leslie Wolff:

I feel that skin to skin after birth for the first two hours is SO important -more important than making a big effort to get that baby to breastfeed.. MAINLY because I realize that it helps the dyad - mother and baby - to recover from the birth experience, is a Win-Win situation that requires no effort, there is nothing to “succeed” in - it is just a “being” situation that is beautiful for Mom and baby. And if the baby goes for the breast - great..and if not, or the breast is offered and the baby doesn’t GO FOR IT - that’s fine. . . I know that babies are “supposed to” “immediately” start breastfeeding beautifully - but I see so many mothers and babies that are SO content just lying there Skin to Skin, relaxing, bonding in their own special way. In the past, before I discovered the beauty of Skin to Skin, I remember many frustrated Moms and babies doing their best to breastfeed, because Mom and Dad both knew that was the best thing to do immediately after birth.

I was recently reading "Your Amazing Newborn", by the wonderful Dr. Marshall Klaus, and I was interested to read that he thought that pushing the baby to latch on as! soon! as! possible! after the birth was unnecessary, and even a little interventive. As I'm sure you know, he writes extensively about following the baby's unhindered, natural cues as much as possible within the first hour or so after birth, and goes on to explain the self-attachment behaviors at length.

I can completely see where the impulse comes from, though. Delaying breastfeeding for TOO long via separation of mom and baby is so often a huge problem, so I understand the emphasis on getting breastfeeding, and making this a major priority. But it makes much more sense to me, having read Klaus and now this, to allow mom and baby to take some time to just BE. The baby's just undergone the biggest transition there ever was or will be, after all! Let the kid take a moment to just adjust to breathing, for one thing, and simply being with mama. Like Leslie wrote, if nursing is part of that just-being, GREAT, and it really is the foundation of the mother-child relationship, after all - but if it's not immediate, let them find their own way within the first couple of hours, I feel. As long as mom and baby are not separated unnecessarily, are in a supportive and nurturing environment, and skin-to-skin is encouraged, it's bound to happen organically, so to speak.

(Click the photo for some great resources from a Baby-Friendly initiative in New Zealand.)

From continuous support to a continuum of support

The third Healthy Birth Blog Carnival is nigh, and, following the other great Carnivals on Lamaze's Healthy Birth Practices, this time Science and Sensibility is calling for entries on the third practice: Bring a loved one, friend, or doula for continuous support.

Seems like a no-brainer for me to weigh in on, no? Well, you see, I am but a young padawan doula. Number of births I have attended in person thus far: one (mine). Much as I aspire to not only start attending births as a doula but eventually train as a midwife, I'm still very much inexperienced in the real birth world despite my book and web-learnin' on the matter. I am sure this Blog Carnival will offer up scores of excellent posts by birth veterans, detailing the benefits of that incredibly important continuous support during labor, as well as birth stories in which that labor support person (whether a pro or a family member or otherwise) plays a vital role in healthy, satisfying birth experiences, and I look forward to reading them.

But here's something that's been on my mind as a newbie doula (which I recently realized makes me a 'doubie'): I'm starting to feel that even within the midwifery model of care, the amount of support a woman gets drops off dramatically after the first few days postpartum. Forgive me if I'm playing Captain Obvious here, but I'm currently witnessing the impact of this firsthand, as well as starting to see this pattern in the birth, breastfeeding, and postpartum depression stories I read so voraciously, both in print and online.

Nowhere is this more apparent than in births that have taken place in hospital settings, of course. Let's take the matter of nursing for just one example of the value of postpartum support. A woman heads home after a birth which may or may not have gone smoothly, where she may have received terrible breastfeeding advice, where she may have been separated from her baby, where her baby may have been given formula from a bottle with or without her consent or even knowledge. She may have even been given a "gift bag" containing you-know-what. Think about this mother headed out of the hospital has been really been set up. She may already be on a downward spiral.

Let's say, though, for argument's sake, none of the negatives in the hospital scenario above have happened. Let's say that in every instance, she experienced the best case scenario: no artificial nipples, no separation, a good birth, and so on. The environment at home can vary WILDLY in terms of what kind of support she has, in terms of both quantity and quality. The father most likely only has a few weeks of paternity leave, if that. She may have extended family living nearby, but this is becoming rarer and rarer in contemporary society, so she might have her own parents or in-laws coming to visit and help out for a while. She may or may not have friends in the area who can help out here and there; sometimes a meal rotation has been set up for the first week or two.

Within whatever existing support system she does have, there may be experienced, knowledgeable breastfeeders - and there may not be. If many of the less desirable variables are present, any difficulty she experiences can be exacerbated. So many nursing relationships can be sabotaged by well-meaning but ignorant advice. If the mother had hired a birth doula, a few postpartum visits are typically included, which is a help, but is it enough to make up for regular, quality help from the rest of the mother's support system?

Even if we take the hospital out of the picture, continuity of postpartum care can be lacking. She might have even had a home birth. Midwifery care does provide for MORE postpartum care than a hospital birth provides, typically scheduling a visit for the day after, then the third day (often a day of reckoning), then a week later. It's definitely an improvement, but I feel that a lack of regular support at home, and lack of accessible and timely lactation support, can still be devastating. Midwives who attend home births (primarily CPMs but also some CNMs) may or may not be skilled in lactation support. I think it's fair to say that most know the basics, and the type of sabotage that sometimes occurs in hospital settings is highly unlikely, but when serious issues come up, the variation in skill becomes much more crucial.

When more lactation help is needed, then, outside help needs to be called for, creating a new set of variables in terms of skill and accessibility, as not all lactation consultants are created equal, and the best ones may not be in the area, or may be out of a price range. Days or even weeks can go by before help arrives, time during which the breastfeeding relationship can be damaged in a number of ways.

I don't know if there are existing studies comparing the connection between breastfeeding success rates and better postpartum support, but from what I understand, many developed countries which have universal health care also provide for home health care visits for all new mothers. Here's one glance at different countries and their breastfeeding rates from the State of the World's Newborns Report 2001 via Kellymom:

Breastfeeding Rates Around the World

Country	% of mothers who start	% who continue 6 months or longer
Sweden	98	53
Norway	98	50
Poland	93	10
Canada	80	24
Netherlands	68	25
Britain	63	21
United States	57	20

Is it asking too much of midwives that they also be well-versed in breastfeeding support, and that they spend more time devoted to postpartum care? I don't mean to ask this as an accusing rhetorical question. It really may be too much, given the depth of their expertise in birth and the devotion it takes to acquire their skills, not to mention the considerable existing demands on their time - and if that's true, then we need to start thinking about finding ways to pass that baton to another support provider much more regularly and smoothly than we currently often do.

There is La Leche League, if you have an active chapter in your area with good leaders who will do phone consultations, which is not a guarantee, and honestly not a substitute for one-on-one help from a trained professional. Speaking of, then there are the lactation professionals, the gold standard of which is the IBCLC. Fantastic people, most of them are - if you have access, and even still, there is a break in the continuity of care, a disconnect, a stranger stepping in.

Another factor in postpartum support of the friends & family variety: it tends to peak within the first few weeks, which is when such support IS most needed (particularly in terms of breastfeeding), true, but many mothers find that they really could use help beyond that initial period. Suddenly, dad is back to work, family returns home, friends have gotten their fill of the novelty of the new baby, and the meal rotation comes to a close. Suddenly mom finds herself more alone than ever, which brings me to another area where postpartum support is vital: postpartum depression, or more accurately, the spectrum of postpartum mood disorders.

Isolation is a huge risk factor here, and feeling 'abandoned' once the baby is 3 or 4 weeks old can feel devastating to a mother. In my DONA postpartum training, listed within the services that a postpartum doula provides, right alongside education in newborn care, aid in mom's emotional and physical recovery, light housework, and breastfeeding support, is "companionship". Simple as that. This is not an insignificant or trivial thing. Having another adult around to relate to can really be a lifeline to a mom who is sleep-deprived and struggling, especially if that adult is trained in recognizing the symptoms of postpartum mood disorders.

You can see where I'm going with all this. My bias as a new and eager postpartum doula is showing, I know. But I think there's a case for shifting our view of the journey to motherhood. The moment of birth IS profound and amazing and deserves the most devoted support throughout that experience as possible - but can we start to see that this is just one part of the journey, climactic though it may be? Can we start to see it as more of a continuum? What would it be like if something resembling continuous support (though obviously not as intensive or constant as labor support) lasted throughout what has become widely recognized as the "fourth trimester"?

After the long buildup of pregnancy, and the transforming apex that is birth, with much societal (not to mention medical) attention paid to both, many women often get the relative equivalent of a handshake and a "good luck!" Women and babies deserve more. WE as a whole deserve more. I'm not sure what form this would take. I like the concept of reframing care as, perhaps, perinatal, rather than divided into prenatal, birth, and postpartum. I absolutely think postpartum doulas are one way of finding a solution, of course, but I don't mean to make this post one big sales pitch for them (especially, again, as a novice). I'm open to more solutions. Maybe the concept of Freestanding Maternity Centers, as Rixa of Stand and Deliver recently pointed mentioned recently. and as Dr. Stuart Fischbein has endorsed, could include more extensive postpartum support that flows out of existing relationships, and could thus move towards more of a continuum concept, to twist a phrase.

I've focused here on breastfeeding and to a lesser degree on postpartum mood disorders, but even if neither proves to be a problem, mothers still deserve to have much more support during their "babymoon" than they often get. These were just examples of postpartum needs - there are so many others, too. Adjusting to our brand-new identities as mothers is an world-shattering experience - hopefully mostly in the best possible ways, but in the event that challenges arise, I think mothers with newborns deserve to have the equivalent of counterpressure on their sacrums, cool cloths held on their foreheads, and strong, caring hands to hold when the going gets tough.

Postpartum Doula FAQ

. . . Or, "The Best Baby Shower Gift of All Time".

I put these two documents together last weekend for a health expo, the first part giving general info about postpartum doulas, and the second getting into some more FAQ detail, and thought I might as well share it here! It still needs some tweaking, and I'll be jazzing it up with a logo and some coherent color schemes and all, but I think the content is decent. Feedback?

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What IS a Doula?

From Doulas Organization of North America (DONA): “The word ‘doula’ comes from the ancient Greek meaning ‘a woman who serves’ and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.”

So what exactly is a Postpartum Doula?

She is a specially trained woman who comes to the home of a new mother and provides evidence-based educational, emotional, and physical support after birth. This allows the new mom to rest and bond with her new baby during her much-deserved “babymoon”, and helps the whole family transition into their new roles during the first three months of life, sometimes referred to as the “fourth trimester”.

What can a Postpartum Doula do for our family?

*Basic breastfeeding support
* Instruction in newborn care, such as bathing, diapering, babywearing, and infant soothing
* Teaches coping skills for both parents
* Aids in mom’s physical recovery from birth
* Meal preparation
* Household organization and light housekeeping
* Errands such as grocery shopping
* Infant and sibling care
* Emotional support and companionshipInformation and professional referrals

Why should we hire a Postpartum Doula?

The postpartum period is a time of recovery and transition for the new mom. Surrounding her with emotional support, attending to her physical needs, and caring for her home and family allows her time and space to rest and recover from the birth, learn to feed her new baby, and smoothly transition into her new role with genuine self-sufficiency.

The bottom line: the presence of a postpartum doula has been shown to reduce the incidence of postpartum depression, increase the development of successful breastfeeding relationships and enhance ALL relationships in the family as they welcome their newest member.

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Postpartum Doula FAQ

For how long does a mother usually hire a postpartum doula?

This depends on the needs of the family. A postpartum doula is typically engaged from between 2-6 weeks, starting as soon as possible after birth (easiest if arranged ahead of time), but this care can extend through the first three months - the “4^th trimester”.

It’s not a test of competence or strength to be able to "do it all by yourself." New moms were not meant to be alone during the postpartum period. Much attention is paid in our culture to prenatal care, and to birth itself, but postpartum care is lacking in many form. Many new mothers feel overwhelmed and isolated in the first few months of motherhood, even if they do have family nearby - and especially if they don’t.

It’s important to gather support for this significant period in your life so that your newborn can be welcomed into an environment where the mother is calm, as well-rested as possible, and supported.

When do we arrange for this service?

Meeting your postpartum doula and planning for care ideally happens prenatally. This gives mom and the doula plenty of time to talk about goals and expectations, and discuss scheduling. When you first make contact, you’ll be given an intake form to fill out at your leisure, which will be reviewed at your consultation, which is free of charge. Of course, postpartum doula care can absolutely still be arranged after the birth, but scheduling may be a bit more challenging, and may miss out on the first few critical days and weeks, when help is most needed and effective, especially regarding breastfeeding support.

The best case scenario is where mom receives a gift certificate for this at her baby shower, and she sets up a plan and gets to know this new support person in advance of the blessed event, secure in the knowledge that this extra support will be awaiting her!

How long does a postpartum doula spend with a new mom each day?

Again, this depends upon the needs of the mother. Many women schedule a four-hour visit 3 to 5 times per week. Some doulas are able to do longer shifts with enough advance notice. A few also do overnight shifts.

My husband has two weeks of paternity leave. With his support, wouldn’t a
postpartum doula be unnecessary?

Don’t underestimate the impact of sleep deprivation on both parents, nor the learning curve for both father and mother. Having an extra set of experienced hands to reassure, teach, and support can make all the difference in the transition that the whole family is making. This is particularly true for first-time parents, though families with older children also need the extra help in different ways – see below.

My mother and mother-in-law (or other family) are coming to help out for the first 2 weeks. Won’t they cancel out postpartum doula care?

Care from friends and family is incredibly valuable. Feeling connected to your family at this time in a new mom’s life is wonderful. There’s no “substitute” for it. Doula care can still enhance this time for the entire family, helping everyone to adjust to their new roles, and also offers evidence-based information to the new mom, something which some family members may not always have. Care from friends and family tends to peak within the early weeks, with lots of visits and casseroles, and then dies down, while mom may still need just as much help. Doula visits can then be scheduled more frequently to make up for the difference.

What if this is not my first baby? I already know how to breastfeed and care
for a newborn--why would I need a postpartum doula?

The needs of a first-time mom are different than those of a mom with an older child or children, but postpartum support can still be vital. In fact, many members of her own support system may think exactly what was posed in the question: She’s done this before; she won’t need as much help this time. On the contrary, mom may find herself in need of more support than ever, learning to balance the needs of her other children with those of the new baby.

Additionally, mothers who had an easy time breastfeeding their first baby may still encounter some challenges with subsequent children, and mothers with older kids can still be susceptible to postpartum mood disorders. All of the above can be eased by a postpartum doula.

This is the perfect baby shower gift for a family with existing children, as many of the “big ticket” items like car seats and breast pumps and high chairs have already likely been purchased with previous babies, and many clothing items and the like will be hand-me-downs.

None of my friends ever had a postpartum doula—so why would I need one?

Chances are, the reason they didn’t have one is that they simply didn’t realize this type of support is available. Ask your friends who have had a baby if they would have liked to have had the kind of help postpartum doula offers. Try asking them. They’re likely to tell you exactly why you would want one!

What do you offer for multiple births?

For reasons both obvious and subtle, the transition into motherhood can be even more challenging for a family bringing multiples into their lives. On top of the usual education, emotional and physical and support (all doubly needed now), the postpartum doula can help the new mom discover strategies to make her life easier with her new little ones, particularly in the realm of household organization. The doula can also help the new parents find resources especially for parents of multiples.

We have not budgeted for this expense--how could we justify it?

The presence of quality postpartum support can make a huge impact on a mother's physical recovery, emotional state, and success with breastfeeding. Getting the right start can be truly priceless. Another doula says: “The best response to this question was one I heard from a set of grandparents who were paying for a postpartum doula for their daughter: ‘We put aside money for our child's college education years in advance--but is not this postpartum period, and the experience the child has in these first months, just as important?’”

Family and friends who want to help, but are unable to offer much if any postpartum support themselves, are often very grateful for the chance to hire a doula to go in their place. It should be noted here: a gift certificate for a postpartum doula is one of the best baby shower gifts of all time!

Also, be sure to submit to your insurance. Some insurance plans will cover part or even all of postpartum doula services. Speaking of:

Does insurance cover the services of a postpartum doula?

Many insurance plans will reimburse for some or all postpartum doula services. We can provide sample letters of authorization from your doctor or midwife to help in this process.

Sources: DONA International, Postpartum Doula Services of Northern Virginia

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Oh, and I finally decided on a business name. It is FAR FROM original, but in the area I'm currently living, I needed something that would clue people in immediately as to what's being provided, and inspire them to look further into it, as well as something that could also cover labor support eventually. So I went with:

BABYMOON
Postpartum support at home for mom, baby, and the whole family.

Like I said, NOT ORIGINAL, but it gets the message across. I can also tweak the tagline to include labor support once I'm ready to start attending births. Someday . . . *sigh*

Becoming Alice

So, I have my first gig as a postpartum doula this week. I'm so excited, and also really anxious about it! We spoke on the phone tonight. She just had her fourth baby on Friday - talk about fresh out of the chute! I'll be doing about 7-8 hours Tuesday-Thursday this week (and we'll re-evaluate then to see if she wants one additional week).

I was going to have to limit it to 3 or MAYBE 4 hours due to Lily being brand new to day care (sob) . . . but then my client asked if I would be okay with bringing Lily with me, which pretty much solves everything! I wouldn't have presumed to suggest it myself, especially my first time out, with a brand-new client, during our first week of service to boot, but she just needs the help so much that it's worth it to her. I'm reducing my rate a tiny bit as a result of that (knowing my attention will be slightly more divided), and it was already very low due to the fact that I'm currently in the midst of the training process, so I feel this is a fair tradeoff.

As she already has 3 other kids, all boys, a lot of it will be helping care for the other kids and doing household chores. That's all good. Here's what I'm most anxious about, along with generally being sure that I'm really being of value to her: she said that she really needs a lot of support with breastfeeding. When I first learned about her, I assumed she'd have it down pat since this was her 4th kid. But she has inverted nipples, and thus needs a lot of help. Yes, she's experienced, but part of that experience includes knowing that she needs extra help. Goes to show what assuming will do . . .

I know what you're thinking - but Anne, you know tons about breastfeeding. And I do, yeah, but having gone through such a trial myself, and knowing just how absolutely BAFFLING, not to mention emotionally charged, nursing difficulties can really be when you're in the midst of it . . . I'm just so afraid I won't be able to help her enough. My own nipples were a little flat, so I do have some experience with it, but inverted is even harder. I'm of course going to look up everything I can on inverted nipples on kellymom and in Jack Newman's book, which I'm going to do here in just a minute.

Anyway, wish me luck! Any advice you have for dealing with inverted nipples would be most welcome, too.

(She told her husband "I need an 'Alice'," which is kind of a great description of what postpartum doulas offer, if The Brady Bunch featured lactation information and help with care for a tender perineum.)

AfterBirth

(Okay, so, is that a great or a HORRIBLE name for a postpartum doula service? I've been brainstorming on it so long that I've lost all perspective. You can level with me!)

Anyhow. I had to write up a brief account of my own birth and postpartum experiences for my DONA registration, and I thought it apropos to include it here. I've already shared both my birth story and our extended breastfeeding adventure, but there's something about the immediate postpartum period that amounts to its own distinct experience for moms. It also discusses some details from my pregnancy that I haven't gone into here -yet; I do want to write about my experience with "parallel care" in a future post.

My first and so far only daughter, Lily, was born in April 2008 at home, under the care of two midwives and my best friend, who acted as informal doula. It was a water birth and a wonderful experience all around, especially after a somewhat difficult pregnancy which was shadowed by a complete, then partial, then marginal placenta previa that persisted all the way up to the 34th week. A vaginal birth was no guarantee, up until that final ultrasound, let alone a home birth. Due to the previa, I had been on pelvic rest and forbidden exercise from week 18 on, and partly as a result of that, I gained far too much weight.

On top of that, for the first 20 weeks, the threat of an ‘incompetent cervix’ has hanging over my head due to a cone biopsy I underwent 16 years ago, since the medical practice I sought parallel care from insisted upon digital exams every other week to determine whether a cerclage would be recommended. I also had some sciatic issues that were resolved by chiropractic care, some nasty carpal tunnel, which B vitamins helped, and finally the dreaded rash known as PUPPP, which nothing really relieved much at all. So the birth was a huge relief in every way, and will always be remembered as the most incredible day of my life.

My postpartum experience has much to do with wanting to do work as a postpartum doula; I saw firsthand how much support means to a mom, especially a new one, and even more especially in those crucial first days. The stress, the assorted fears, the physical healing, the engorgement, and the sleep deprivation alone affected me much more dramatically than I had anticipated. Add into that the formidable hormonal wallop that results by shifting from pregnant to not-pregnant, and then from not-lactating to lactating.

I don’t think there are more dramatic hormonal transitions in a woman’s life except for puberty and menopause, and both of those processes take place over years and years; these postnatal changes happen within days, or a handful of hours, even. And then add into it the most devastating part: extreme difficulty nursing. You’ve got yourself a recipe for some considerable feelings of despair and helplessness. Day three-into-four was the day of reckoning for me, where I truly felt I was staring into the abyss.

The story of Lily’s nursing struggles is far, FAR too complicated to go into here; I will summarize by saying that it took 5 months of constant work with an IBCLC plus regular craniosacral therapy for her to be able to latch on. We’re still going strong at 17 months, so it’s quite a happy ending, but those early days were nothing short of terrifying. I was very short on support at that time, which I absolutely will make sure changes for the next child (if there is one). The postpartum visits that I did get were so incredibly important to me. I could have used a lot more of it, for sure, but that was simply our situation at the time, and I’m grateful to have experienced it at all.

I saw firsthand just how valuable postpartum care can be, not just from my midwives' three visits and through my best friend, who came by about every three days for a while, but from the first in-home lactation consultant who visited me twice and checked in multiple times by phone. This was not the genius IBCLC that I later saw, and who truly got us breastfeeding after a very long struggle, but she was helpful in her own way; getting me started with finger feeding and the breast pump, advising on other postpartum issues, and even helping to change the sorely-overdue sheets. More than anything, the kindness and the simple human contact (mother to mother, too) made a difference, in itself. She was filling a bit of the role that a postpartum doula does. I consider it only right to return that service to others.

That's what I sent to DONA; all completely true, but without some of the messy details.

That third day. I still shudder to think about it. I had probably slept a total of 4 or 5 hours since the birth. A foreshadowing of the breastfeeding difficulty to come was a growing concern, as Lily showed no rooting reflex and seemed totally uninterested in nursing, and had not yet effectively latched on, so I was desperately pumping to ensure that my supply would still come in without Lily stimulating me, and to produce a few drops of colostrum which then would be cupfed to her. My hemorrhoids were positively frightening, making every position uncomfortable. I needed to take both my and Lily's temperature regularly, I needed to massage my fundus gently but regularly to help it shrink back down, keep replenishing my witch hazel and comfrey pads in the freezer to soothe my bottom, all tasks I could never seem to keep up with enough. I also had to put in the sun for a few minutes periodically to help with her mild jaundice, and at one point I was CONVINCED I had given my newborn a sunburn and was despondent.

I could never decide whether it was better to swaddle her or keep her skin-to-skin with me - whichever one I chose, I'd feel guilty that I wasn't doing the other. I had a gorgeous Maya Wrap ring sling* given to me at my shower, but for the life of my I couldn't figure out how to use it thanks to the incredibly confusing instructions on the DVD that came with it. I watched over and over and over again, and couldn't even get beyond the intro part of threading the damned thing.** Then her umbilical cord started to look seriously funky***, possibly gangrenous in my increasingly paranoid mind, and I had no idea what was normal.

More than anything, the sheer responsibility of it all was starting to really hit me. At one point I had her wrapped up and lying on a heating pad, and her diaper leaked, wetting the pad (I hadn't gotten the hang of using the waterproof covers yet). I decided that I had almost electrocuted my own daughter in my carelessness and itwasallmyfault and proceeded to sob hysterically, and I mean hysterically, over it for about a half an hour. My milk then came in and left me freakishly engorged with what felt like rocks in my boobs and armpits. Again, I had no clue what was normal, and rather than resting when Lily slept, I took to scouring the web for advice. I remember sitting at the computer on the MDC boards at 6 am with cabbage leaves stuffed into my bra, weeping and feeling like the most pitiful mother ever to barely-qualify for the title.

. . . Yeah, you could say I was a little overwhelmed.

Later that day, seeing how unhinged I was becoming, Aaron insisted that I take a walk, as I literally had not once set foot outside the house since I was about 6 hours into my labor. Lily was asleep, my list of tasks would wait for 5 minutes. I protested a bit and finally reluctantly agreed to walk out to the mailbox, at least. I put down my checklist and I ambled out the front door in a daze, and got about three steps before suddenly realizing I had walked out there with my shirt COMPLETELY unbuttoned and hanging open, the state I'd been walking around the house in. Thank goodness no neighbors were around to see, and it did give me the first laugh I'd had.

Hopefully, I'll be able to help mothers through the labyrinth with a little more grace than I.

*Wonderful product, but check out the videos on this page rather than the product's DVD.
** We love and use it constantly these days, as per below.
*** It was completely fine.