Question of the Quarter

Issue 61: Postpartum

Issue 61: Postpartum

Q: What are the essential elements of good postpartum care? What is your most noteworthy postpartum experience, and what was the outcome?

A: I believe the most essential elements of good postpartum care are listening, encouraging and information. Moms want to talk about their birth experience, breastfeeding, lack of sleep and all the feelings that go with being a new mom. They want encouragement that what they are doing, thinking and feeling is OK, and they want information to help them make choices about their baby's care and well-being.

My most noteworthy postpartum experience was working with a mom who had just birthed her fourth baby. She had not breastfed any of her kids and when I suggested she nurse the fourth baby she was strongly against it. After the baby was born I once again suggested it, but she still held her position. Three days after delivery she called me—her milk had come in! I was trying to give her information on how to stay comfortable while her milk dried up when she announced, "You don't understand. I want to breastfeed!" I counseled her over the phone, told her to call back in an hour and I prayed!

One hour later the phone rang. She was able to breastfeed her baby—no problem! She went on to nurse her son for eight months. That was lesson for me to never give up on a mom. You just might get a wonderful surprise!

Karen Olivier, Certified Doula

A: Postpartum care is a large part of my practice. I have seen a lot of what I personally consider to be woefully inadequate postpartum care. As a homebirth midwife, I believe that women are entitled to comprehensive postpartum care in their homes. I visit these ladies in my care on the first, third, sixth, and tenth days postpartum and then they come to see me at three weeks and six weeks postpartum. If I happen to have appointments or errands near their homes, then I "spoil" them and do all the visits in their home. This is especially helpful if they have several children.

These visits usually last at least 1 1/2 to 2 hours and consist of:

  1. Vitals on mom and babe (Mom—BP, pulse, temperature; Babe—heart rate, respiratory, temperature). I weigh the baby on the third and tenth days and at three and six weeks. Mom weighs whenever she wants and at six weeks. I do head circumference on the baby at birth, three weeks and six weeks. I do length at birth and six weeks.
  2. Assessment of emotional/psychological status: How much help is she getting? How much interference is there around mom and baby? How much work is she doing?
  3. Assessment of lochia/fundal height (palpate fundus; amount, color and consistency of lochia: visualize perineum if there was damage during birth or mom is bothered by something). Prepare sitz bath, if the mom wants it.
  4. Assessment of lactation, condition of nipples and breasts (latch-on; how many wet and soiled diapers; color of stools; frequency of nursing, etc.).
  5. Lots of time to answer questions.
  6. Newborn Laboratory Screening on appropriate day (if desired by parent).
  7. Administration of oral Vitamin K with appropriate timetable (if desired by parent).
  8. Assessment of baby's care. (How is baby dressed? Cleanliness? How does the mother hold and interact with the baby? How does she respond to other children, family members, etc.? How do they react to the baby?)
  9. Assessment of mom's fluids, diet, supplement intake, her ability to urinate and stool.
  10. Discussion of birth control methods (if desired) and sexual activity.
  11. Information on circumcision providers (if desired).
  12. Advice to see the pediatrician if baby is outside of normal ranges. Advice to see OB/GYN if mom is outside of normal ranges. I usually accompany them on these trips in order to hear the doc's diagnosis firsthand and have records available.

These new moms also get phone calls on the second and fourth days postpartum to be sure all is well. Some women are afraid to tell you that they are frustrated and that phone call gives them permission to talk about it. I believe it goes a long way in the prevention of postpartum depression. I also make a point of getting together with them at about three months postpartum just to chat and see how the baby is doing. This isn't an "official" visit—it has more of a social atmosphere.

My most memorable postpartum experience? A little one born with six fingers on each hand. I called a pediatrician and he agreed to see the baby immediately (on a Saturday morning). We took her to the office and he removed the extra fingers. We were back home before she was three hours old.

Pamela Crowl, RM, CPM, Colorado Security, CO

A: The most important element of postpartum care is willingness to listen, which includes willingness to go to the mother on her schedule, when she needs you. Attention to physical healing is of course important, but more important in the long-term is that the mother feel well-nurtured and well-taken care of in the vital first days of motherhood.

Good postpartum care starts in pregnancy for doulas and midwives alike. It is during pregnancy that the structure of a healthy postpartum is built. Pregnancy is the time to lay down plans for friends, families or paid postpartum doula help. Family and friends should understand how to most effectively support the new mom—particularly when they have with limited experience with newborns or breastfeeding.

Each family is different in their needs for the postpartum period. Some families do best with intensive support in the form of a relative or friend staying for several weeks or months. If the support person is well-suited to the needs of the family, this kind of arrangement can help stave off postpartum depression in vulnerable moms. Families that tend to benefit from this kind of care include first-time parents and families in which the mom suffered a prior postpartum depression (especially if due to lack of support.) Here's what I tell that special support person.

The postpartum is a special time in which the baby and mom and dad get to know each other. Mom and Dad need to gain confidence in their baby-care skills and baby needs to learn effective ways of communicating needs. The most important thing in the first days and weeks postpartum is for Mom and Baby to spend as much close, skin-to-skin, nursing time as possible.

The biggest help a support person can give is to make sure nothing distracts Mom and Baby from that important learning process. This means rather than doing baby care, the support person should spend more time doing laundry, cooking, cleaning and any other tasks that might have Mom wanting to put the baby down "to get something done."

Dads need time too. With a breastfeeding family, if Dad can do a lot of the work of diaper-changing, burping and walking, bonding will happen naturally. Feeding is an important bonding experience, but Dad's need to bond does not justify bottle-feeding. If an extra support person is taking care of the household chores, it will help free Dad to spend more time with both Mom and Baby. The postpartum is a vulnerable time for a new family, and Dads are important both in helping Mom feel less overwhelmed (by doing many of the diaper changes, burpings, etc.) and in "refilling Mom's emotional cup." Taking care of a brand new baby can be overwhelming and draining for any new parent—the more parents can give each other, the more they'll have for their new baby.

The support person should not impose their expectations of baby behavior and care based on a prior failed experience with breastfeeding or a baby bottlefed from birth. Breastfed babies eat often, and frequent feeds don't mean insufficient milk. If pee and poop are coming out, that means that breast milk is going in. (I find that most grandmothers are relieved to know there's such a simple way of knowing if baby is getting enough. One wet and/or poopy diaper per day that the baby is old—so at least 2 diapers on day 2, 4 diapers on day 4, etc.-up to day 6, at which point we have at least 6-8 diapers per day from there on out.) Baby and Mom drowsing together is encouraged—one of the ways people make newborn care difficult is to persist in the notion that babies need to be set down in a crib or bassinette to sleep. Mom or Dad or Grandma's shoulder or chest is a perfect place for baby to sleep. If baby must be put down, a snug swaddling and placement in a car-seat will cradle the baby in a curled position. But the ideal is for baby to drowse and lull the caregiver to sleep. This is nature's way of helping Mom get through the long, wakeful nights.

It is important to remember to call the caregiver and ask questions if nursing is not going well or if the baby is acting in a way that seems strange to the parents or support person. Often the caregiver can simply reassure the family that the behavior is normal, and other times a quick home visit may quickly avert developing problems. This is especially true in breastfeeding—I tell my families to call me if things even start to be uncomfortable. I also tell them that calling me before they resort to a bottle is essential.

Moms need the people around them to have a thicker-than-usual skin. Hormones fluctuate wildly in the postpartum, and it's very easy for a mom to say things she doesn't mean or seem overwhelmed by seemingly unimportant things. Gentle tolerance for these emotional swings will help minimize them and reduce their impact. All family members need to know that these swings are and should be temporary.

For families in which live-in support is not possible, not wanted or not needed, a daily visit from someone who can help with the routine housework may be a great alternative. Many moms thrive on having a visit each day for a week, every other day for another week and then weekly for the next few months. These visits can be as simple as making dinner and doing the day's dishes, starting and changing a load of laundry and making sure clutter is kept to a minimum. An experienced doula can often manage that in a two-to-three hour block of time. I found this support to be so important to new moms that I hired someone when my daughter was three to come help me out on an ongoing basis. Just one two- or three-hour block of time each week (costs between $20 and $30) is a sound investment in my ongoing sanity as a single mother.

For some families, having a community that can help with nutritious meals each day for the first month takes an enormous amount of pressure off that precious bonding time. Some families prefer to have a great deal of privacy in the first month or so of life. For these families I strongly recommend that they prepare ahead of time by stocking up a deep freezer with easy-to-prepare one-pot meals, by accumulating menus from restaurants who offer takeout, and/or by keeping a list of ready-to-eat hot foods that the family likes from local supermarkets.

Ultimately, support should adapt to the needs of the family. The worst situations postpartum are those in which the mother ends up either having to fight to parent the way she wants to or having no support whatsoever. Cultures that set aside the first 40 days of a baby's life as a sacred time for special indulgence of mother and child together are on the right track. This special time creates a foundation for easier, more confident parenting down the road. Just as meeting the dependency needs of an infant will help that infant be more independent down the road, nurturing a new mother will enhance her ability to be the nurturer in the long run.

I remember in my first days postpartum feeling like I'd been reborn myself, that all I wanted was to curl up in someone's arms with my new baby until I felt ready to emerge as my new self. Not having the support I needed, how I needed it, it took 18 months of struggle to emerge from the grief of that lost time.

Jennifer Rosenberg, Doula and Graphic Designer for Midwifery Today


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