PostPartum: 40 Long Days and Nights

Welcome, Carnival of Evidence-Based Parenting readers! This month’s Carnival, in honor of Mother’s Day, is Transition to Motherhood. I will be linking to the full carnival and to individual posts as they come in during the day.

Marissa Meyer made headlines when she decided to take only a two week maternity leave before returning to work as the new Yahoo! CEO.   There’s a reason why.   The conventional wisdom is that the first 6 weeks after giving birth are critical to bonding, healing, and breastfeeding.

Ms. Meyer did end up increasing Yahoo’s maternity leave. I have far from any schadenfreude on this.  I believe she did so for business reasons, the same way her edict banning working from home was business-related. And so far I have seen no indications that she regretted her two week leave – especially as she had a nursery built in her office, allowing her to keep her baby close.

She’s entitled to her choice. Running a Fortune 500 company, after all, portends all manner of sacrifices. Men make similar sacrifices too, at the expense of their families.

However, I’m glad I was not newly postpartum during the time Ms. Meyer was in the news. I felt bad enough that I couldn’t get the laundry done, my makeup on, the dishwasher running. I couldn’t even contemplate working a full day. And that sort of new mother stress – expecting to bounce back immediately – is the product of how we view motherhood and maternity in the Western world.

In fact, the Western world is unusual in how fast mothers are expected to return ‘to normal’ after giving birth. Even during 6+ weeks of maternity leave, mothers in the Western world generally go on outings, do the shopping, the cooking, and the cleaning.

In contrast, in many other cultures around the world, to include Chinese, Haitian, Cambodian, Thai, Indian, Bangladeshi, Ethiopian, Mexican, Guatemalan, Arab (to include in Jordan, Palestine, and Egypt), Indonesian, Malaysian, and Korean there is a 30-40 day ‘confinement period’ for a new mother.  Even the book of Leviticus describes a 40 day postpartum confinement period.

Many of the concerns regarding the postpartum period include protecting the mother and child from evil spirits and from the cold (including cold foods and showers). .

Fascinated by all this, I set out to write an article with research discussing the postpartum confinement period. What does the ban against cold food mean? Just how important is  the first 40 days anyway?

Sadly, there was not a lot of research at my fingertips. That is not to say I did a full literature review, but a typical Google search did not reveal the answers I wanted.

As a ‘conservative’ in the sense that I often trust the wisdom of those who come before me, I’m inclined to believe there is something to this 40 days/6 weeks number. Perhaps it has only to do with the fact that lochia (postpartum bleeding) can last up to 6 weeks, and then most cultures took that fact and extrapolated that the woman is weak. But given my discharge orders even banned vacuuming for the first 6 weeks (a ban I took to heart, believe me), there is probably something to the fact that gosh darn it, the mother needs as much care as the baby.  And, the prevalence of the hot/cold belief indicates there’s likely something to it.

Alas, without convincing research, all I can do is try to break down some of these cultural beliefs to the best of my ability.

Being Unclean

Being ritually unclean is a concept in many religions that often applies to bodily discharge. It’s no mystery then why a postpartum woman would be considered ritually unclean. Bodily discharge is an unavoidable side-effect of giving birth.  Lochia is the term for the discharge of blood, mucus, and placental tissue that may continue up to 6 weeks after delivery.

Best way to deal with this? Well, pads of course, but enterprising nurses and midwives have thought up various ways to maximize absorption and pain relief in one.

One way is the ice diapers – a newborn diaper cut open with ice placed inside. Maximum absorption + relief.

Frozen padsicles is another.  Take a maxi pad, and put some witch hazel on it. Freeze.

For more, check out these helpful and entertaining posts.

Needing Rest

Western medicine agrees with traditional medicine on this one.  Women need rest after giving birth. Definitely no exercise and no sex for the first six weeks, say most hospital discharge instructions.

Now, traditional cultures take it quite a bit further. In some, women’s feet cannot even hit the floor for 30 days. And, as the name implies, during confinement public outings are definitely banned.

The jury is out on whether postpartum confinement helps prevent PPD, exacerbates the possibility of PPD, or has no effect. However, a major difference I and many others have noticed is that there is a focus on the mother in addition to the baby. In the Western world, traditionally the postnatal period focuses primarily on the baby. The sore, tired, and overwhelmed mother is largely ignored.

It is possible an increased focus on the mother — to include normal household duties being largely taken over by others — could help prevent PPD.  In addition, successful breastfeeding, due to the time and focus the mother can dedicate to the baby, can perhaps also help hinder PPD — both because breastfeeding failures can lead to an increase in PPD symptoms and because hormones associated with breastfeeding can protect against PPD.   However, in traditional cultures, the very isolation of the woman for 30-40 days may be the thing to lead to depression.  Certainly, getting out of the house with the baby (taking strolls to Starbucks, for example) is anecdotally helpful to many women during the postpartum period.

To help get the rest one needs, I’d advise the Western mother to line up help for the first few weeks with baby – but productive help.  People who will take on tasks without being asked, for example. It’s a fine line, as the presence of relatives, no matter how helpful, can also be stressful.

Regardless, I, and most other experienced mothers, would advise women to not expect to get into a routine the first few weeks. Focus on bonding and feeding (whether formula feeding, breastfeeding, or combo feeding). Have meals pre-prepared or line up a meal train for help.

Luckily there is more and more research on the postpartum depression and anxiety experienced by some mothers.  Check out Katherine Stone’s website Postpartum Progress for all the latest, and for resources.  However, there is much less research out there on the “Baby Blues”, commonly thought to be a result of the hormone changes occurring after birth.  Anecdotally, women talk about “Day 3”, or “Day 5” or some variation thereof in which extreme weepiness and hopelessness hit very forcefully – something that can be quite disconcerting if one does not expect it.

Does placenta encapsulation help avoid the baby blues and/or PPD? As expected, there is not much research out there. However, speculation exists that the placenta helps keep up levels of CRH – the corticotropin-releasing hormone — which in turn may protect against the stress of labor and delivery.

Needing Heat

A common confinement theme is the need for heat and fear of the cold – to include showers and ‘cold foods’ such as vegetables and sandwiches.

Like everything else, I can’t find much on this. However, a feeling of being constantly ‘cold’ postpartum could be related to thyroid problems, anemia, or just hormones — all things somewhat common for the postpartum mother.

Heat and a fear of showers also brings up the topic of needing heat to heal perineal wounds. Cold packs and ice are applied for the first few hours, but after that, western medicine recommends heat therapy, often in the form of a sitz bath – sitting in a few inches of very warm-but-not-hot-water.  You can also get special herbs for the bath.

One can do this by sitting in a regular bathtub, or there is a plastic device that sits on the toilet and constantly refreshes the water.  Why the plastic device? Because some health care providers are very against a real bath postpartum, for the fear that germs (such as foot germs!) may end up infecting wounds and the cervix.

How long do you need to wait before being able to take a real bath?  Oh, the difference between the traditional healthcare providers and the midwives on this one! It’s almost as bad as “Can you take a bath when in labor” question.

Some care providers say you can take a bath immediately. Others say wait two weeks. Others say wait 6 weeks. Still others say just wait until postpartum bleeding is over.

I am one of the few people in the universe that HATED that nifty little sitz bath device. The reason the first time around was that it hurt.  I had severe tearing and some other issues so the pressure it put on my stitches was not fun. So, despite my own discharge instructions (which said no bath until active red bleeding ended), I took a freakin’ bath.

Foods

When L was born, my South Asian grandmother started going on about how I needed to eat some kalo jeera. I had no idea what she was talking about, and I basically ignored her.

One failed breastfeeding attempt later, I was ready to listen. When J was born, I asked my mother what the heck kalo jeera was. It was basically black cumin seed, ground up.

Black cumin seed is a galactagogue, which means it is purported to help with lactation. Other galactagogues are fenugreek, brewer’s yeast, mulunggay, blessed thistle, goat’s rue, alfalfa, flaxseed, and steel-cut oats.

To maximize your galactagogue power, consider making lactation cookies, or drinking Mother’s Milk Tea, or buying More Milk Plus capsules. Also, since the over-drinking of water may at some point negatively affect lactation, try water with electrolytes, Gatorade, or coconut water to keep you hydrated.

Belly Wrapping

Like confinement and the eating of foods that serve as galactagogues, postpartum belly wrapping is common in many traditional cultures. My grandmother was distraught when she realized I wasn’t belly wrapping, and insisted my stomach would become flabby. (She was right). For the record, I did own a postpartum girdle-thingy, but despite trying to use it after both children, I hated it, and was just like, “screw it, I’ll be fat”.

Does it work? Anecdotally, yep.

The best-known belly binder is the Belly Bandit.  I had the Gabriella Band, which is much cheaper and still had good reviews.

To sum up: traditional cultures may have a few things right here. Rest. Eat foods that will help you heal (and increase milk, if you are breastfeeding). Take care of your body with heat therapy.

After all, it’s only 40 days.

 

Here’s a quick list of our contributors for  this second edition of the Carnival of Evidence-Based Parenting:

The Transition to New Motherhood (Momma, PhD)

Bonding in Early Motherhood:  When Angels Don’t Sing and the Earth Doesn’t Stand Still (Red Wine and Applesauce)

The Connection Between Poor Labour, Analgesia, and PTSD (The Adequate Mother)

For Love or Money:  What Makes Men Ready for New Fatherhood (Matt Shipman)

What the Science Says (and Doesn’t Say) About Breastfeeding Issues, Postpartum Adjustment, and Bonding (Fearless Formula Feeder)

No, Swaddling  Will Not Kill Your Baby (Melinda Wenner Moyer,  Slate)

Sleep Deprivation:  The Dark Side of Parenting (Science of Mom)

The Parenting Media and You (Momma Data)

Reassessing Happiness Research:  Are New Parents Really That Miserable? (Jessica Smock)

40 Long Days and Nights (Six Forty Nine)

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Combo Feeding – The Best and Worst of Both Worlds

This is part two of dealing with the dealing with a low milk supply series.  Please see part one: Do you really have a low milk supply? for additional information.

*This article does not replace medical advice. Please consult a medical professional if you suspect your child is not getting enough to eat.

Most articles ignore combo feeding and supplementation because of the desire to encourage the mother to exclusively breastfeed. That is valid- there is the concern that the more one supplements, the less one will nurse, thus leading to a cycle that eventually ends the breastfeeding relationship (or the baby may develop a nipple preference).  However, there are mothers (including yours truly) who combo feed successfully for months with a baby who still preferred nursing over the bottle and who eventually managed, especially with the introduction of solids, to move back onto breastmilk and no formula.  In addition, instead of bottles, there are other ways of supplementing, especially with a younger baby, that doesn’t lead to as much danger of harming the nursing relationship.

The number one rule is “Feed the Baby.” If your baby has not lost a dangerous amount of weight, it is perfectly acceptable to continue to exclusively breastfeed while trying to increase your milk supply and to go in for regular weight checks to monitor progress.  However, it is also acceptable to choose to supplement and/or combo feed. (It goes without saying that any feeding program is acceptable, whether combo feeding, formula feeding, or breastfeeding, regardless of reason.  Just so we’re clear).

How to combo feed or supplement

The difficult thing about combo feeding and supplementing is that there is no rule really on how to do it – really, finding a rhythm that works for you and your baby is really the ideal.

When it comes to terms, “combo feeding” and “supplementing” are generally interchangeable. If you want to make a distinction, usually supplementation refers to offering formula or pumped milk after some or all breastfeeding sessions whereas combo feeding refers to a program of doing formula for some feedings and breastfeeding for others. Combo feeding, then, would apply to working mothers who give their children formula for when they are in childcare as opposed to their pumped milk.

Therefore, in general, when we are talking about actions when facing a low milk supply, we are talking about supplementation – offering formula and/or pumped milk after a nursing session. However, in some cases, a mother with low milk supply will choose to replace a whole feeding with formula or saved milk. (I did the whole gamut of options, but for a while, my lowest milk supply was around 6pm.  Some mothers would choose then to just give up that feeding and offer a bottle instead. I usually still attempted to nurse first in the interest of stimulating milk production, but the baby would down about 6-8oz of formula, so in effect he didn’t really get any breastmilk around that time.)

For the interests of simplicity, I’m going to assume the combo feeding/supplementing is done with formula, not breastmilk. If you are pumping your own breastmilk to give to your baby while you are away for example, that’s not really combo feeding in this sense. (Now, in my case, I had some pumped milk saved from when I had a good supply, so when I started supplementing, I burned through my pumped milk stash first). There’s also the donor milk option, but it is less common. So, let’s go with the assumption formula is in those bottles.

The slippery slope

Why do we say that there could be a slippery slope when it comes to combo feeding?

First, we have the supply issue. Every time you replace a nursing session with a bottle (and don’t pump to make up for it), your breasts are getting the signal that milk production isn’t needed at that time.

Second, formula often makes babies full for longer. Therefore, your baby may go longer in between feeds, which means you are nursing less often, even if you nurse first then formula feed.

Third, many babies may develop a preference for the bottle, as it will have a faster flow than the breast (and if the mother truly has a low supply or slow let-down, the baby will associate being full with the bottle as opposed to the breast.).

Fourth, breastfed babies often suck down a bottle even if they are not hungry. They are obligated to suck when a nipple goes into their mouth and their mouth fills up with milk.

Fifth, growth spurts complicate matters. If you are exclusively breastfeeding with a great supply, your baby will still act super-hungry during a growth spurt. The answer is to nurse, nurse, and nurse some more and your supply will catch up. For low-supply moms who are supplementing, it is much harder. A fussy baby means supplement more. Which means your supply isn’t going to get ‘trained’ to catch up to the baby.

How to avoid these things as much as possible?

*Note, some of these things also apply to the ‘increasing your milk supply’ section. So I will try to do a quick overview of those techniques but get into more detail in the later section about increasing one’s supply.

1.) Wait until the nursing relationship is established before combo feeding or supplementing.

Obviously, in some cases, one has to start supplementing for the baby’s health long before nursing is established. But if you can hold on about 4-6 weeks, your ability to combo feed long-term will be much better.

2.) Nurse first before every feed. Pump after every feed. Pump if you miss a feed. Pump when you are feeling full and your baby doesn’t want to nurse.

Nursing first helps avoid the slippery slope as you are still stimulating milk production (even if the baby isn’t getting a lot at the breast).  Emptying your breasts about every 3 hours or so will help maintain and possibly increase your supply.

If your milk supply is generally established, you can get away with leaving formula with the baby if you are away. But if you can, try to pump to make up for that session (even if you aren’t getting much). Or, for pumping-haters like myself, nurse as soon as you get home, even if the baby isn’t hungry (I always called this ‘getting reacquainted with my baby’ as soon as I got home).

I didn’t pump at all and managed to maintain my nursing relationship, but to ensure you are successful, I would suggest pumping.  (To be fair, in my case, I *did* hand express whenever possible. My body doesn’t react well to a pump but did fairly well with hand expression).

Pumping and hand expression resources

3.) Offer the smallest amount of supplement possible

Okay, this was the most stressful part of supplementing for me. Assuming you are dealing with a baby who is losing weight or not gaining enough, you are trying to make him or her healthy again. BUT, you are also trying to maintain supply.  In my daughter’s case, I was told to give her as much as she would take. But she was in a much dire situation. We ended up giving up combo feeding in about two days and going exclusively to formula.

In my son’s case, it was up to me. So I would only give my son about two ounces at a time. It was frustrating though because sometimes he would be fussy 30 minutes later. Was he hungry? Was I starving him? Who knew? Eventually I decided it wasn’t worth the stress of wondering if he was still hungry, so I went to the ‘give him as much as he would take’ model. That meant that at times, he would get supplemented with 6 ounces of formula. I was convinced our nursing relationship was doomed. For many different reasons, it wasn’t, and we continued nursing for months thereafter. As I mentioned before, the reason we went to formula had nothing to do with supply issues, and instead because I needed to go on non-breastfeeding safe medication.

So,try not to offer too much supplement, but if it stresses you out, do what works for you.

4.) Pay attention to growth spurts

Try to nurse more often during common growth spurt times. (ex: 7-10 days, 2-3 weeks, 4-6 weeks, 3 months, 4 months, 6 months and 9 months)

5.) Alternative delivery mechanisms

Instead of bottles, consider using a supplemental nursing system, a syringe, or a cup to supplement your baby. (This is especially applicable for the younger baby, before the nursing relationship is established.)

A supplemental nursing system allows you to supplement at the breast, thereby letting the baby suck and stimulate your milk production while he or she is getting formula/extra pumped milk.

There are two main brands of supplemental nursing systems. One is the Medela SNS.  (and here is the starter kit, useful if you have a newborn in a hospital who needs supplementation just in the short term) The other is Lact-Aid.

Check out this good Amazon review for a comparison between the two. This review is helpful for those using the Medela SNS starter kit.

You can also make your own SNS. Here is one set of instructions. Google around to figure out what works for you.

6. Use the slowest nipple flow possible and Bottle feed the breastfed baby differently

The biggest thing here is to hold the bottle upright so the baby has to work more.

7. Encourage reverse cycling

Encourage the baby to nurse more when you have a higher milk supply and take less supplement when you have a lower milk supply. In my case, that meant nursing at night instead of encouraging night weaning. (This was easy. My son preferred nursing over bottles, so he naturally reverse cycled. The day I stopped nursing him at night and started offering him a bottle was the day he night weaned. It wasn’t worth it for him to wake up for a bottle).

In terms of increasing milk supply, nursing or pumping between the hours of 12-3am generally helps increase one’s supply anyway.

8. Breast compressions while nursing/pump right before nursing/work on latch and positioning while nursing

Kellymom has information on what to do if your baby develops a bottle preference while supplementing,and I used those techniques to avoid bottle preference as much as possible while I was combo feeding. For my baby,nursing upright made him happy (I would have to walk around the house while nursing him). Breast compressions also helped as it helped the milk let down faster. Most of the time, the reclined breastfeeding position helped him latch as it was a relaxed position (but as I had a slow let-down, sometimes it made it worse.).

Above all, do not force your baby to nurse. Seduce him to the breast.

Other experiences:This is a good blog post on another mother’s experience with combo feeding. Sounds similar to my experience in trying to balance the “feed the baby” rule with the “maintain your supply” rule. Go to BabyCenter for some support from other moms.

Basics: The First Six Weeks – a Breastfed Baby Goal Chart

newborn

click here for PDF

Sources and additional information:

Breastfed Baby Weight Gain:

http://kellymom.com/health/growth/weight-gain-calculator/

http://www.cdc.gov/growthcharts/who_charts.htm

http://www.babycenter.com/0_your-childs-size-and-growth-timeline_10357633.bc

Clinical Resources for Pregnancy, Birth, and Breastfeeding:

http://www.breastfeedingoutlook.com/index.php?pageID=35

http://kellymom.com/professional-handouts-set-1/

http://www.childbirthgraphics.com/index.php/

Basics: Low Milk Supply Part One – do you really have a low supply?

Aka: I just link a lot to KellyMom and Nurshable

Do you have a low milk supply? First, is it actually low? KellyMom has an amazing resource page regarding whether or not a mom’s supply is actually low, and if it is, possible causes and solutions. I really can’t add more, as it is very comprehensive. However, some key highlights: If the baby is cluster feeding (nursing off and on for hours), it may just be a growth spurt. If the baby is fussy at the breast, it may just be a new awareness of the world around her, or a need to burp, or just plain baby fussiness. It may be related to the milk – a lower milk supply or letdown is common in the evening, but even that isn’t often a big deal.

Other things to consider – if the baby is moving down the percentile chart, it may just be the chart your pediatrician is using or just a regular slowdown that will later catch up at the next growth spurt.  If the baby is slowing down on diaper output (fewer BM diapers, for example), it may just be an age-related change.  And remember, birth-6 weeks is different than an older baby.

Please keep in mind that not all babies fit prescribed patterns – be safe and weigh your baby just in case, but personal experience indicates a two week old can go two days without pooping and be going UP the percentile chart. In fact, many knowledgeable moms indicate during a growth spurt that BMs slow down during a growth spurt because the baby is using the milk more efficiently. I would love to find actual research on this (or ask one of our contributors, the Lactation Chic at Holistic Mothering), but it fits my personal experience.

Here is another article on our site with useful information on newborn weight gain and stooling.

In general, there is a wide range of normal for poopy diapers for breastfed babies.  And, in general, there is a wide range of normal for breastfed baby behavior.  In fact, check out AlphaParent’s Timeline of a Breastfed Baby to ease your mind. Or, buy Breastfeeding Made Simple, a seriously easy, basic read on breastfeeding without all the complicated rules.

However, a combination of these things may indicate a low milk supply. If your baby is increasingly fussing at the breast, feeds for a long time (past the first few weeks, and for more days than an average growth spurt), has low diaper output, and is going down the percentile chart, then you might want to consider trying to increase your milk supply (and/or supplement either permanently or while trying to boost your supply).

So what can you do? What are the myths and what actually works? Later, we will be going over (or, er, linking a lot to the above sources) combo feeding/supplementing, pumping/nursing tips, prescriptions, and galactagogues.

For more discussion on low milk supply, check out http://www.lowmilksupply.org/ and the Breastfeeding with Low Supply forums.

If you have a medical issue (ex: Breast Hypoplasia/Insufficient Glandular Tissue) check out this podcast.