The Fourth Trimester

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photo credit: Birthing Beautiful Communities

When a newborn emerges from the womb, it leaves behind a warm, dark, and physically stimulating environment that includes the mother’s heartbeat, the sounds of children or other adult voices, and the rocking, jostling, and rhythmic steps of the mother moving about. Upon birth, a baby will turn toward the familiar sound of its mother’s voice. We teach new parents to lay the baby down in quiet rooms, away from noise and the hustle and bustle of life, away from the mother’s familiar heartbeat, but what if what they really need is more of what they experienced in the womb?

The concept of a fourth trimester was first communicated by British childbirth educator and author, Sheila Kitzinger, in 1975: “There is a fourth trimester to pregnancy, and we neglect it at our peril. It is a transitional period of approximately three months after birth, particularly marked after first babies, when many women are emotionally highly vulnerable, when they experience confusion and recurrent despair, and during which anxiety is normal and states of reactive depression commonplace.” And other anthropologists like Jean Liedloff, author of The Continuum Concept, have studied multiple cultures or indigenous populations, looking for answers for problems faced by mothers and babies during the fourth trimester and beyond.

The fourth trimester concept embraces the idea that human babies are born three to four months earlier than developmentally ready. With evolution, the human brain has grown larger, but the woman’s pelvis has not. Thus, babies are born when their skulls are approximately eleven centimeters and before they have the muscle control to hold up their heads or roll over.

A friend who recently had her first baby remarked that while she had probably over-prepared for the birth, she hadn’t prepared at all for the first three months. Women no longer live and work in the same environments; we don’t see parenting up close with our communities or do as much caring for younger children as we once did when families were larger and life was more communal. We’ve moved into the workplace, attending college at large numbers, and waiting until our thirties (on average) to have children.

The transition from baby-in-the-womb to baby in the room can be just as jarring for today’s new mother as for the baby.

Buzzwords and parenting trends come and go, but the needs of the baby and new mother remain constant. During the fourth trimester, the mother faces: changing hormones, physical and sometimes emotional recovery from the birth, an initial unusually heavy period, soreness, moodiness, sleep deprivation, feeding and caring challenges with the baby, and, frankly, a world turned topsy-turvy. First time mothers are adjusting to the fact that every decision they make—even slipping into the bathroom to shower—impacts another person. Essentially, her life is no longer focused on her own wants and desires. More than men, women’s lives are greatly disrupted and reshaped by the arrival of a child, especially in the first months after the baby’s birth.

Both mom and baby are thrust into a new world, requiring adjustments, time, and a steep learning curve. If it’s a first baby, the learning curve is steep, but even consecutive babies create a learning curve, given personality and developmental differences baby to baby.

didymos-baby-sling-baby-carrier-baby-brightThe concept of the fourth trimester helps during this vulnerable time of change—looking at the early months through the eyes of the newborn, with empathy, helps the new parents in terms of setting expectations and making decisions. For instance, babywearing, especially with cloth wraps, can soothe even the fussiest of babies. The baby returns to the familiar warmth, heartbeats, and movement of its mother in the wrap. Wrapped securely, mothers can grocery shop, take care of older children, walk around the house, prepare food, or rest on the couch while the baby naps in its familiar cocoon. Some physicians and development specialists recommend swaddling to achieve a similar sense of security, but it remains more controversial in terms of neurological and motor development, especially if done for extended periods of time. One of my favorite wraps is the Didymos, but there are many types and styles of wraps on the market today and a mother might find that different styles are better for certain situations. For instance, for a quick errand at the store, a ring style sling might be easier to use. And babywearing can be a lifesaver with colicky babies.

Looking through the lens of the fourth trimester, it’s easy to see why a baby might nurse at uneven intervals; in the womb, the baby received nutrition continuously and in synch with the baby’s development. In the same way, a baby will nurse more when it’s making big developmental leaps, cutting teeth, or going through a growth spurt—as well as when it’s upset, scared, or angry. The media (books, TV shows, movies) often portrays sleep as something to be managed, when in reality, the baby knows what it needs and the sooner the new mother (and father) accept a more flexible approach to feeding/nursing, the easier the fourth trimester becomes. Full nights of sleep WILL return, but to expect full nights of sleep when the baby is young is contrary to its needs and development.

In the meantime, what makes sleep easier? Many families find that co-sleeping or using a side basinet works well. If breastfeeding, the mother gets more sleep when the baby is close by. And regular sleep/arousal cycles are healthy for infants and decrease the risk of SIDS. Every baby will sleep on its own when it’s ready. Managing expectations about sleep is just as important as managing the baby’s care. Attitudes should match development, not external schedules or sleep rules. These guidelines for safe co-sleeping can be helpful. Never sleep with an infant if the accompanying parent(s) have been using drugs or alcohol, as they may impair instincts and awareness. Dr. McKenna, an anthropologist and infant sleep researcher, cautions against co-sleeping when the mother is unable to breastfeed. In that instance, having the infant in the room in the early days will allow the parents to respond quickly to the baby’s needs. To learn more, check out McKenna’s Behavioral Sleep Laboratory at Notre Dame.

More and more research, as well as community programs, is focused on the concept of the fourth trimester. The University of North Carolina has a team of investigators looking at ways to improve outcomes during the first months of motherhood and infancy. Mothers and babies need support during those tender first months and health professionals are beginning to realize the importance of timely health encounters to reduce the incidents of post-partum depression, breastfeeding problems, and other maternal health issues. As women, we no longer live communally, but we can create a sense of community and support with our care providers, support groups (La Leche League or new parent groups for example), extended family, and friends who are already mothers.

Midwives see the care of the mother from a holistic perspective. From pregnancy to birth to postpartum, the midwife educates and supports the mother. It’s just as important that a new mother reach out to her midwife or care provider when feeling overwhelmed or unsure. Like the baby, the new mother is going from a constant environment—one in which she did things a certain way—to a completely changed environment. Support from other seasoned mothers and from health providers can be crucial to moving successfully through the final trimester and first months of motherhood.

(Locally, check out the Premier Birth Center postpartum support group, which meets every month in Winchester).

Breastfeeding Wisdom: Encouraging Words from Experienced Moms

 

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To wrap up National Breast Cancer Awareness Month, we’re focusing on breastfeeding—one of the many ways a woman can reduce the risk of breast cancer.

To start, we asked a panel of experienced moms to share their top tips for new breastfeeding mothers. Some of the women surveyed were long past their breastfeeding days—their children now grown adults—a few were still actively nursing children, and one mom had just recently had her first baby and was new to breastfeeding. One of the moms also works as a doula and has helped hundreds of new moms adjust to breastfeeding postpartum. This wide cross-section of experience has resulted in a beautiful heartfelt list of encouraging words for other breastfeeding mothers. If you’re new to breastfeeding or have been breastfeeding for a while, but could use some encouragement, read and savor this special list:

  • Don’t give up. The first days are the hardest—especially when your milk comes in and your breasts are hard as rocks and your nipples raw.
  • Be prepared with easy access bras and nursing pads. I wore my husband’s t-shirts at night and just threw them off if they got wet when my milk let down.
  • Put your phone down. There were no smart phones when I was nursing, and I remember those nursing baby eyes gazing up at me. You don’t want to miss that special bonding time!
  • Give yourself time to get the hang of it. I remember the first outing and breastfeeding in public. I was so nervous!
  • Expect your life to be turned upside down at first. You have someone who is wholeheartedly dependent on you and you’ve never had that before. Expect the range of emotions.
  • Know that the days before your milk comes in, it won’t be consistent and what they tell you in the hospital in relation to schedule most likely pertains to the phase when your mature milk has arrived and is established.
  • Day three or four will the “crying day.” Baby crying because he/she wants more substance (don’t fret—it’s coming!), mom crying because she doesn’t know how to meet the baby’s needs yet (don’t fret—just nurse!) PLUS the lack of sleep all around. It’s a perfect storm of emotional/physical exhaustion. Hang in there.
  • Decisions made in the moment that work—pumping or supplementing or nipple shields or bottle-feeding—don’t mean that your breastfeeding relationship is compromised. It doesn’t have to be all or nothing. Keep at it and hang in there. What’s helpful in the moment is just that. Helpful.
  • Nursing feeds so many of the baby’s needs, not just the need to eat. Security, comfort, warmth, belonging, stress reduction, just to name a few. A schedule will not address all of the complex needs. Follow the baby’s cues and nurse on demand.
  • Don’t be shy about breastfeeding in public.
  • Enjoy those beautiful hours.
  • Sleep with your baby so that nursing is easier for both of you (and for your partner!)
  • Get a sling and wear your baby, especially if it’s your second child—it’s much easier!
  • Find your local La Leche League and attend a meeting. You’ll make wonderful, supportive connections.
  • Don’t bother with formula samples or coupons if they give them to you at the doctor’s office or hospital—you can do this!
  • Just remember that your “sisters” did this a hundred years ago and longer.
  • You don’t have to answer if someone asks how long you are planning to breastfeed that baby/toddler/child.
  • Make your first latch a proper latch.
  • Invest in a breastfeeding consultant to support you in the beginning of your breastfeeding journey to ensure a good, painless start.
  • Drink lots of water and stay hydrated.
  • Use this time to bond with your baby by gazing deeply into her/his eyes and offering your finger for her/him to wrap her/his tiny hand around.
  • Try different positions to find the most comfortable one for you both.
  • If your baby tends to spit up after nursing, burp her/him several times while she/he is eating.
  • It will be difficult at the beginning and throughout, at times. Get support.
  • Let your support team know what you need to hear. I know you can do it—hang in there—remember why you’re doing this—or whatever will work, so that they don’t feel as if they have to “fix” it for you.
  • There may be vulnerable moments in the beginning. Creating the right support team will help you to ensure success.

Breastfeeding is a richly rewarding experience for most mothers, but there are times when complications develop. Some mothers have a low supply in the beginning. Staying hydrated, getting rest (nap when the baby naps!), drinking herbal teas, or using herbs can help increase supply.

Plugged ducts can often be handled through massage and ensuring that the breast with the plugged duct is properly emptied. In difficult cases, the nursing mother can get on all fours, placing the baby on his/her back on the floor. Nursing in this position allows gravity to aid in unplugging the duct. Sometimes gentle massage in a warm shower or after placing a heating pad on the breast (on the lowest setting and over a piece of clothing) can release the plug as well.

Mastitis is a more serious complication that leaves a woman feeling flu-like with symptoms like the chills, low-grade fever, and fatigue. Mastitis is often a sign that the mom is doing too much or that a plugged duct has resulted in infection. If the case is mild, it can often be managed with natural remedies, rest, and increased nursing. Some herbs have been known to help with mastitis, however, if the condition worsens, it’s important to see a physician and to take oral antibiotics.

Breastfeeding is rewarding and most mothers find that it increases confidence and mother-baby bonding. As we close out National Breast Cancer Awareness Month, we want to send a shout out to the many women—mothers, daughters, grandmothers, aunts, sisters, and friends who have been affected by breast cancer. We stand in solidarity with you all.

 

 

 

Breast Health: Basic Anatomy and Cancer Prevention

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It’s Breast Cancer Prevention Month. Midwives care for the whole woman, from pre-conception to well-care post-childbearing. Invasive breast cancer affects 1 in 8 women. It’s sobering to think that, in 2016, there are more than 2.8 million women with a history of breast cancer in the U.S (women currently receiving treatment and women who have finished treatment.) Throughout a woman’s life, normal breast changes occur. So how does a woman stay informed on what is normal and when to be concerned about changes in her breasts?

Most of the women we see in our practice choose to breastfeed and are successful. A breastfeeding mom experiences changes in breast shape, the feel of the exterior of the breast (engorgement before and then a smaller breast once the baby has nursed) and sometimes-painful knots – or plugged ducts. New moms who choose not to breastfeed or have barriers to breastfeeding may also experience changes in their breasts postpartum. Most of these changes are normal, and breast cancer while pregnant or lactating is extremely rare. Older women also experience changes, such as softer, fattier breast tissue, or mammograms that show calcifications.

It can be hard to tell what’s what and with national concern about, and awareness of, breast cancer, it’s helpful to review the basic anatomy of a woman’s breast. The National Breast Cancer Foundation has a wonderful video on female breast anatomy. Imagine if all women learned about this basic female anatomy in school, well before their risk factors increased? Female breasts are complex systems of lymph vessels and nodes, blood vessels, milk ducts, lobes and lobules, nerve endings, ligaments, connective tissue, and fat tissue. Check out the video to better understand how all of the elements work as one complex system.

Certain factors in a woman’s life increase risk, such as genetics; a mother, sister, or grandmother who has had breast cancer; alcohol consumption; a first child after the age of thirty; not nursing or nursing for less than a year; early menstrual onset; non-bio-identical Hormone Replacement Therapy (HRT); previous radiation exposure; poor diet, which increases risk of all cancers; obesity; and ethnicity—white women have a slightly higher chance of developing breast cancer, but African American women who are diagnosed young are at risk for a more aggressive, more advanced stage form of breast cancer.

Midwives encourage mothers to breastfeed, eat healthy, and limit alcohol consumption. But life isn’t just a series of neat checklists and all that we can do is our best with any given situation. If you know you have one or more of the risk factors, do your best to affect the other factors. Angelina Jolie very publicly chronicled her painful decisions about her risk of breast cancer, and then later her painful decisions regarding ovarian cancer risk. The mutation of her BRCA1 gene meant she had an eighty-seven percent higher risk of developing breast cancer and fifty percent chance of developing ovarian cancer, cancers that claimed the lives of her mother, grandmother, and aunt.

The basic tenets of breast cancer prevention that we recommend to the mothers we serve include:

  • Regular breast exams. You know your breasts best. Pay attention to even subtle changes and don’t be afraid to ask your healthcare provider questions.
  • A healthy lifestyle. Limit alcohol consumption, eat a diet heavy with fresh vegetables and fruits and limit fatty foods, exercise regularly—especially walking or yoga as they give cardiovascular benefits without stressing the immune system—and, if you are planning to have children and have no physical obstacles to successful lactation, plan to breastfeed for at least eighteen months.
  • Clean air, clean water. Research suggests that toxins in our environment contribute to higher cancer rates. Rid your home of toxic cleaners and perfumes and use a good water filter to ensure a clean home and safe drinking water.
  • If breast cancer or ovarian cancer run in your family, ask your doctor to run the BRCA1 test to check for mutations.

Many of us know women who have been affected by breast or ovarian cancer. Support the women in your community who have to undertake this painful journey. Womanhood is a sisterhood. We’re all in this together.