Optimizing Breastfeeding in the Hospital Setting with Arya Pretlow, MSN, CNM, IBCLC, C-IYAT

Ready to master the art of breastfeeding? Join us as we sit down with the brilliant Arya Pretlow, a certified nurse midwife, lactation consultant, and yoga therapist, whose wealth of experience guarantees a comprehensive guide to successful breastfeeding. The conversation takes off right from the hospital setting - preparing you to navigate through the complexities and challenges that new parents often face. Arya emphasizes the crucial role of prenatal breastfeeding classes, the potency of a strong support network, and the benefits of a lactation consultant and local La Leche League meetings.

Our discussion with Arya delves deeper as we explore the nuances of the first feed, the importance of patience, and how to best support your newborn during this time. Arya imparts vital tips on achieving a deep latch and highlights the must-know techniques and considerations surrounding breastfeeding. She also addresses the potential influences of spinal anesthesia and the epidural on breastfeeding, underlining the necessity of evaluating the larger picture of labor and delivery when identifying breastfeeding issues.

As we progress, Arya guides us through the fraught process of making informed decisions for infant feeding, particularly for preterm and early-term babies. She stresses the need for healthcare providers to offer more comprehensive education on potential outcomes. Furthermore, we take a closer look at lactation support for pumping and nipple shields and the significance of finding the perfect fit for you. By the end of this episode, you'll be armed with invaluable insights and practical tips from Arya's vast expertise to ensure a rewarding breastfeeding journey. So, why wait? Tune in now!

Connect with Arya at apwellnesservices.com

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Transcript

Speaker 1: 0:29

Hello, today I have with me Aria Pretlow. Aria is a certified nurse, midwife, an international board certified lactation consultant and a certified yoga therapist. On top of that, she is a mom. She is in the process of getting her doctor of nursing practice and today she's going to talk about optimization of breastfeeding in the hospital setting. You can work with Aria by going to apwellnessservicescom. This will also be in the show notes so you can actually just click the link if you want to. Aria, welcome and thank you for joining me yet again.

Speaker 2: 1:05

Thank you for having me yet again.

Speaker 1: 1:07

I'm happy to be here so as a nurse and, in doing this podcast, hear a lot about how breastfeeding in the hospital setting isn't necessarily easy, based on all of the things that happen in the hospital setting, like maybe an induction or maybe IV fluids, or maybe an epidural or the spinal, if you have a C-section and all of the checks and disturbances and whatnot. So, starting from delivery, what can moms do to advocate for themselves and for their newborns, to try to optimize this, in spite of having interventions and in spite of the setting that they might be in, to help make sure that their breastfeeding journey is successful?

Speaker 2: 1:56

There are many, and I would like to propose that the preparation begins well before coming to the hospital, because education is key and in the postpartum period in particular, your brain does not care to learn new things. It is very busy learning all about your baby and literally it's so plastic, it's so moldable, it's in the process of rewiring to prioritize survival of this baby, and so it's a really hard time to process and hold on to information that people, particularly strangers, are saying at you, right? So if a person takes a prenatal breastfeeding class, that is critical to some of the key components of the basics. Yeah, you're practicing with a baby doll, which is not at all the same, but you're getting a sense of like oh, I can hold it this way and I can hold it that way and I could hold it this way. No, I see I will need lots of pillows.

Speaker 2: 3:00

Yeah, or I don't like this particular breastfeeding pillow, but I love this other model, you know whatever, right, and I think the one that becomes most critical, having worked with new parents in the hospital, finding how frequently to breastfeed and how to tell if your baby is hungry, when they are satiated and if they're getting enough. Quote unquote air quotes. If you have learned it ahead of time, then any words that come out of the nurse or the lactation consultant's mouth is a review and a reminder and not you hearing me say it should be about this frequently and your brain being like the fuck Right, like because you didn't realize it was going to be that much. So let's first encourage everybody to do the prenatal work.

Speaker 2: 3:55

Yeah, Then assuming that has happened. Then there's all of this like we go in and, just as so many other things in life, birth goes how it goes, and there are things that we have control over, and then there's literally the other 95% of it and the best we can do is the best we can do with the situation in which we find ourselves. So I think that one of the things so we could start with like, okay, so you've taken a class, well done, and you've talked to your people, so your people are on board, whether that's your partner, whoever's going to be in the room with you, your partner, your doula, your parent, your mom, your mother and a lot. We've seen all the combinations of family support, right. These indicate that the support of the breastfeeding parents' mother and mother-in-law are as critical sometimes more so, than the support of their partner, because you're going to hear it from grandma if she's worried about that baby getting enough food in a different way than you're going to hear it from your partner, who tends to be more like this looks really hard. Are you sure you want to do it Like I'm worried about you and also the baby and the grandmas are like that baby needs to get fed right, and you're like I am feeding them. Behold the feeding, it is happening and the baby is doing well. So, having that support structure, the social support family and social support structure, I would say know ahead of time.

Speaker 2: 5:23

Just like you are going to post somewhere, I don't know, do people still use magnets on the refrigerators or is that to like 80s and 90s? I don't know. I still put magnets on my refrigerator with important information, right? So, just like you're going to have what, okay, we all know to call 911, but like, here's a pediatric urgent care, here's the pediatric hospital I would go to, here's my kids pediatricians number. Here's the poison control phone number, right, like all of those important numbers, add to that the contact information for a lactation consultant in your area who either you can get to their clinic or who does home visits, and also when the local La Leche League meeting is. Like anyone who's going to be a peer support to support you're in your journey later, so that all of this is done before you're in the hospital dealing with actually feeding. You already have a sense of like, okay, I know I also have supports in place for later, because that alleviates a lot of stress of just like it's all new and how am I going to do this? And this is so much harder than I imagined. So then you have the baby. Yay, hooray, congratulations, and one of the best supports that you can give yourself and your baby if it is clinically feasible, and by that I mean baby is stable and transitioning to air, breathing appropriately, so baby does not need resuscitation or support.

Speaker 2: 6:51

Fabulous, the place for that baby is on top of its parent, right, preferably the birthing parent. Obviously in a C-section. That isn't always the case, depending on the hospital. But if it could go right on top to the birthing parents belly or chest, depending on how long that umbilical cord is that is the place for that transition to be optimized and for the baby to already have that connection of the potential to do what we call a breast crawl to make its way up to the breast. So, being clear at check-in that your intention is to breastfeed, that you want immediate skin to skin, that you understand that that means baby doesn't need to get a bath right away or even get weighed right away. Right, like we can do those things after you get that initial recovery period. The quote unquote golden hour skin to skin with your baby, that proximity, while the baby is really. I think of it as sort of landing on earth, right, because you know that we've seen, right that babies are like, uh, what is just happened? Right, they're just like, whoa, there is so much out here I had no idea. And their little nervous systems are just trying to accept all this input from all of these sensory organs that they didn't even know they had. Right, they have smell now and they can hear so much more and there's bright lights and all of their skin is picking up stimulus and so they they are processing a lot. Having them be able to be right there on what is still their home, which is the gestational parents body, is critical to their ability to transition as smoothly as possible. Assuming that they're doing that well, right, so, like again, sometimes babies need some extra support and that's what we're there for.

Speaker 2: 8:52

I remember seeing frequently parents who were very enthusiastic about breastfeeding you know that baby might be five minutes old and they're like, can you help me get it latched? And we're sort of like, um, I mean, yeah, but it's five minutes old. Like, give it a minute. I say it because I don't know. It could be a boy or a girl, it doesn't really matter. But it you know, give the baby a few moments to actually settle in here, they're gonna show interest, they're gonna start, even left to their own devices, they will make their way toward the breast, just scooching along mom's body so we can put them in a position and get you all set. But it's also not going to disrupt initiation of breastfeeding. To let them explore Ideally that's actually part of the process is them finding their way to the breast, following the smells, following all of the feedback that they're getting from the parent's body, that this is the way toward what you need. So a lot of that whether there are interventions or not, is part of what can facilitate initiation of breastfeeding, is really just that background preparation, having support in place and then respecting this period of time from leaving the inside of your body to landing on the outside of your body and letting that landing process kind of unfold on its own.

Speaker 2: 10:16

So breastfeeding a baby, like a neurotypical, well-transitioning, healthy neonate, is going to seek nourishment. But we have to remember they're not born hungry. They were being nourished as long as the umbilical cord was still intact, right. So they're not hungry and they probably still have some amount, depending on how long pushing took some amount of amniotic fluid in their stomach and so they're not starving for their first meal. On the outside it's okay, but there are normal behaviors to get a baby to that first feed that we want to give the space and the peaceful environment and the time for that to develop, without forcing or rushing it, but also trying to facilitate it. Light's low Get.

Speaker 2: 11:12

If a repair needs to be done, the repair can be done with the baby already on the parent's chest. All of that is fine. We don't need to take the baby away from the chest. We can do the i-anabiotics, we can do the vitamin K. We can do those things with the baby on the parent so that there's no reason to move the baby away from that process that they are already experiencing of making their way toward a first feed.

Speaker 2: 11:35

And then it's really about the parent learning. So I think what I have seen is it's hardest for the first time feeders and then it's harder for the people who are still feeding a toddler because they are so accustomed to gymnastics and for get newborn requires a whole other level of parental involvement and support that a toddler. A toddler can literally toddle over and in any from any angle, attach, take a few slurps and be like, bye, I'm gonna go play with my truck and that's amazing and wonderful and I love that. But then the parent is sort of like I don't understand why this newborn's having trouble and like the newborn's not having trouble, the newborn's being a normal newborn. That's not trouble, that's normal. But you're just used to a professional breast-beater, so we have to like remember when your toddler was new?

Speaker 2: 12:32

Yeah, okay, so let's overlay that on this new person and provide the same amount of support. Only this time it's actually likely to go smoother for both of you, because you do have that experience to fall on. So if we remind them, you still need to support your breast during the whole feeding. I know it's annoying, I know that it's tiring. That's what pillows are for, because as soon as you let go of your breast, your baby, a newborn, has trouble maintaining their latch. That's because they're so new, right? Yes, you need all the pillows, all the pillows. You can bring a breastfeeding pillow from home. That's great.

Speaker 2: 13:14

Some hospitals have them, but we can't guarantee that they aren't all in use, right, or one is available at the time. It's not like every room has one. A hospital with 14 beds might have five breastfeeding pillows, and if all five are in use, then you get what's left of all of the bed pillows that we try to stack like Legos under your arm and your baby to varying degrees of efficacy, and even that in my experience, sometimes there aren't enough pillows to go around because everybody's using tents. What happened to go like? Leave pillows from other units? So bringing a supportive breastfeeding pillow. There are many brands. I like the ones that belt around a person the best. They tend to provide more support and actually hug up against the body a little better. That can be really useful.

Speaker 2: 14:05

It is difficult to breastfeed in a hospital bed. It really really is. That's not a position. Sitting up with your legs straight out in front of you is not a super comfortable position for most adult people. And also you're not in your home, right. So it's like the little if there's a chair, or like the sofa that your partner sleeps on in the postpartum room. Those aren't super comfortable either, right? Like nothing is set up for this to be like a comfortable learning experience, unfortunately. So really getting as comfortable as you can in the environment in which you find yourself and remind yourself, if at all possible, that when you get home you're gonna be able to tailor this to your needs. You're gonna figure out what location you like best. And oh yeah, actually I thought that footstool was a silly idea and then I breastfed using a footstool and I don't understand how anyone does it any other way, right?

Speaker 1: 14:59

Or whatever it is for you, you'll figure out, but you're not gonna be a pro before you discharge from the hospital, unless it's your multipolith baby to breastfeed in which case you're like yeah, yeah, yeah, yeah, yeah, yeah, even the second time. Moms, man, it's almost like they I don't know, both first time and second time is when moms do the baby smush, yeah, and it's like you can't smush your baby onto the bed. The baby has to like latch.

Speaker 2: 15:26

They have to open their mouth Mm-hmm.

Speaker 1: 15:29

And to open your mouth like, if you're gonna eat a hamburger, you can still let your head back. To open it. Yes, yes, You're not gonna. You're not gonna eat it with your nose. That's not how that works.

Speaker 2: 15:36

I see so much like, well, the baby has a tiny mouth and that seems pretty wide open and I'm like, yeah, yes, and your breast and your baby's mouth there's like they don't match up size-wise right, and so if your baby doesn't unhing, it looks like a snake unhinging his jaw right, like they can open much wider. But a lot of times the parents are so motivated, trying to be diplomatic. Some of them are anxious. It is anxiety, pure and simple. Some of them are just super motivated and don't know that that's not a wide open mouth but they try to like smush soft tissue into a not very big firm opening in that.

Speaker 2: 16:17

Baby lips are soft but baby gums are not right. So if the mouth hasn't opened very far, I don't care how much you try to shove your breast into that tiny hole, you're only gonna maybe get nipple feeding and then you will be sad. You will be so sad because your nipple will hurt. So, yes, there's, waiting for the baby to be ready is key, and a lot of that involves the time of learning your baby and developing trust in your ability to read your baby's signs, and that's fundamental to literally the rest of your parenting right Like trust your baby and their signs and trust your instincts.

Speaker 2: 17:02

And also take that prenatal breastfeeding class that you have some information to fall back on. That is like scientific and great advice. But there's that bit of like nope, that's not a big enough. Mouth, that's not big. That's not big. That's not big. Ooh, that was big.

Speaker 2: 17:16

Great, the baby's being trained and if you let them have a shallow latch every time, that's what they're learning is a latch. They don't. They keep landing with some amount of breast in their mouth and they're like okay, I'll do what I can with this, but it doesn't pay off in the end because a shallow latch will eventually injure your nipple and it doesn't transfer adequate milk. It's not an effective latch. So stop messing around with it. Like, just stop it. You need a deep latch for it to count.

Speaker 2: 17:47

That's a latch, because then you're set up for success instead of like well, the baby's on and they're spending like 40 minutes per side, why it seems like they should be more satisfied and like no, but look at that latch, they're spending 40 minutes in a quarter. A latch. That's a quarter of the amount of depth that it should be. That's why they're on for so long and then fall asleep because they're not adequately transferring milk, because it's not an effective latch, because they don't have enough breast tissue in their mouth, and then they're worn out from the exercise of doing it, and so then they fall asleep, and then you're like my baby's at seven percent weight loss or you know whatever, and you feel like you're doing all this work and not really getting return.

Speaker 2: 18:34

And then that starts to set up this feeling of like I'm Not enough and it's not that the parent is not enough.

Speaker 2: 18:43

It's often that the latch is not correct and and that again, assuming a Full term neurotypical baby without any kind of facial structural abnormalities. That's really about education and practice and and trained I Taking a look and being like, oh yeah, I can see why you think that that is a good latch, but let's try this. And then you get a deep latch and you're like, yes, that's very different feeling, because it's a very different feeling.

Speaker 1: 19:16

It really is. And the other thing is that I noticed a lot is to piggyback on them super motivated I'm still trying to find another word for that, because it's like I'm just gonna say it. There's a level of impatience, yes, yeah, it's like they're being great. There's like right, yeah. And so when I come in as a nurse trying to help somebody get that latch, what I usually do is I will have them move their hands away Because, yes, whatever they're doing to smush the baby on the breast is not helping the process. So like our hands up, like you're. And then then there's the.

Speaker 1: 19:51

Watch me grab behind the baby's head, support behind the baby's shoulder blades and allow that baby's head to kind of tilt back, nose to nipple, and then open that mouth Really wide and then, instead of so, they, they teach in these breastfeeding classes. They, they teach the sea hold that big feelings about that too, because it doesn't do anything to get the breast tissue into the mouth. That's for someone that has like nipples. That will go directly into the mouth. Yeah, you want to kind of Squeeze that tissue like Lining up like it's a hamburger that they're gonna take a bite of, and aim that nipple towards the roof of the house.

Speaker 1: 20:30

Once that mouth is like so wide, and then you'll get your deep latch, yeah, and then I will take their hands and put them where my hands were. Usually I start with, like the I think it's cross cradle. I get confused cradle versus cross cross.

Speaker 2: 20:45

I think it's the cross cradle. Is your hand at their shoulder blades and their hips? Yeah, a lot near your elbow.

Speaker 1: 20:51

Yeah, I usually start with the cross cradle newborn right, and then we work on that and then, if that's not working, well then we shift to the football. Yes, but the whole goal is to get the nose to nipple and show the parent how to get the like, just to Visualize and control the head. Yeah, those two positions are really the only ones that I find are helpful in those newborn moments where you're trying to teach them and and parents, when you're trying to do this, you really really do need to take a step back.

Speaker 1: 21:24

You can't force this process. You have to look and look for what is happening with the mouth and what's happening with the nose and what's happening with your nipple and where you're gonna support your baby and all that stuff, because that's key to being able to get that good lunch and the immediate feelings of I feel like there's. I get a vibe of being impatient and overwhelmed. While I empathize and understand and validate those feelings, what is helpful is to take a big deep breath, lean back, relax and observe what a good latched looks like and then try to make your hands and body Continue that process until you can actually do it yourself. It's not gonna happen the first try. Yeah, it really is not, and don't expect it to, because in a hospital setting, that is what the staff is there to help you with yeah anywhere, like even if you're having a home birth.

Speaker 2: 22:15

There's someone there to help you with that, so allow them to do that, short of actually allowing a breast crawl and like lying back doing laid-back breastfeeding and letting the baby work, it's way up and and just they open wide and they fall they just face plant on the breast. Short of that, everything else in my experience pretty much needs the help of another set of hands while you're learning how to do it and.

Speaker 2: 22:39

I think that, like a couple of ways that I phrase it for people, and a challenge on on right now is I use my hands a lot as I talk and educate people, so your listeners can't see this. But if you think, if you feel with the your own tongue, where the hard palate of your mouth Meets the soft palate way about right way back there, don't gag. That is where the reflex for suckling is. This is why bottle nipples work, because they're long and firm, so the baby doesn't have to open its mouth wide. That thing is going to stimulate what I call the suckle button.

Speaker 2: 23:18

It is not a suckle button that is not trademarked, it's not registered, it ain't nothing, but something I say.

Speaker 2: 23:24

I mean maybe some other people the suckle button when you have a ginormous postpartum breast and a tiny baby head right. You, you need that baby, yes, lined up nose to nipple, as you said, not mouth to nipple, nose to nipple. So when they lean their head back, they are able to lean their head back. They're not very good at reaching. They don't have the strength yet to reach their head forward, right. So that's where your hands come in to help steer them on. Yes, they need to land so that Any part of your nipple, depending on your nipple anatomy, is as close to the suckle button as possible. So when they close their little bottom jaw, that they are stimulated to start actually suckling and as they do, they might slide a little bit and that can be okay because they are Lengthening the nipple so that it continues to stimulate but also becomes what we would just In generic terms, a, a teat right. It becomes something long through which the milk flows.

Speaker 2: 24:29

I have seen over, I don't know, thousands of babies they have. They all have a tell, and so people be like how do I know when they're opening their mouth enough? How do I know? How do I know how to know? And I'm like okay, if you, if you've ever watched a cat or any cat video on Facebook, right, or whatever on social media, like ooh, cat video, so cute. Look, it's gonna pounce on its friend. Ha ha, hilarious, it is hilarious. I love watching the cat, but you know how they're like wait for it, wait for it. Like you could tell the cat wants to do something mischievous, but they start to like coil into themselves and they're not gonna pounce until you see their butt wiggle. When that cat wiggles, it's, but that's like its fuel for Jumping babies. Don't wiggle their butts, they wiggle their heads, and so when your baby is like, they'll do the same, or they're like I'm gonna come in and out of my microphone, right?

Speaker 2: 25:24

I can bounce bouncing bouncing in the mama's like why can't they just stay? I'm like there, they're just trying to find it. It's okay, all of this is normal. They're not failing, they're doing their job. But when they finally mean their head back and are like they kind of shake the head side I'm and that's the moment where they are about to go for it. The problem is they suck no pun intended at going for it in so far they don't have coordination Not great coordination yet, and they aren't good at working against gravity.

Speaker 2: 25:53

So, depending on the position you're in, that's your moment to be like Move faster than you think you should move with a baby in your arms to get that baby in contact with your flesh. Their body should already be in contact with your body, but when they move their little head back, that's, and they wiggle it. That's the moment. Regarding seaholds, I feel like, in an effort to explain something that is really quite simple, we have sadly made it seem like a set of rules or checkboxes that should be filled in order to achieve success, and so it's like, if I use the seahold, I will achieve a latch.

Speaker 2: 26:29

And then everyone's like a see from what perspective? A See from your perspective, nurse, a see from the baby's perspective, a see from my perspective, looking down at my breast. What if the baby is in football hold? Then the shape of the breast needs to, as you said, like a hamburger, right, it needs to get. The shape of the breast needs to match the shape of the mouth opening, and so we can't we, we have to line up the axes of things.

Speaker 1: 26:55

You don't hold the hamburger side Parallel to your nose.

Speaker 2: 26:59

If you're to take a bite, you have to have it Parallel to your right or if you think of a taco with a hard shell and you're holding it upright, you have to turn your head sideways in order to take your back right. Well, you can't like it, won't it won't work so. So I Dispelled with the seas. I was like, look, all you really have to do is make a shelf with a nipple on the end and Keep your fingers away from the areola.

Speaker 2: 27:29

So yeah, so I'm gonna show you I'm keeping my shirt on, but so because people will go here like here's Me here's me right and they'll be here. And every time the baby tries to go there, the parents index finger stimulates their they're searching and they zoom, they turn toward the parents hand because they got that firm stroke across their cheek.

Speaker 2: 27:55

Of the parents finger and they're like, oh, is that where the nipple is, like they were headed for it, and then they zoom off. It's always because a parent Finger touch the baby's face somewhere. Then it got the baby thinking, oh, that's the direction I need to go. So it really needs to be way down where, like, your underwire goes. So so that from that I mean.

Speaker 1: 28:13

I have a pretty good, but I like it so you go here to here right, so you have a shelf for people that can't see. She's just basically pushing her boob up. Yeah, I have my hand push up your boob, you don't need to make a see. My hand is the cut push in a push up bra.

Speaker 2: 28:29

This is love it. So that is the shelf. The shelf is just your hand, is the support. The shelf is actually your breast, but on the end is a nipple and you don't unless someone has Inverted or very kind of flat nipples, and maybe they need what's called a teacup hold, which is a very specific technique for trying to help shift that flesh into a shape that will more easily be latched onto by the baby in the absence of that.

Speaker 1: 28:58

I'm still stirring at your boots. Oh sorry, Thanks, I mean that's a professional hazard.

Speaker 2: 29:04

There's a lot of me pointing to my own breasts when I'm talking to people about breastfeeding, yeah. So, unless someone needs help with like a teacup hold depending on their nipples, if you have nipples that avert with stimulation, then all you got to do is put it in a position where it is the only thing that the baby's mouth is going to come in contact with right.

Speaker 2: 29:24

So I don't care, it depends on, because the sea gets confused also when people like but what is it if it's football? Hold now it's a you and I'm like I just don't, it doesn't matter. It just doesn't matter. Just put your hand on your ribs and Don't shove. Shove sounds so violent, but just. Support your breast in an upward.

Speaker 2: 29:46

Baby, a baby give it more like work against gravity, and the larger the breasts, the more you have to do that, to the extent that sometimes you know we roll up washcloths or something to put under very large or very Pendulous breasts because the hand isn't isn't enough. So you get like more support, more support, more support holding this breast up so that the baby Just is gonna find nipple and not get hung up on Fingers getting in the way. It also helps stop people from this thing that they like to do, which is push with their thumb Often it's the thumb to keep the tissue away from the baby's nose. Mm-hmm, that's. That's not a thing. So the the fact that your baby can pop off the breast is part of how they don't Suffocate on your breast, right? So babies are obligate nose breathers.

Speaker 2: 30:38

If your baby is suckling, it is breathing because it has to breathe out of its nose. What they do is they suckle, suckle, suckle however many times, pause, breathe, swallow, or Pause swallow, breathe, whatever. But the point is they suckle there. They're not actively breathing and suckling at the same time. That's like that takes way more coordination, like breathing while you suck through a straw, right Like wait, that's a Time.

Speaker 1: 31:04

Well, I don't even know.

Speaker 2: 31:05

I like to aspirate. That's dangerous. So they're just busy suckling, but they're not. Not breathing, but they can.

Speaker 2: 31:12

All babies are born with these flat little wide Nostrils so that they can be smushed up Right up against the tip of their nose, against breast tissue, and still be able to breathe.

Speaker 2: 31:23

If you could put even just like a Slip of paper between the breast tissue and the baby's nostril, the baby can breathe. You don't have to keep pulling the breast away from the baby's nostrils, mm-hmm. So when you press your thumb into the breast to move it away from the baby's nostrils, you also pull away from the suckle button and you make that latch shallower and, as we already stated, a shallow latch eventually leads to nipple injury and also Less milk transfer, therefore a less effective feeding. So if you have concerns because of the size or Softness or fluffiness or whatever of your breast, then other you know, try other positions where you can let go of your concern about the baby breathing. But some of that also is what comes up with, like if you do the prenatal education, you learn these things and so then when you're trying to actually put it to use postpartum, when you're already amped up with like, oh my god, I have to keep it alive. On the outside You're not also like what if it can't breathe while it's feeding?

Speaker 1: 34:12

That's, yeah, yeah, something. That's a concern that we definitely want to overcome. Yeah, and Because breathing is important, it's the most important and that pressing can also lead to inflammation.

Speaker 2: 34:23

That can cause ductile narrowing, and that is what we used to call a plug duct, which we don't call it that anymore because it's not what it is. So don't give yourself ductile narrowing like you, that that also leads to other problems.

Speaker 1: 34:36

Yeah, so some of the things that have come up when I'm talking to people that have delivered in the hospital so.

Speaker 1: 34:45

Often with hospital births, there are other interventions that come into play, whether they're on purpose or unintended. Regardless, they are available and offered Based on the patient need. So I've been hearing a lot about fluid overload, both from parents and from medical Professionals, and how that may cause a couple of things. Newborn weight loss, potentially because of the Baby, receives the fluid overload through the umbilical cord. Then when they pee off the Fluid, then they might have more weight loss than these parameters in the hospital would allow and Additionally a Dima in the breasts, so it makes it harder for the breast to latch.

Speaker 1: 35:31

So what might we do if, due to the interventions in the medical need, we've then given more IV fluid than anticipated and maybe we're feeling some Edema, swelling in the breasts or potentially even the baby? How can we kind of counteract that?

Speaker 2: 35:50

So it is an interesting topic that comes up. When we look at Something that is a really important indicator to how well breastfeeding is going and how well a baby is transitioning, which has to do with that initial weight loss. And yes, if the baby loses usually the hospital guidelines are like seven percent we start to be like, hmm, but why? So? That means like, say, a baby I don't I'm not gonna do the math right now, but say a baby is born six pounds, eight ounces, and, and every day they get weighed, or every however often in that hospital they get weighed to see, like we expect all babies to lose weight. They are getting rid of that amniotic fluid in their stomach and in their lungs and all these things, right, the meconium. They have to poop out all that meconium, all of this. So it's normal for them to lose weight. But there's a point at which we become concerned because if they're losing it and not Replacing it with adequate colostrum, that becomes the concern. So, yes, if a parent had a lot of IV fluid, which ideally would have been managed right, like there, it's supposed to be managed and Sometimes we on purpose overload people because we need that to happen in preparation for things that will cause Low blood pressure, like getting an epidural right, like we need to give them that leader of fluid, at least one, because we know they're gonna become hypotensive and then that causes other issues of perfusion. So the solution is not to stop using IVs. Clearly that is an important component of the care, but neither is it to say I don't believe that weight loss, because I had an IV for however many days, because what we can't know is how much of that baby's weight loss is, because they peed out quite a bit of that IV fluid that mom got versus. No, they really actually are also just Latching very shallowly or or something is going on where they're not adequately transferring colostrum, and so it's. It's a, it's an accurate weight loss.

Speaker 2: 38:02

Either way, the solution is to feed more frequently, right, and to do things that help your, help, provide your breasts with adequate stimulation to facilitate the transition from colostrum to Transitional milk, which eventually will become mature milk.

Speaker 2: 38:20

So somewhere between, usually, days three and five if you're a first-time breast feeder, it's often sooner. If you have breastfed before and if you were still breastfeeding while pregnant your older child, then you already have milk. So so you figure it's gonna be colostrum, which is all the baby expects for the first few days, especially if it's your first baby, and that is enough if the baby is able to transfer it. Well, so you can help by doing lots of skin to skin, by feeding on cue, by rooming in, by having the baby on the gestational parent and not on a grandparent or like, and sitting there like cueing right, the baby is sitting in their grandparents arms, smacking their lips, trying to do all these things to show that they're hungry and everyone's busy watching the football game, especially this time of year, right? So a lot of it is because we cannot disregard the weight loss, because we know they had an IV, because too much is at stake, right, like we have to be able to identify before that baby goes home that it is not eating. That's important.

Speaker 2: 39:29

And also clinically, in the big picture there is some amount of like okay. But we know this was one of those three day inductions that then also had an epidural for a long time, so there was lots of fluids and then also ended up a C-section, so there was lots of fluids and so their 7% isn't as scary as the person who came in didn't even have an IV right and just shot their baby out and that baby loses 7%. I'm more concerned about that baby 7%. But I'm gonna encourage both parents to hand express and do breast massage and keep that baby on them and offer the breast as frequently as possible and do all the things to help facilitate not only access to the breast and therefore the food, but also the stimulation needed for the breast to more quickly be encouraged to make more volume of milk. And I think, as far as the overload goes, that part's really hard because the larger your breasts, the more they are susceptible to dependent edema, just like your feet right, so they are lower than your heart and there's gonna be pooling of fluid and that's gonna be right where it could be more difficult then for your baby to distinguish nipple from other parts of the breast and so you can wear a supportive bra to keep them don't smush them but to keep them supported so that there's less just dangling and pooling.

Speaker 2: 41:00

You can do some. We have a technique called reverse pressure, so that's something that you can look up on lactation education resources or I feel like CHOP Children's Hospital of Philadelphia probably they have great resources. But anyways, just a technique of pressing your fingers into the areola on either side of the nipple to help, just like you might massage your feet and ankles to try and move fluid back up, kind of lymphatic drainage. You can do that for your breasts as well, to help move some of that edema out of them. Yeah, kinda like make a little hashtag, yeah, make a little hashtag and that just helps move. And yeah, if they're like soft and doughy kind of, then you know it's edema. That's not engorgement, it's not just normal breast tissue, it's edematous breast tissue and there's techniques to help with that.

Speaker 1: 41:50

Thank you. You've talked about rooming in. You've talked about hand expressing, the golden hour positioning. Let's see.

Speaker 1: 41:57

Along with positioning and I guess we can kind of walk this all in there's concern with spinal anesthesia, slash, spinal analgesia and the effect it might have on breastfeeding.

Speaker 1: 42:09

I've heard concerns that there's a direct effect, but you and I have both looked into it and can't find any specific direct effect from the spinal or the epidural to hindering breastfeeding. But we've talked about some things in the hospital that might be considered a secondary effect to impeding breastfeeding. Some of the things we've talked about today go hand in hand with this, like the fluid overload for the need of having the fluids before the spinal or the epidural positioning. If you're numb from the waist down, there's nothing more important than getting you into a position that is comfortable because you can't really do it on your own. So you're gonna need some assistance with that. But essentially everything that we've found is just a secondary type of situation where it's either from edema or it's from the numbness or essentially positioning. So I feel like we've mostly covered that. Was there anything else that I'm not thinking of that we've identified as a secondary problem to interventions like the epidural or the spinal anesthesia.

Speaker 2: 43:16

Yeah, well, one thing I wanna give a shout out to nursing education and the degree to which we are trained to find the literature, assess the literature critically and then apply the literature. And so one of the things we always have to look at is I have seen studies that are like oh, also, by the way, we noted that breastfeeding was challenged in these people who had epidurals, but that was not the primary research topic, and so it's just we wanted to note that because we think that some more researchers need it right. And so we get into that issue of we cannot say it caused it. Correlation is not causation. And so, that being said, because it is a correlation, we have to consider all the things that go along with an epidural.

Speaker 2: 44:09

Almost always, if someone has an epidural, something is going on with their labor that is making it so painful or so long right, or so I just can't take it anymore, and that could be so many things, and that's a whole other topic to get into.

Speaker 2: 44:25

But something is making it intolerable, even with normal endorphins released, to be able to manage a labor without pain medication. Yeah, sometimes that process goes awry, often along with an epidural. Now we need to manage, or we already were managing contraction patterns with pitocin. Because pitocin is synthetic oxytocin and because oxytocin is so strongly involved in breastfeeding and in the baby's ability to recognize kin, it does make sense that pitocin by itself can interfere and there are studies related to that, that the use of pitocin in intrapartum, not necessarily only postpartum to manage hemorrhage risk, but like throughout to manage a contraction pattern because the baby is getting some amount of it, so it impacts the babies in itself, which we call endogenous production of oxytocin. Postpartum the baby's not getting the oxytocin to the same degree, right, but the parent is getting it and so their production of oxytocin is decreased and oxytocin, again a key hormone in breastfeeding. So a lot of times with an epidural or a spinal I mean a spinal goes with the C-section right and so-, but you've been laboring with pitocin for days before you get that.

Speaker 2: 45:47

Yeah, so we can't say it's the epidural for sure, just like we can't say for sure that it's the pitocin. But since pitocin so frequently goes along with an epidural, that is a component of this bigger picture of things impacting initiation of breastfeeding. And so the other component is like was the postpartum then more painful? Was it a worse tear? Is she having more difficulty getting comfortable? Was it a C-section? And so everybody's just exhausted and she lost more blood and even if it's a quote, unquote, normal amount for a C-section, it's more blood loss and so she's more tired, and all of those things play into the initiation of breastfeeding. So I think it's something.

Speaker 2: 46:37

Always we talk about modifiable risk factors and non-modifiable risk factors, and so there's a point at which, if everything has led to C-section, for example, that is no longer a modifiable risk factor. You've had it, you can't change it. That was part of the 95% of your labor that was out of your control. You presumably you and your team did everything you could to have a vaginal delivery if it was indicated. So now you gotta work with what you got. So that is something that cannot change. The C-section already happened. So then what do we do? We keep in mind that establishing breastfeeding could be a little bit harder. That there is a correlation with difficulty initiating breastfeeding with delayed lactogenesis two, which is that three to five day, especially for a first time mom, like it's gonna take longer for your milk to come in.

Speaker 1: 47:33

It is.

Speaker 2: 47:34

It does seem to be related to lower rates of exclusive breastfeeding at three months and six months, and that could be for so many reasons. People often use up most of their postpartum leave still recovering from a C-section. That's not the same as if you have a vaginal birth and have the same amount of leave, but spend it healthy and feeling like up on your feet and recovering right. Then it's a very different transition into parenting this child. So, giving yourself some grace and extra support in all the things to help breastfeeding and also to try to decrease your own anxiety about is this working? Is this working? And know that if you're doing all that you can, sometimes a little more support is needed and it's not your fault, right? You modify what you can and you have to just take into account the non-modifiable aspects and know it that it's having an impact and let go of any feelings about that. Just know that that's a thing.

Speaker 1: 48:41

And then work with it and then work with it.

Speaker 1: 48:44

yeah, I think that even if someone makes the informed decision to get a C-section without laboring, or even if they decide to have an elective C-section, or even if somebody decides to have a scheduled induction and elective scheduled induction, I feel like they've made an informed decision, knowing the risks and benefits. That doesn't necessarily set you up for failure when it comes to breastfeeding, and what I want potential birthing people to know is that just going in informed and knowing that there may be some extra hurdles, but arming yourself with that education to help you get past that to know that.

Speaker 1: 49:21

You wanna do that golden hour. You wanna do that skin to skin. You wanna do the try to do the breast curl. Support your breasts have all. Bring your breastfeeding pillow and make sure that there's pillows there in the hospital. Have a partner, bring pillows from home. Whatever it needs to make your breastfeeding experience as optimal as possible. And then, using things like hand expression and making sure that you're paying attention to those cues, all of those things are going to send you in the right direction, to set you up for success. And, like you said, if success isn't achieved in the way that you had envisioned it, let go of some of those expectations and remember that the goal is to feed your baby. And if you have put the effort towards doing all those educating yourself and doing all the right things, know that not everything is going to be always perfect, and that's okay. Yeah, you get to, but we're here to educate.

Speaker 2: 50:19

The goal is to put that out there right now, so that everyone knows that, yeah, you get to redefine your goals and just because, like, let's say, let's say someone has a really long induction, let's say gestational hypertension, your preeclampsia, okay. So your preeclampsia, your 35 weeks, you're going to be induced, depending on how far along the preeclampsia is. You're either gonna have a baby real fast because your body is like you ja, ja, ja, ja, ja or your body is like ah, right, and it's gonna be a long process because it's still 35 weeks.

Speaker 2: 50:56

I've seen it go both ways Preterm babies and early term babies. You're 37, 38, 39 weekers. They're not good at breastfeeding.

Speaker 1: 51:05

They're not.

Speaker 2: 51:07

And so sometimes there's this if your baby's not good at it yet, even though you're doing all the things you could given the situation in which you found yourself, sometimes the formula is needed because it's medicine, and it doesn't mean breastfeeding has failed. Breastfeeding hasn't even really gotten off the ground yet. It's still like warming up its engine. Right, and so we also. It doesn't have to be all or nothing the whole time, right, it's not like well, we had a supplement and so that's it. It might as well throw in the towel. Sometimes you have to supplement for a little while and then you end up being able to exclusively breastfeed for until they're ready to eat table food. So that's something I always wanna encourage is like it's okay to have any configuration of feeding your baby that works for you and your baby. And if we could all take away the value and judgment ideas and be like okay, the science is very clear that the standard should be. The standard is that what your baby's body expects is human milk that's clear and makes sense. And also sometimes, for any number of reasons, that's not available, and so we have alternatives that don't have to be the forever alternative, and sometimes only time is what we'll tell Someone might have polycystic ovary syndrome and they might overproduce, underproduce or produce just right. It really is the Goldilocks and the three bears like one porridge is too hot, one's too cold, one's just right. We can't know until they try. We have no way to predict. All we can do is say let's see what happens, but know that it's a risk.

Speaker 2: 52:48

I think, as far as the informed decision goes, one of the complaints amongst the populace and I think that it's a correct complaint is that it's not included in the informed decision about surgery, about epidurals, about IV hydration, about hospitalization in and of itself. That's not part of what happens in the informed consent conversation with the OB or the anesthesiologist, and so they don't know that it might make breastfeeding a little more difficult, even if only because you're gonna be more sore, like, let's say, it's a C-section, you're gonna have a decision, it's major abdominal surgery, and so we're gonna need to use some more supports. You're gonna have to get more creative with how you hold your baby to not have pressure on your incision and you're gonna be more uncomfortable. That can impact breastfeeding because it's hard to relax and be at ease and if you're not relaxed and at ease then you don't release as much of the hormones to help with the milk let down.

Speaker 2: 53:49

Well, that's a whole big conversation that doesn't happen until after the decisions have been made, and so I think that's one of the challenges in general for the way in which we have siloed specialties, where it's like oftentimes OBs unless they are somehow also a lactation consultant they're just sort of like how are you gonna feed your baby? And then they just mark it in the chart and they're like all right, you should probably like take a class or something, and that's it Like don't ask your OB if the baby's getting enough or which formula or whatever. Right, that's a pediatrician question.

Speaker 2: 54:26

But the pediatrician doesn't know until you meet them. And then the lactation consultant comes in and is like how did no one tell you that this was a likely outcome, that your baby is 35 weeks and of course, breastfeeding is difficult? How did that not come up?

Speaker 1: 54:43

Because there's that wasn't. We're just trying to get the baby out. Yeah, exactly.

Speaker 2: 54:46

It's not on the radar. Once the baby is out, the obese job is done. They are now only responsible for the birthing parent. So who's on first? Who's on first?

Speaker 1: 54:58

Yeah, and that's a really good point, because there's all this expectation on the OB about or, you know, since we're talking about a hospital the OB or the midwife, depending on your situation, to provide all of the education.

Speaker 1: 55:11

And quite frankly, that's not in our healthcare system. That's not feasible, that's not possible. I know most of my visits were like I got, if I was lucky, 15 minutes of FaceTime with my OB, and I think that's an over estimate. And so that's why I'm here trying to provide education. That's why Ari is here trying to provide education, because there needs to be more access to the information. People need to be making more informed decisions, they need to be knowing what questions to ask and they need to be taking the courses to be able to prepare themselves for the after part. Getting the baby out is important, and how you do that is important, but also it's important to know how to care for that baby, and so there's a lot that goes into and there's. I mean, back in the day we used to have the village. Help us, you know, with that, and now we have to recreate the village With strangers that we only know for however long we're in the hospital.

Speaker 2: 56:07

Yeah, I think that the more a person accesses available books, classes, just whatever education they can get, and doesn't rely on the relatively small amount that their healthcare provider has the time or expertise to provide, depending on their own education, then the more that the patient will be able to also advocate for themselves and their baby in a way that is well informed and not. I saw, I don't know what did the kids use.

Speaker 2: 56:42

Now I saw on TikTok, that blah, blah, blah, like I don't even know. I get people literally come into my office. They're like there's this thing on TikTok and now I'm convinced I need to be tested for it. Will you test me for it? And I'm like I mean I'll test you for it. But here's the five reasons, just right now, looking at you, that I don't think you need to worry about this. But okay, I mean I don't know if your insurance will pay for it. Like there's no code for me, there's no diagnostic code for worried cause she saw it on TikTok. But yeah, sure.

Speaker 1: 57:12

I'll test you.

Speaker 2: 57:15

So I think that that ability to advocate for oneself and I think this is becoming more of a thing in the last couple of decades that people understand that the pace of the healthcare environment and the staffing shortages and the workload of every single person who works in the hospital that comes in contact with that patient is such that there's no way for all of them to provide all the information. It's impossible because they're not your personal representative. You have to be your personal representative and prepare yourself with as much education as possible, not to be defensive, not because there's this onslaught of people trying to do things to you, but to better understand what is happening and to be able to feel empowered to ask those questions. I would also say that these days, everyone listening. It is, in my experience, normal and expected To get questions from patients clarifying questions. I do not take offense to that Right.

Speaker 2: 58:21

Occasionally it is sometimes annoying when someone comes and is like well, I researched it on Google and I'm like that's not what research is, because I am here with these five articles and a textbook and your Google search is not the same right, because you read it online all the people's opinions, and that's not the same as me coming in here. You asked a question is this medication that is clearly indicated to, for example I don't know prevent maternal seizure, gonna cause a problem for my breastfeeding newborn? And I come with all the resources that we use to make clinical decisions and you come back with, but I saw on Google that it might give him the runs. Okay, well, we're trying to prevent a seizure and brains don't get oxygen during seizures. We're trying to preserve brain function in the mother and your baby already has the runs. It's called newborn poop, right, basically, it's not gonna injure the baby. So we want.

Speaker 2: 59:24

Risks versus benefits are very important. It's fine to have questions and it's always appreciated if they are posed with curiosity and diplomacy and some amount of respect for the years of education, preparation and expertise that you're hopefully trusted. I mean you hired them, healthcare providers bring to the table, and so when I talk about advocating for yourself, it's also like I think sometimes there are certainly still some populations that are like you just don't you just don't, you just do what the doctor says. But that's not the norm, I would say, generally in American healthcare anymore, and certainly not with our generation of healthcare providers, right? So we're not gonna pat you on the nog and be like good job, honey. We're gonna be like what questions do you have? What have you read? What do you know about this? How can I help you understand it better? I want you to feel like you have enough information to make a decision you, at the very least, feel okay about, even if you don't love your options.

Speaker 1: 1:00:33

Yeah, was there anything that we didn't touch on that you wanted to talk about?

Speaker 2: 1:00:37

I think just the last thing I would leave everyone with is remember that the time in the hospital is a very short period of time of establishing breastfeeding and it takes about. We don't consider breastfeeding quote unquote well-established until at least six weeks. And then what I tell people is like that's when your baby is better at most of the time latching pretty well, right, most of the time. And then the first week really, because people will come in on day three and they'll be like he's doing so great every single time. And then they'll and we're like uh-huh. It's like the people are like I have the calmest baby and you're like uh-huh, he's 12 hours old. We'll see, maybe, maybe, but 12 hours old, he's just sleepy because he had a big long day. So when you think about like in those early days you'll get a really great latch and your confidence is amazing and literally you might have three really good latches in a row and the fourth latch is like seriously, kid, how do you like not know how to do this anymore? And your baby's like I mean, I'm a day old, I don't even remember what I did two hours ago. I don't, I don't know what I'm doing yet. So it will become over time. We hope more good latches more frequently and the occasional where you're like, oh, my God, really Like, oh, I love you so much. And also, ow, why did you latch that way? And you just go back to all your basics and remember that it's a process that you start. Of course you hope to start with your best foot forward in the hospital and then you're going to go home and do literally all the rest of it, which is why I emphasized at the beginning do your prep work, know who you're going to call If you're like I want a breastfeed connect with a lactation consultant who works in the community before you have your baby, so that you can be like okay, I want to get an appointment at about one week or two weeks just to make sure that I'm on the right track, because I'll see people who have been feeding with a shallow latch for like three weeks and don't have nipple pain. Sometimes that happens, there's no injury, but I take one look at that latch and I'm like no, they're like no, and then we can do the. You know, weigh the baby before, weigh the baby after the feed and they don't transfer very much and so it's like. It looks like they're feeding well, but they're not actually moving much milk, and over time that also presents a risk of low milk supply. You only have so much time to establish what will be your milk supply, and that is regulated physiologically by hormones.

Speaker 2: 1:03:18

There's nothing to be done once you're outside of that window other than try to prop it up with as much extra stimulation and occasionally, sometimes medication or something like that. Like if you can just get as much stimulation as possible, that is a good deep latch. In those first few weeks you set yourself up better. So know who you're going to call. Even if it's just for a checkup, your baby gets a checkup. If you see an OB, you probably don't get a checkup for six weeks and they're not looking at your breasts and by then your window has closed. So see the people who are the experts at breastfeeding.

Speaker 2: 1:03:52

If what you want is to breastfeed long term, so that you can make sure you're already off to a good start, and if you go home from the hospital pumping, we have to say this Kelly, if you are started pumping in the hospital, it's hopefully for reasons, but it doesn't mean you should pump for the rest of your life. Please don't keep pumping at the same rate. Go to like you need follow up. Before your six week appointment with your obstetric provider, you're going to show up with the most gigantic and gorged, ridiculous breasts and also so exhausted because all you do is feed and pump, and feed, and pump, and feed and pump, and it was never intended to be a long term thing. That was a short term solution to something going on in the hospital picture. You don't go home and keep doing it the same way. You need lactation support if you go home pumping or with a nipple shield. Please, please, please, okay.

Speaker 1: 1:04:45

Totally Well, Aria. As always, it has been quite a pleasure, it certainly always a lot. It's all good. That's why I love you.

Speaker 2: 1:04:55

I love coming on.

Speaker 1: 1:04:55

This is awesome, so fun. Well, thank you so much, and I'm really excited for this episode.

Speaker 2: 1:05:00

Thank you so much for having me and keep up these wonderful conversations.