Movement for Every Trimester: Adapting Your Routine as Your Body Changes

There have been so many fitness trends in my longish life. It’s hard to know what to believe sometimes. And when you’re thinking about pregnancy fitness, there are trends, but it also feels like a more high stakes situation that you probably want to get right. So what is the right thing to do?

In almost every pregnancy, there is general agreement that movement is good for you. Exercise can help you have a healthier pregnancy and feel better while you do. It’s a lot harder to figure out what type of exercise to do and how much is healthy. And there are different considerations depending on whether you’re already an athlete or are just starting to get into exercise.

A Brief History

A few decades ago and even more recently in the United States and in other cultures, pregnant women were treated with a lot of delicacy. It was thought that she should rest a lot and be taken care of. Manual labor might have been prohibited and exercise just wasn’t a thing. But a healthy pregnancy might have also included alcohol and cigarettes, so they may not have been getting everything right! I have a friend from eastern Europe who was horrified to see me using a tile saw during my first pregnancy. He was raised to believe that using electric and power tools was dangerous during pregnancy, so they were even discouraged from using appliances like a vacuum. Our children and future grandchildren are very lucky that we have learned more about how to be healthy during pregnancy.

But if you go back even further to biblical times, scholars were observing that women who were more active during pregnancy, such as people from the slave and servant classes, had easier deliveries. Those kinds of observations even led Aristotle to recommend exercise to ancient Greek aristocrats!

Benefits of Exercise

Besides being fun or the fact that it can make people feel better while they’re pregnant, research shows that a healthy amount of exercise can offer the following benefits:

• Decreased risk for high blood pressure and preeclampsia
• Decreased risk for gestational diabetes
• Better sleep. It can be hard to sleep well when pregnant, but when your body is strong and flexible, some of the pregnancy discomforts that might keep you awake will be gone. Good sleep during pregnancy lowers your risk for postpartum depression.
• Exercise during pregnancy also more directly lowers your risk for postpartum depression.
• As long as you are having an uncomplicated pregnancy, exercise can actually lower your risk for preterm birth.
• There may be a link to improved brain development for babies.
• Increased energy levels
• Improved mood
• Increases your chances for a complication free birth
• Exercising during pregnancy can help you maintain healthy levels of weight gain which can also assist in helping you return to or maintain a healthy weight after you give birth.
• Exercise in pregnancy can help you have a quicker and less complicated physical recovery postpartum, lowering your risks for pelvic floor disorders and diastasis recti.

How to do it

I interviewed Stacey Rikalo of femSTRONG for help with this article. She has been working as a fitness and strength trainer, specializing in the perinatal period. That means she works with folks who are pregnant or returning to exercise following birth. Based on her work, she knows that women can do a lot during pregnancy. They can maintain most of their routines and maintain a pretty high level of fitness. She usually works with athletes. These are people who were already doing a lot before becoming pregnant. They know a lot about fitness, what their bodies can handle, and are working with a trainer or coach to help them continue safely. Not everyone has that benefit. I highly recommend watching the recorded interview with Stacey below for a lot more detail, but here are some key takeaways that apply to most everyone:

• FIRST, talk to your health care provider. While it’s true that in general exercise is healthy and safe, there could be some risk factors that make it unsafe. Talk to your care provider about exercise to make sure you don’t have any risk factors that mean you need to be more careful.
• Walking counts! Walking is great exercise no matter your fitness level and is a safe entry level exercise for most everyone.
• Housework/yardwork count too! If you do a lot of physical activity for your job, or you’ve spent the day at home cleaning or doing yardwork and then don’t feel like doing exercise, DON’T! You already did. Exercise doesn’t have to be an organized routine. Moving your body while you clean or do home improvement projects is healthy and counts as exercise. Of course doing more is OK too, if you feel like it.
• Your aerobic and anaerobic capacity diminishes during pregnancy. This basically means that things that used to feel easy or manageable now feel more difficult. Maybe you used to be able to climb the stairs without feeling winded, but now you can’t. This is a normal part of being pregnant. So many of your energy resources are going to growing your baby and your placenta. You just don’t have as much fuel. It’s very reasonable not to push yourself to do the same amount you did before.
• You are TOO flexible. You have a hormone in your body during pregnancy that softens and loosens your connective tissues. That means you have a bigger range of motion in your joints. This is great for allowing your pelvis to shift and widen to accommodate your baby during pregnancy and for birth, but it also means that it’s easier to overdo it in other parts of your body too. When you’re stretching, try not to do the maximum that your joints are capable of. Stay a little below the edge so you don’t cause injury.
• You are less coordinated. This is not a judgment of you, and it’s not your fault. Your uterus is stretching to fit a larger and larger baby, so it has to expand forward and up out of its usual spot in your pelvis to fill your abdomen and then stick out in front! This means that your center of gravity changes dramatically. This is why most people do report feeling a lot more “clumsy” during pregnancy. This also means that you should be extra careful when exercising. For your safety, it might not be a good idea to do things that require a lot of coordination. For example, rock climbing without a pregnancy harness might not be an ideal choice.
• Body temperature is harder to regulate. Pregnancy causes a lot of strange physical changes, and one of them is a decreased ability to regulate your body temperature. This is especially useful information for my local area in Texas! It gets very hot here, and when you’re pregnant, it’s easier to overheat. Consider limiting the amount of time you spend outside in the heat, or do your workouts inside.
• Can you control your movements? If you can walk, run, lift, swim, etc. smoothly and with control, you’re probably doing ok. If your movements feel more choppy, forced, or out of control, you can consider backing off a little.
• Are you feeling heaviness “down there”? It can be a hard thing to understand until you feel it. Some people describe a feeling of fullness in the vagina. It might feel like swelling or bulging. However you describe it, you’ll probably be able to recognize it when you feel it….especially if you’re looking for it. This is the feeling of your pelvic floor organs being squished downward because of some pressure from your movement and probably because of the extra weight from the baby and the laxity in your connective tissues. So, pay attention when you’re exercising. If you notice that a particular movement causes this feeling of heaviness, you might consider doing less.
• Breathing well helps. Stacey talks a lot about breathing as a tool for helping you exercise safely. Your breathing muscle (diaphragm) can be useful for protecting your pelvic floor from injury. Breathing well itself can be a restorative and healthy movement that can also help prevent injury.

First Trimester

For safety, most types of exercise are fine! You don’t have too much going on yet related to your size or progress in pregnancy that can limit your mobility. However, you might not FEEL like doing much. Most people feel very tired and might have a lot of nausea and vomiting. These symptoms can definitely make it harder to exercise. That’s OK! I think you should give yourself permission to lie down if that’s what you need. Sleep if that’s what your body is asking for. Take it easy. Your reserves are being used right now. Your body is deciding what to do about the “invader” that has taken hold. It’s asking you to save your energy to fight off a potential threat OR save it up to give your baby the best start. If you feel up to it, you probably have the most freedom to do what you want for exercise during the first trimester. Move however you can, and remember that some gentle exercise might actually help you feel better.

Second Trimester

Most people feel better during the second trimester. I want to recognize that this is NOT true for everybody. Most people though are feeling less tired, more hungry, and starting to get that “pregnancy glow” that people talk about. You’re starting to see a bigger, rounder belly, and hormones are stabilizing a little. You’ll likely still have other symptoms that come up during the second trimester like heartburn or constipation or hip pain, but they just might not be the sorts of symptoms that make exercise impossible. So, you might start to feel more ready to exercise, AND THEN you might notice that it doesn’t feel the same or you have to modify things. That is normal. It’s a good idea to listen to your body when you notice these differences. Do less when you need to. Pay attention to the “HOW TO DO IT” section above. The second trimester is the point in pregnancy where it might be most important to follow some basic guidelines so you don’t overdo it. On top of all of the other things already covered, your abdominal muscles will begin to separate, and you want to make sure you’re guarding that area. That might mean changing the way you are doing core strengthening. Stacey loves to recommend “carries” during the second trimester.

I also want to recognize that many athletes out there aren’t so good at “listening to their bodies”. This is NOT a criticism! It just means that intense training often involves pushing past a threshold. Athletes have to work harder, push themselves, feel the burn. Most of the time, this is a great way to get stronger, but in pregnancy, your body might actually be trying to give you warning signs. If you are an athlete, try not to ignore those signals, or give yourself some great boundaries to stay within for safety.

Third Trimester

When you reach your third trimester, you might still be feeling great, but eventually most people start to feel more heavy and less energetic. A lot of people feel like winding down some and conserving energy in preparation for birth and early parenting. You might also be having some new pregnancy symptoms that make things harder. You are carrying a lot of extra weight. Your baby might weigh 4-7 pounds, your placenta probably weighs 1-2 pounds, you’re carrying about 2 pounds of amniotic fluid, a pound of extra breast tissue, 3 lbs of additional blood, a couple of extra pounds of uterine muscle, about 4 lbs of extra water, and about 8lbs of maternal fat stores. That basic gain alone is 20-30 extra pounds! For the fitness fanatics reading this, imagine carrying around a weight that size at all times. You are using energy that you weren’t using before.

You may also need to do more modification in your exercise related to the size of your belly. It’s pretty large in the third trimester, and can definitely be an obstacle to some of the things you might be used to doing. You also might be feeling more heaviness in the pelvis during the third trimester which is a good indication that you should do less.

Pelvic floor strengthening is recommended for many people, especially in the first and second trimesters, but the third trimester is a good time to focus on learning how to relax and soften in the pelvic floor.

I am most definitely not a fitness expert. In my own pregnancies I walked and did prenatal yoga. I can definitely recommend that program, although it’s definitely not the perfect program for everyone! Besides the morning sickness, I felt pretty good. I was strong and had a fair amount of energy. I did learn that my pelvic floor needed some guarding though! I had some injury to my pelvic floor after my second birth. I saw a pelvic floor physical therapist for help, but I sometimes wonder if I might have prevented some of the injury by seeking that help during pregnancy. Seeing a pelvic floor physical therapist is a great idea for anyone who wants to work on pelvic floor strengthening, control, AND softening. It’s also a good idea to talk to your pelvic floor physical therapist about your exercise program. They can help you ensure safety for your pelvic floor while getting the most from your workouts.

I was very happy to have guidance from Stacey in writing this article. Please watch the video to see more and find out about some of Stacey’s favorite resources related to exercise during pregnancy. You can also look for two more follow up articles and recordings discussing exercise AFTER birth!

References:

Physical Activity During Pregnancy – Past and Present – PMC

Breaking boundaries: A chronology with future directions of women in exercise physiology research, centred on pregnancy – ScienceDirect

A comparison of beliefs about exercise during pregnancy between Chinese and Australian pregnant women – PMC

Antenatal taboos among Chinese women in Hong Kong – ScienceDirect

If you are or have ever been pregnant, you probably know exactly what pregnancy brain is. But if you try to describe it to someone who has never heard of it, you might not be able to! It is actually a common pregnancy side effect that is poorly understood.

What Pregnancy Brain Feels Like

A lot of people don’t recognize that they feel different. Other people notice big changes. You might notice some or ALL of the following:

• Forgetfulness
• Loss of focus
• Trouble concentrating
• Clumsiness
• Slow thinking or response time
• Brain fog

Sometimes it’s really hard to describe. Some people report that they just don’t feel like themselves. Things might feel harder, or time might feel like it’s moving more slowly or quickly.

What Pregnancy Brain Looks Like

Even when you might not notice anything different, other people around you might! I remember being pregnant for the first time and realizing that my job had gotten a lot easier. It seemed like there just wasn’t much work to do anymore. Later, my boss told me that she just kept the work away from me, because I was making so many mistakes! I didn’t realize I was making those mistakes, but that was a little bit of a wake-up call for me, and I started to notice some of the other changes. I was definitely more clumsy, and just had a harder time keeping my thoughts organized. I’ve heard plenty of stories about people doing strange things during pregnancy. Some of my favorites:

• Finding their phone in the refrigerator
• Leaving the car running in the driveway all night
• Putting multiple cribs on the baby registry
• Forgetting their own baby shower!

How the Brain Changes

This is going to sound a little bit scary, but there is an actual physical reason for pregnancy brain. Saying “it’s hormonal” is an oversimplification and an understatement. That is definitely happening, but there’s more.

Researchers have been studying the pregnant brain using MRI scans. They have discovered some very interesting changes.

• The actual volume of the brain decreases significantly. You actually have less gray matter during pregnancy! So you can literally say that you have less brain. That’s the part that sounds a little scary, and also like it might account for the pregnancy brain symptoms.
• There is an increase in white matter throughout the brain during pregnancy. White matter increases are also observed when someone is developing a new skill such as learning an instrument. I like to think that the brain is restructuring during pregnancy to help us be great parents!
• There is also an increase in the volumes of cerebrospinal fluid in the C-shaped cavities called lateral ventricles in the brain.
• Some of these changes are at least partly permanent, while others go back to baseline after pregnancy.

The Role of Hormones in Pregnancy Brain

It does seem like hormones are the trigger for these brain changes. Your steroid hormone levels, including estrogen and progesterone can increase by 100 to 1,000 percent during pregnancy. These big hormonal increases definitely seem to be what cause the changes in the brain. So in that way, pregnancy brain is hormonal. But it’s more than that. The hormonal changes can have a big impact on the way you feel and how you operate, but add the actual change in brain volume to that, and you get pregnancy brain.

Managing Pregnancy Brain

Here are some tips to help you manage pregnancy brain:

• Use recurring phone alarms. Did you know you can probably even speak the command into your phone? “Set a daily alarm to take my vitamins at 8am.”
• Do double checks. For example, before you leave the house, have a checklist. Did you do everything? Do you have everything?
  • Turn off lights
  • Turn off stove
  • Phone
  • Keys
  • Shopping list
  • Etc.
• Pack separate bags for things and keep them near your door or wherever you keep your keys. If you’re going to the gym, take your gym bag. If you’re going to work, take your work bag. It can be pre-packed with everything you need for that activity so you don’t forget something as you’re rushing out the door. 
• Ask someone else to double check things for you, especially at work! You might have a sympathetic co-worker who can read over your emails before you send them, or double check your work before you finalize things. 
• Give yourself extra space. Recognize that your spatial awareness and judgment might be a little off.  To avoid bumping into people and things, you might just exaggerate the space you give. 
• Set up routines or do some “coupling”. To avoid forgetting things, try adding things into your already well-established routines (the things you never forget). For example, start keeping a glass for water next to your toothbrush. Every time you brush your teeth, this can remind you to drink a glass of water. You have “coupled” teeth brushing with water drinking. Maybe you can couple your pelvic floor physical therapy with watching your favorite show. 

What Does This Mean For YOU?

The restructuring of your brain during pregnancy happens in a certain order. Certain things happen in the second trimester, others in the third. I like to think this means that you get time to adapt, so you might even be thinking more clearly at the end of pregnancy. Science has been able to see WHAT is happening in there, but they can only guess at WHY. I think it’s fun to make up those reasons for ourselves now. I like to think that these brain changes are providing us with necessary coping mechanisms. Our brains have to reorganize and restructure to help us deal with what’s happening in our bodies, and also to help us prepare to care for a small vulnerable baby. It’s a brain workout in preparation for parenthood.

I think it’s also great to remember that pregnancy is a big deal. Your body is doing some very amazing and challenging things, even while you’re just sitting or sleeping. I think this means that you should take it easy on yourself. It’s ok to do a little less of the things you were doing before. If you’re making a lot of mistakes at work like I did, ask about lightening your workload a little or finding things to do that are less critical or delicate. Don’t beat yourself up when you make mistakes, forget things, or lose something. This is just part of the deal when you’re growing a baby. Your body is strong and wise and knows what it’s doing. You might even embrace it and write down the bloopers so you can laugh about it later.

References:

Brain changes observed during pregnancy | National Institutes of Health (NIH)

Neuroanatomical changes observed over the course of a human pregnancy – PMC

Change in the Brain’s White Matter: The role of the brain’s white matter in active learning and memory may be underestimated – PMC

A breastfeeding strike is when a baby refuses to breastfeed. Some people might also indicate that their baby “self-weaned”. These things can happen… sort of. But it’s really important to understand the differences and how to manage those situations, especially if you want to continue breastfeeding.

Understanding and Overcoming Nursing Strikes

A baby will sometimes refuse to breastfeed for a lot of reasons. It’s usually abrupt and can take you by surprise. When this happens, it can be so frustrating and disheartening. You might have worked so hard to finally achieve breastfeeding success, and then suddenly your baby doesn’t want it anymore?! It can be hard not to take it personally.

Please feel confident that your baby still needs you and wants you. A nursing strike does not usually mean it’s time to wean! There’s just something going on that needs to be discovered. Here are some reasons a baby might suddenly refuse the breast:

• If you changed the products you use and smell different to your baby.
• If there is a lot of stress in the home.
• If there are changes in routine.
• If the baby is suddenly spending a lot more time with another caregiver.
• If you’ve been eating something new that adds a lot of flavor to your milk supply.
• If the baby is sick.
• If the baby is going through a big developmental milestone like cutting a tooth or learning to roll over.
• If your baby bit you and you had a big reaction that might have scared them.
• If you are pregnant.
• If you have an overactive letdown.
• If you have a lower milk supply for some reason, like your ovulation returns.
• If your baby is in pain.
• If your baby has developed a preference for the bottle.
• If your baby is distracted by too many stimulating things in the environment.

Some of these things might be easy to recognize and fix, or you know they will pass. If you change back to your old lotion or stop eating tons of chicken curry, the baby might suddenly return to the breast very happily.

Some of these things might not be so easy to determine or address, so here are some tips that might be helpful:

• If you have a very powerful milk ejection or “overactive letdown”, try some of the techniques recommended in this article to help your baby feed more easily.
• If you suspect that your baby has developed a bottle preference, try making bottle-feeding less easy. Many babies develop a preference for the bottle because the milk comes out more easily. They just don’t have to work as hard! When this happens, you can back up and try again. Use the recommended methods to make bottle feeding more like breastfeeding.
• A nipple shield might be helpful if your baby has developed a strong preference for the bottle. If the recommendation above isn’t quite enough, you might try this in combination. This can be a temporary bridge back to direct breastfeeding.
• If you’re having low milk supply issues, it could be a temporary issue caused by a hormonal change like the return of ovulation. If that’s the case, it will hopefully normalize quickly and your baby can feed again. If you have low milk supply caused by other factors, you may need to do some things to increase your milk supply.
• Lots of skin-to-skin time. Staying very closely connected to your baby when you’re together might help your baby back to the breast.
  • Try using a baby carrier to keep your baby close.
  • Try sharing a warm bath with your baby.
  • Do all feedings against your bare chest. You want your baby to have positive associations with the breast even if that means getting a bottle. Sometimes you can put the bottle close to your nipple, then make the switch!
• Movement might help. Babies tend to like to be walked, rocked, patted, bounced, or swayed. If you’re wearing your baby in a carrier, try nursing there after a little walking or dancing. Or try bouncing a little or patting your baby’s bottom before attempting to latch at the breast.
• Put some drops of breast milk on your nipple so the baby gets a taste and might continue.
• If your baby is eating some solid foods, try smearing a little of their favorite food on your nipple!
• Keep it positive. Don’t force your baby to the breast if they are unhappy about it. You want to maintain positive associations with breastfeeding.
• Attempt to feed a happy or drowsy baby. Sometimes, when a baby is very relaxed or even partly asleep, they’ll latch on. It’s not usually a good idea to wait until the baby is very hungry or overstimulated. They might be too grumpy to accept at that point.
• Set up a quiet and distraction-free environment for feeding your baby.
• Try nursing in different positions. Sometimes it just takes a little change!

However long a nursing strike lasts, it’s also important to continue to pump at the times your baby would have nursed. When you can maintain that routine, you’ll continue to have pumped milk to feed your baby, and you’ll also maintain your milk supply so that when the strike is over, you can continue breastfeeding.

How to Recognize When Your Baby is Self-weaning

A nursing strike is usually sudden, too soon, and temporary. When a baby self-weans, it looks different and it happens later. A baby might gradually start to wean, but it can take many months before breastfeeding stops completely. This usually starts when a baby is between 18 and 24 months of age, but can happen a little sooner.

The baby won’t just suddenly refuse the breast completely. You might first notice that your baby is just nursing a little less often, or that the breastfeeding sessions are a little bit shorter. They might get more easily distracted during breastfeeding. They show more interest in and start eating more solid foods. Over time, eight breastfeeding sessions per day whittles down to just three, two, then one. Where it used to take 20 minutes for your baby to finish a breastmilk meal, it’s now only a two minute snack break.

Self-weaning is a gradual process that happens over many months and can be hard to recognize at first. I didn’t notice it was happening until I realized that I wasn’t nursing at all in between naps and bedtime anymore! When the baby takes the lead and weaning happens gradually, it can be a very easy process. You might not have any issues with breast pain, engorgement, or leaking, and your baby won’t have to go through a difficult transition.

If you notice that your baby is self-weaning, and you want to continue to breastfeed more, you can offer more often, or use some of the tips in the list above.

If you notice that your baby is self-weaning and you’re ready too, you can also encourage the weaning by doing a few simple things:

• Don’t offer the breast. Let your baby ask.
• If you’ve been using nursing to get your baby to sleep, try doing something different at naptime. Does your baby fall asleep in the baby carrier or the stroller? Does your baby like to cuddle or be rocked? Will they fall asleep when you read a story?
• If you usually breastfeed when your baby is waking up, try offering a snack instead.

However and why-ever your baby stops breastfeeding, it’s important to support your bond with plenty of cuddle and connection time. If your baby is self-weaning, this connection will help you both through the transition. If your baby is just on a nursing strike, that connection might help you discover what is causing the strike and bring your baby back to the breast. Your bond with your baby is what matters most!

Reference:

Why Baby May Suddenly Refuse the Breast

I love to talk about birth plans, write about birth plans, and help people make birth plans. You’ve probably heard about birth plans. What a lot of people don’t often hear about are postpartum plans. As much as I love birth plans, I might argue that postpartum planning is equally, if not more, important.

What is Postpartum Planning?

To simplify, it’s just the process of thinking about and planning what your postpartum recovery time will be like. What happens AFTER birth? In the recorded interview below with postpartum doula, Amy Tucker, she describes a postpartum plan as a continuation of the birth plan. She recommends going through a similar process in making this plan as you would a birth plan. It takes a lot of thought and many conversations with loved ones and partners. You want to spend some real time and energy on this. It might sound like an unpleasant homework assignment, but it might be as bad as you think, and will likely save you so much frustration and stress later on. You want to prepare yourself to have the most peaceful and restorative postpartum experience possible. This can help set you up for a lifetime of better health and parenting.

Why is it Important?

When you are pregnant, you usually get to be the center of attention. Your needs and your health become top priority. You get parties and gifts, and people hold the door open for you more often. People might tell you you’re beautiful and “glowing”, and you might even feel like that! After the baby comes, things change. Most of the attention shifts to the baby. Your attention has to shift a lot, but it’s likely true for the people around you too. You might not have much support or encouragement at a time you need it the most. I like to suggest that your most important job is taking care of your baby, but everyone else should be taking care of you! Instead of offering to hold the baby for you, a friend or family member could offer to bring you a cup of tea or fold a load of laundry.

Your body is doing some BIG healing from pregnancy and birth, and it’s important to rest and support that healing. In some other cultures, there are specific recommendations and rituals related to postpartum healing. Communities are set up to provide care and feeding for the postpartum parent. They continue to be top priority. Unfortunately, in our modern Western culture, the expectation is that we hurry up and get back to our bodies and life as usual… only new and improved and WITH a new baby. This is not real. Even if you can fit into your jeans and get things done, you might not be truly healed on the inside. I mean your organs and soft tissues, AND your emotional state.

After birth, most people do experience some big changes in their mental health. Even when things are “normal”, postpartum emotions can be hard to manage. You might not feel like yourself for at least a few weeks. Most people feel overwhelmed, weepy, irritable, tired, or foggy at least some of the time. This is normal, but it can also become something more difficult to manage especially when you don’t get proper care or if you have some risk factors. You need help from others, and you also need to learn how to take care of yourself.

Like Amy says in the interview, a family is a system. When one part of the system is not functioning well, the whole system suffers. Your baby is an important part of that system, and so are you. Postpartum planning can help you be a healthy part of that system.

How to Make a Postpartum Plan

You can just sit down and make a list. You might get everything covered, or you might not. To make the most of your efforts, Amy recommends following some guidelines when you’re creating a postpartum plan. If you want even more guidance, the Life with Baby Workbook is a great tool!

• Talk about it. You’ll want to have some conversations with the people who will be supporting you and your family. Find out how they intend to help, or ask for what you think you’ll need. It’s important to figure out what your resources are before you make a plan.
• Write it down. Once you have a better idea of what is available to you, write out many paragraphs, or an outline, or a list. You might organize it or just rough it. The point is to get everything down on paper. You can refine it later.
• Get feedback. Once you have your document, you might want to go over it with people who can offer encouragement or helpful suggestions. Your sister might notice that you didn’t ask for help with meals on your plan and might be able to give you some suggestions for that.
• Share it. Once you feel good about the document, you can share it with all the people who might be supporting you in the postpartum period. This can include medical professionals and doulas, but also your partner and any family or friends who might be spending time with you after you get home with your baby.
• Remember that this is a living document. This is not a POSTPARTUM PLAN. (period) This is a postpartum plan… You can and should change your mind about some things. It’s so important to be flexible. When you’re actually in the postpartum period, you might notice that you need more than you thought, or just different things. Change it! People can change a lot from pregnancy to postpartum. Your expectations about what it would be like to have a new baby might be completely different from your reality. That’s OK. I would even say that it’s a great character asset to be able to say, “This is not what I thought I would do. Oh well, I guess I need to adjust!” You might have planned to use cloth diapers, but then feel like you want to switch to disposable. Or maybe you thought you’d want your baby in their own room right away, and now you want your baby right next to your bed, or even in your bed. This happens to all parents. No one has it all figured out at the beginning. Parenting is a journey of learning. We never stop learning new things about our kids and about ourselves. It’s part of the beauty.
• Remember that this is just a guideline. So many of us enter pregnancy with the desire to control our experiences and our lives. We can even start to feel some sense of control when things go well. At some point, we all have to come to realize that control is an illusion. If you think you have it, it’s just luck. But luck runs out at some point, and you have to recognize that you can’t actually control everything. Having children can expedite this understanding for a lot of parents! These little people have their own ideas about life and how they want to do things. Postpartum recovery is the same. It’s impossible to predict what might happen during birth and during our recovery. A postpartum plan can’t give you absolute control, but it can give you a framework and something to refer to for options and help when things don’t go exactly as planned. It can’t offer you total control, but it can offer you direction.

What to Include on a Postpartum Plan

If you’d like to be very organized with your document, you might divide your list into sections, categories, or buckets as Amy calls them. It can be helpful to start with this framework even when you’re just having conversations or organizing your thoughts.

• Your emotional health/support: Consider what you might go through emotionally after giving birth. Do you have a history of or any risk factors for a mood disorder? How do you handle difficult emotions? What do you need to support your mental health?
• Everyday basics: Think about the stuff you do on a daily or weekly basis. Do you wash dishes, do laundry, walk the dogs, eat, sleep, stretch, take medicine, make and keep appointments, etc, etc, etc. What about during postpartum recovery? Remembering that you’ll want to take care of your baby and let other people take care of you and the rest, who can you enlist to help with some or all of these things?
• Transitional preferences: If you have a co-parent/partner, it’s really important to figure out these things together on a postpartum plan. Do you plan to stay home with the baby for some amount of time? What about your partner? What happens when you or your partner go back to work? What does this mean for your planning, breastfeeding, childcare, etc.?
• Communication/relationships: It can be so hard to ask for help, but a postpartum plan is a great way to organize your needs and then communicate them. It can also be a lot easier to do this before the baby arrives when you’re not so overwhelmed that it’s much harder to ask for help. Since you’ll share that plan with your support system ahead of time, hopefully, they can step up and provide the help and support you need when the time comes. You might also need to ask for more, or remind people. You might have very strong emotions that make communication difficult. Your postpartum plan can provide some direction for you in this way too. You might set up some time for you and your partner to meet and talk or connect on a regular basis. You might include some information about how you would best like to communicate needs or frustrations with your partner during this time. Maybe you’ll write things down instead of speaking. Maybe you choose a “safe word” to use when you’re feeling very overwhelmed so your partner can understand that they might not be doing something especially wrong, but that you’re feeling especially bad. Then they can be prepared to be extra compassionate. You might plan for your partner to handle the logistics of other people’s involvement in your care (asking for help and setting it up). Your partner might help by communicating and holding boundaries with family members or friends. Setting these boundaries in a postpartum plan is also a really important thing to do! You might love to have visitors, or you might not. In that case, you might communicate something like, “Thank you so much for bringing us a meal. In the first couple of weeks, we plan to lay low and recover and minimize visits, so please drop it on the front porch and send a quick text. We’ll follow up with you soon so you can meet the baby!”
• Resources: This last section of a postpartum plan is where you put all the phone numbers and information for resources you think you might need. I love to recommend having a lactation consultant’s phone number readily available in case you need some help with breastfeeding. Breastfeeding Success has a 24/7 hotline that you can use for some quick help or to schedule an appointment! 512-808-0237. You might have some names and phone numbers for a therapist, the pediatrician, your acupuncturist, a postpartum doula, neighbors, etc.

Self-care for You

First, I encourage you to lower your expectations related to self-care. I don’t mean that you shouldn’t do anything, just change what you expect to do and how much. You’re not likely going to want to take vacations or go to a spa or lots of your favorite fitness classes. You might not be going to happy hours with friends or co-workers for a while. You might not even get to church or take nice long walks or baths. If these sorts of things were part of your self-care routine before, it’s ok to let those go temporarily. Or you might even find that some of those things can change forever! You are not “giving up” when you modify your life to work better as a new parent.

Second, it’s important to have some self-compassion. It will help you to learn to be OK with doing “less”. The fact is that it might look like doing less, but you’re actually doing as much or more. It just looks different. When you are recovering from pregnancy and birth, your body is making a heroic effort to heal. Your uterus needs to shrink and move back into its proper position. Your other organs need to shift back into place. Muscles, ligaments, and tendons need to shorten and heal. Your skin and bones need to readjust, and your hormones will need time to rebalance. On top of all of that, you’re learning how to do something huge… parenting. A newborn is a very special little human with high needs and a high level of dependency on YOU. It might look like doing “less” when you’re lying in bed holding your baby skin-to-skin, but you’re actually encouraging your milk supply to stabilize, your uterus to shrink, bleeding to lessen, hormones to rebalance, and your baby to adjust their bodily functions like body temperature and blood sugar levels, to being outside the womb. When you can put it that way to yourself, you might recognize that you’re doing pretty big things “just lying there”. When you’re able to be compassionate with yourself, you will likely feel better and heal better. Remind yourself that “productivity” will look different temporarily, and when you can allow this time to fully heal, you’ll be better off in the long run.

Here are some good examples of postpartum self-care, but this might look a little different for every person. Just do what works for you. Whatever you choose, integrate the practices into your daily routines so they become automatic, and you don’t forget or skip it.

• Check in with how you’re feeling. You might do this each time you feed your baby, or after every diaper change. You might also set recurring alarms on your phone to do this every 2-3 hours. Do you need to use the bathroom? Are you hungry? Then make sure to meet those needs!
• Make yourself a cup of tea or a special drink before you sit down to feed your baby.
• Rinse your face and put on some lotion after you feed your baby.
• Do a few simple stretches or some diaphragmatic breathing exercises at every diaper change.
• Eat really nutritious but delicious meals. This is best when you can let other people make them for you! And don’t skip meals.
• Take 10 minutes to lie down and listen to some alpha and theta frequency binaural sounds for relaxation.
• Take 10 minutes to lie down and meditate or pray.
• Try to accept help with your baby so you can sleep. Listen to your body and take the opportunity to do this whenever it feels like you might be able to fall asleep.
• Have a conversation with your partner or support person about setting up a regular time each day for you to have a break from baby care. It might be just 30 minutes or an hour. Use that time to do something that supports your mental health. You might read a book, take a short walk (if you’re at that point in your healing), take a bath, have a cup of coffee with your neighbor, etc.
• It’s also OK to ask someone else to take care of your baby for a little while because you really want to fold a basket of laundry or do some dishes. If that makes you feel good, that’s ok! When I was recovering, I had helpers to do those things, and I let them most of the time. But every once in a while, I just wanted to do a simple household chore. It made me feel a little more grounded. As long as you’re not doing so much of this to be holding up your recovery, that can be self-care too.

Final Takeaway

In the recorded interview, Amy makes sure to emphasize something really important for ALL parents. She reminds us that EVERYONE has to learn to be a parent. I’ll even add to that and say that we have to learn how to be a parent again for every child we have. It might not be as much of a struggle, but every child is different. Every new child is a learning experience. It WILL feel like a struggle and an adjustment at times. This is absolutely normal. No one has this all figured out when they become a parent. We are all learning at all times along the way.

(Trigger warning: discussion of prematurity and NICU stays)

A NICU is a Neonatal Intensive Care Unit. These special units in the hospital are for newborn babies who need some extra care. Not all hospitals have a NICU, and they also come in different levels. No parent hopes that their newborn needs time in the NICU, but it happens. Fortunately, most of the time, a NICU stay is recommended because a baby needs a little bit of extra support but is overall healthy.

NICU Levels Explained

Most hospitals have either a Level 2 or Level 3 NICU. That means that they can support babies who are born prematurely, or have another condition that means they need extra support before they’re ready to go home. A level 3 NICU can support very early preemies or sick and fragile babies, but they might also have very healthy full term newborns who just need a little help regulating their blood sugars or to be treated for jaundice. If you are pregnant and in a situation where you know your baby is at high risk for needing high level NICU care, you might want to learn about the NICU at your hospital. The table below shows more detail about what the NICU levels mean.

Adjusting Expectations

NICU stays usually come as a surprise, and many parents feel overwhelmed and anxious when they’re told their baby needs to transfer to the NICU. Most parents feel shocked and don’t know what to do or what to expect. You probably had visions of what it would be like to meet your baby for the first time, and a NICU stay means you have to be separated and you don’t get to have your vision realized. You may not get to have that “Golden Hour” with your new baby that you were hoping for. You will have to adjust your expectations, but that can be so hard. When plans change, know that you can still find ways to connect with your baby. There are still things that you can do to provide for your baby and be there for them.

A Day in the NICU

The birth parent will still be a hospital patient, and in most cases, will be in a different part of the hospital. Some NICUs now have private rooms where parents and babies can stay together, but most of the time, the birth parent will stay in the postpartum room until they are discharged. This separation can be very difficult. Parents can visit their babies, but for the birth parent, it means having to get out of bed and get help to get there. It’s a good idea for parents to have a conversation about how they might want to handle a NICU stay. If Mom can’t get to the NICU right away, should Dad go to be with the baby? With smart phones, you can have a video call to stay in touch that way. Later, both parents will be able to visit with their baby.

By most accounts, NICU nurses, lactation consultants, and staff members are especially compassionate and accommodating. Parents are usually encouraged to be at their baby’s side whenever they want. When the baby is stable enough, you may even be encouraged to hold your baby skin-to-skin. Both parents can provide this kind of care. There is plenty of evidence showing the benefits of skin-to-skin care for even very fragile newborns in the NICU. Breastfeeding rates and breastmilk supply are improved, the baby’s vital signs can improve, and it’s even associated with improved neurodevelopment as the baby matures. The NICU staff can help you do this safely. They understand that you are going through a very difficult time and you might feel nervous about holding your baby. They also understand that your baby benefits from having you close.

So you might be holding or touching your baby, or just being there next to your baby. Some parents spend the day at their baby’s bedside while reading or watching TV or even getting some work done. Some parents spend time pumping milk for their baby at the bedside. A lot of parents feel they are most successful with pumping when they can be close to their baby

Once the birth parent is discharged from the hospital, they may spend more or less time in the NICU depending on how they feel and their circumstances. It also might depend on the type of NICU available. If the baby has a private room and a bed is provided for parents, some parents choose to spend most of their time at the hospital.

A nurse will probably teach you about your baby’s basic care needs and even encourage you to help with their care. Most NICUs also have a lactation consultant on staff who can help you with your feeding goals.

Breastmilk in the NICU

Breastmilk is great for all babies, but it’s especially beneficial for premature and sick babies. Milk Banks collect donor human milk with the primary goal of supplying NICUs with human milk as medicine for the most vulnerable babies. Breastmilk can mean the difference between life and death for these fragile babies. While any human breast milk is medicinal for these babies, your own milk is actually even a step above. It is especially designed to meet your baby’s very specific needs. You might be able to give your baby breastmilk directly from your breast right away, but that’s unusual in the NICU. Most often, babies are too small or weak or sick to do that. It takes a lot of energy and strength to get milk from a breast. There are many ways to give babies breastmilk:

• Gavage feeding: When babies are very small and the concern is getting them to grow, it’s important that they not burn any more calories than absolutely necessary. In this case, babies are fed breastmilk through a gavage so they don’t have to suck and swallow, burning precious calories. Gavage feeding is when they insert a very small tube into the baby’s nose and feed it down all the way into the baby’s stomach. The milk is pushed through the tube using a syringe. A registered dietician calculates the amount of milk needed for your baby to grow.
• Gavage feeding at the breast: Once a baby is strong enough to do a little work, they might be given their gavage feeding at the breast. The baby is encouraged to smell and touch and lick the breast while the milk is pushed into the tube. They can start to associate the feeling of a full belly with being at the breast and can more easily graduate to direct breastfeeding that way.
• Combination feeding: A baby might still get fed through the gavage, but may also be encouraged to try direct breastfeeding or bottle feeding for some snacks or meals. Sometimes, a baby might even get small amounts of breastmilk from a sponge, cup, spoon, or syringe.
• Bottle feeding: It’s important not to let a baby become too comfortable drinking from a bottle, so a slow-flow nipple is usually tried first. The baby has to do some work to get the milk out, making it more similar to breastfeeding. You may also learn how to position your baby so that the milk in the bottle doesn’t come out too quickly. A lactation consultant might teach you to feed your baby in a side lying position.

Exclusive Breastfeeding

The goal in the NICU is to get the baby feeding at the breast as often as possible. Most babies leave the NICU before they are at the point of exclusive breastfeeding. Most of the time, babies leave the NICU getting some or even most of their milk from the breast, but are still supplementing with pumped milk, donor milk, or formula in a bottle. It’s very possible to continue to increase the amount of milk your baby gets directly from the breast until supplementation is no longer needed. Some families struggle to do this. It can be hard to imagine changing something that’s working, so it’s important to get some support from a lactation consultant outside of the hospital. With a little help, many babies graduate from the NICU and go on to breastfeed exclusively.

Lactation Consultant in the NICU

A lactation consultant should visit with you to talk about your options for feeding your baby and provide support along the way. This will usually be a lactation consultant who works primarily in the NICU. They have some special knowledge and skills for helping these special babies and families achieve their breastfeeding goals. On the first day, you’ll probably get some good education about breastmilk, and how you might be able to provide it for your baby. The consultant might get you a hospital grade pump and get you started on a schedule for pumping. The milk you pump can be given to your baby immediately, but it’s also important to pump on a specific schedule so that you continue to make milk and develop a good milk supply. Most of the time, you’ll pump on a schedule similar to how a newborn baby would eat at the breast. They usually recommend pumping at least 8 times a day, with at least one of those sessions being in the middle of the night or VERY early morning, just like a newborn would do.

If your baby is strong enough to breastfeed directly, your lactation consultant can assess that and help you get started.

If your goal is to eventually breastfeed exclusively, there are ways to start introducing the breast so that your baby can get familiar with it and practice some of the skills they’ll eventually need to breastfeed. A lactation consultant can give you all the tools and support you’ll need to meet your goals. Even more than that, a lactation consultant can be a counselor and even a friend.

The NICU staff may come to feel like a second family. They are usually very compassionate and supportive. They are there because they love to help these tiny babies grow and thrive. They understand how the parents are likely feeling, and they want to make you feel included as part of your baby’s care team and become the leader of that team. They want to help you feel empowered to feed and take care of your baby so you feel ready to go home and do it on your own. It’s important to listen and participate while your baby is in the NICU.

Benefits of Breastfeeding

The benefits of breastmilk to the babies are very clear. It’s medicine. It helps them heal, grow, digest food effectively, and fight off infections. Providing breastmilk can also have benefits for parents. It can be psychologically very difficult to be the parent of a NICU baby. As the birth parent, you’ll be doing your own physical recovery on top of your worries and concerns for your baby’s well-being. You might feel afraid, exhausted, overwhelmed, confused, lost, and even guilty. You might worry that you did something wrong, and that it’s your fault that your baby is in the NICU. These are all very normal feelings. It is not your fault, but you do have the ability to help. It might not feel like it at first. There is a big staff of qualified health care professionals looking after your baby, but they can’t do everything.

For many mothers, pumping breastmilk for their babies from their own recovery room is a way to feel helpful, and is extremely helpful, even vital. Especially when parents can’t be with their babies, it can feel very empowering to provide them with the milk they need to get stronger. Then when you’re with your baby, having skin-to-skin time and learning to breastfeed together, you’re giving them, and yourself, even more strength and comfort.

Benefits of Support

Having a baby in the NICU can be one of the most challenging situations in a person’s life. You need support. In addition to the staff and your own support network of family and friends, most NICUs have peer support groups that they can put you in touch with. Hand to Hold is the group that provides services for NICU families in my local hospital. These volunteers are often former NICU parents who understand the difficulties and special needs of the parents who are caring for babies in the NICU. You may find a lot of comfort in talking to these parents and even other current NICU parents.

As hard as it is to have a baby in the NICU, it’s great to remember that most of the babies leave healthy and strong and go on to live long and productive lives. NICU parents also become stronger and wiser having gone through that experience so early in their parenting. There’s a lot of sadness and hardship in the NICU, but there is also a lot of joy and celebration.

Resources

Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU | Pediatrics | American Academy of Pediatrics

Skin-to-skin ‘kangaroo care’ found to boost neurodevelopment in preemies

(Trigger warning: some discussion of premature birth, stillbirth, and maternal/infant mortality)

Statistics was my most AND least favorite class in college. I had to take this class for my major, but I wanted nothing to do with anything related to math. Why would I need math as a Psychology major? It turned out to mean a lot of complicated math, but it was also the most eye opening class I’ve ever taken. Statistics can be used for good, but you have to know how to read them.

Why Statistics Are Important

Statistics can tell us a lot about our world. We can find out about how similar we are (or aren’t) to other people related to how we might expect to spend money, time, and effort. It can be interesting to read about those things, but for many pregnant people, the statistics they look for are about safety. You might hear the word “risk” tossed around a lot. People are categorized as either having a “high risk” or “low risk” pregnancy. What about medium risk? Can we get at least one more category?

When you are making choices for your maternity care, it can be helpful to know whether you’re considered high or low risk. For low risk women, ALL of the options are available. If you are considered high risk, you might have fewer options, but it depends on the type of issue you’re having.

For example, a home birth midwife might be perfectly well-equipped to manage certain kinds of “high risk” complications, but not all. If you have gestational diabetes, you might be pushed into the high risk category. A home birth midwife may decide that you still qualify for a home birth if your blood sugar levels are well-controlled by diet, and you don’t have any other risk factors. They may suggest some extra monitoring, and manage your prenatal care and birth very appropriately and safely. If you develop placenta previa on the other hand, that same midwife would understand that you need a different level of care and refer you to another provider. That limits your options, because you no longer qualify for an out-of-hospital birth, and you may even require the care of a Maternal Fetal Medicine specialist (MFM).

What does High Risk Mean?

If you have a condition or are labeled high risk because of your age or because of how you conceived, you might wonder what that means. What does “high risk” mean? Does that mean you and your baby are in mortal danger? Or does it mean that your risks are just highER than the next person’s?

In an article we recently published, I went over the differences between relative risk and absolute risk.

Relative risk is the likelihood of something happening (or not happening) compared to someone else. Relative risk would sound like, “Your risk of developing high blood pressure during pregnancy more than doubles after age 35”. So that means, compared to people under 35, your risks are higher. But what does this really tell you? Should you be very worried? Are you doomed to develop high blood pressure? The answer to this would be to ask another question.

What is My Absolute Risk?

8% of people under age 35 develop high blood pressure. For people over 35, the number is 18%. That number is more than double, but does it make you feel better to hear that actual number? When I see 18%, I don’t feel doomed. I recognize that it’s still unlikely. There is an 18% chance that I will develop high blood pressure, but there is a 72% chance that I won’t!

I might also ask about things that can lower my risks. There are probably some great options like getting more exercise, great nutrition, and lowering my stress levels.

Knowing your absolute risk can be very helpful, and I always encourage folks to ask that question when they’re confronted with scary-sounding statistics.

Some Stats for You

I’m writing this article in response to a reader’s request for more statistics. I wasn’t sure exactly which kind of statistics to include, so this is a list of some of the more common numbers that I see or hear about related to pregnancy, birth, and baby care.

For all of these and more, please remember to question statistics. A number might be correct, but not very applicable to YOU. The numbers I show below are averages. They include EVERYONE, and don’t always take into account your risk category or your ethnicity or race. It’s an unfortunate but true fact that black people especially, but also other people of color, immigrants, and people in the LGBTQIA+ community may expect different statistics. This is born of inequities and disparities in care caused by systemic racism and implicit bias. I think it’s wise to take this into consideration when you are facing those statistics, but also remember to determine your absolute risk. Increased risk is a serious problem, but knowing what your absolute risk is can be comforting.

• Prematurity: About 10% of births are preterm. That means the baby is born before 37 weeks. This might sound like a scary number, but remember you can ask the question about lowering risks for anything. This number includes EVERYONE, including people having high risk pregnancies. The relative risk for folks experiencing a low risk pregnancy is about half. The absolute risk for a person experiencing a low risk pregnancy might only be 5%. With this statistics, also remember that a baby born at 35 or 36 weeks is very different from a baby born at 31 weeks. At 35 or 36 weeks, or even younger sometimes, a baby may be perfectly healthy and not need any special care.
• Preeclampsia: About 5-8% of people develop preeclampsia.
• Gestation Diabetes: About 5-9% of people develop gestational diabetes.
• Cesarean Births: The most recent statistic is for 2023 and shows that nationwide, the cesarean rate was 32.3%. If you look at the March of Dimes map, you can see how this is divided by state. Let’s question it. It’s also important to zoom in even more for some statistics. For example, the overall cesarean rate for the U.S. is 32.3%, but for Texas, it’s over 33.2%. HOWEVER, you can look up your own hospital’s cesarean rate! You might see that around the Austin, TX area, the number hovers closer to 29%. I noticed one particular local hospital that is down to 22%. But zooming in even more, the hospital rates show an average of all the providers who attend births there. You might get even more comfort or insight by asking your own doctor about their cesarean rates. For some it will be lower than the hospital rate, and for others it will be higher.
• Stillbirth: In statistics, mortality rates are usually not shown as a percentage. Instead of hearing the percent chance of this outcome, it’s shown as 1 in 175 births. I like to translate that into a percentage. For some reason, it helps me to hear it that way. If you ever want to do that for yourself, you take the Part (1), divide it by the Whole (175) and multiply that by 100.
  • 1÷175=.006
  • .006X100=.57%

So, on average, the chance of having a stillbirth is .57%. And always remember that low risk pregnancies can mean a lower number, and that you may ALWAYS ask how you can lower your risks. Also remember that stillbirths are defined as a fetal death that occurs in utero after 20 weeks of pregnancy.

• Maternal Mortality: This rate is shown as 18.6 deaths per 100,000 live births. That percentage is .0186%. That’s the average in the U.S. The highest rate is for black women, at .05%. The high resource country with the next highest rate is Chile with a rate of .0143%. The lowest rate that same year was for Norway at 0%.
• Infant Mortality: The rate in the U.S. is about 5.342 deaths per 1,000 live births. That rate is .53%. This rate does not include stillbirths, only deaths that occur after birth. It’s also important to recognize that includes infant deaths that occur in the first year of life. Most people think it includes deaths that occur immediately following birth and as a result of birth.
• Birth defects: About 1 in 33 babies is born with a birth defect. That’s a 3% chance. That sounds high, but if you look more carefully, you’ll see that birth defect is a very broad category and includes conditions that are more severe and debilitating, but also those that can be completely resolved with a simple surgery or managed well with medications.
• Sudden Infant Death Syndrome (SIDS): This is a very scary thing to think about for most parents. We have an article discussing SIDS, how it’s different from Sudden Unexpected Infant Death (SUID), and some prevention strategies. The SIDS rate is about 1 in 1000 babies or .1%. The SUID rate is about 100.9 per 100,000 or .1%. This is confusing, right? That’s because SIDS is a SUID, but not all SUID cases are SIDS and they get lumped together. You really have to dig for this one. SIDS rates are actually lower than .1%. More than half of the SUID cases have a known cause. It’s usually an accident that could have been prevented with better education or circumstances. In true SIDS cases, the baby was apparently healthy, and there was nothing in the environment that could have caused the death. This makes me feel better. There is a less than .1% chance that my baby will die from SIDS which is something that parents really have no control over. I can also see from these statistics that I can do something to reduce my risk.
• Breastfeeding rates: In last week’s article, I referenced the American Academy of Pediatrics (AAP) statement that recommends “exclusive breastfeeding for approximately 6 months followed by continued breastfeeding with complementary foods for at least 2 years and beyond as mutually desired.” The CDC issues a health ‘report card’ with a section about breastfeeding. Here are some things to notice:
  • About 84% of babies are breastfed some.
  • About 46% are exclusively breastfed for 3 months
  • About 27% are exclusively breastfed for 6 month
  • About 39% are breastfed at 12 months

This isn’t great. We’re not meeting the recommendation set by the AAP. But that 84% number looks great! Unfortunately, that includes people who go on to breastfeed for 2 years, but also those who breastfeed twice. Also, the 39% at 12 months might seem OK, but remember that the recommendation is that breastfeeding continue for 2 years! Many people drop off at one year, and it’s down to 11.5% at 2 years. It is absolutely true that any amount of breast milk is beneficial. It’s also true that more is better! Our goal is to help families achieve these goals if they desire it. Always contact a lactation consultant for help if you’re struggling. You will likely have insurance benefits to cover it! Once you figure it out, it gets much easier over time.

Breastfeeding rates are a great one to look at, because you can probably do something about it.

Breastfeeding also happens to be an excellent way to reduce some other risks. By getting some prenatal breastfeeding education, and learning about some best birth practices, most people increase the likelihood that they’ll be successful. And then if things don’t go smoothly, you can get help and will likely have great results.

Resources

• What is the difference between absolute risk and relative risk and why on Earth should I care?
• Relative vs Absolute risks: Why Relative Risks Are Misleading, and How To Communicate Absolute Risks
• Gestational Diabetes – CDC
• Premature Birth – CDC
• Timing of maternal mortality and severe morbidity during the postpartum period: a systematic review
• Maternal Mortality Rates in the United States, 2023.
• Systemic racism: individuals and interactions, institutions and society | Cognitive Research: Principles and Implications
• Systemic Racism
• American Black women face disproportionately high rates of maternal mortality | PBS News
• Total Cesarean deliveries: United States, 2023 | PeriStats | March of Dimes
• Data and Statistics on Birth Defects
• About Birth Defects
• Preventing Birth Defects
• Data and Statistics for SUID and SIDS

The focus of our last article was tandem nursing, which usually means breastfeeding a toddler and a newborn at the same time. A lot of people do not plan to breastfeed a toddler, but most babies start “toddling” between 9 and 18 months of age! The recommendation by the American Academy of Pediatrics (AAP) and many other organizations including the World Health Organization (WHO) and UNICEF is to continue breastfeeding with adequate complementary foods for at least 2 years and beyond as mutually desired.

That means that people who are following these guidelines are breastfeeding a toddler! That baby might only be 10 months old or might be two years old. Either way, this is a walking (maybe talking) kiddo that is still getting breastmilk.

I have heard something similar to this comment over and over, “If the kid can walk up and ask for milk, that’s weird and time to stop.” But is it really?

The “natural” age for weaning is a big range. It really depends on who you’re talking to, the culture and what period in time you’re talking about. There are so many interesting things to read about this. It’s been tackled from a historical perspective, an evolutionary perspective, and by biologists and anthropologists. They come to a lot of different conclusions, but the average age of weaning is somewhere between two and four years. There are places and times where children are weaned earlier than that, but also later! So breastfeeding a “toddler” is actually not at all unusual or “weird”.

Perceptions

Many people in the United States perceive that it’s unusual to breastfeed a toddler because we just don’t see it much or at all. The reality is that many people do this, but it happens at home. I did not breastfeed my toddlers in public very often, or at all.

When I had younger babies, I breastfed everywhere. I have very literally nursed babies on trains, on planes, in restaurants, libraries, parks, stores and churches. When those babies needed to eat, my milk was what was available. I never felt awkward or judged. Once they were eating some solid foods, I started offering them other snacks when we were out.

I definitely felt that nursing a toddler in public was different. I know that a part of me was worried about what people would think, and that’s just an unfortunate reality. But I also liked wearing bras and clothing that didn’t have to be breastfeeding friendly sometimes.

Also, my toddlers were easily distracted, and breastfeeding might only last for a minute or two before they were running off. That made it more frustrating for me, and I started offering a snack instead. At least they could eat that “on the go”. Nursing became something we only did at home, and it was usually just around bedtimes when they could lay down, be still, and nurse for a significant amount of time, or when they needed some extra comfort. It was especially beneficial when they were sick.

Are there benefits to continued breastfeeding?

Yes. Although toddlers have very different needs from newborns and younger babies, there is evidence that breastfeeding does continue to provide benefits. But they’re also not completely dependent on milk for their nutritional needs. Babies usually start eating solid foods at around six months of age. At first, it’s just a very small part of their daily intake, but it gradually increases until they are eating a lot of solid foods, and breastfeeding becomes a smaller and smaller part of their daily intake. This tends to happen gradually, and we don’t get to witness it happening out in the world very often.

It’s hard to say exactly what kind and how much benefit there continues to be after age two. There just isn’t much research for that, but the suspicion is that breastmilk does continue to offer some nutritional benefits that they might not get from other food sources. It also can continue to provide an emotional benefit. A two year old is still very much a baby in so many ways. They may or may not be able to communicate effectively and it can still be hard to understand what is happening if they seem upset. Nursing can be helpful in this way for sure. It’s something consistent that the baby has always had, and it’s comforting.

Nursing can also help with bonding. Of course, there are plenty of other ways to bond with our children, but this might be an easy and special way for a lot of families. For some parents who go back to work full time, breastfeeding at bedtime or in the morning is a way they choose to maintain a consistent and daily connection with their baby.

Managing judgments

If you choose to breastfeed your toddler, but worry that people might think you’re “weird”, we understand. Many other parents have had the same doubts and feelings. It can be helpful to recognize the truth of that. Many parents feel the same, which means that many parents are nursing toddlers! You can handle this however feels most right for you. Here are some ideas:

• Do it loud and proud. You can breastfeed your toddler anywhere, everywhere, however, and all the time. You might want to be a public activist and advocate for this very normal practice. Bringing attention to it can help normalize it. But we recognize that this is NOT the right path for everyone!
• Take a moderate approach. You can breastfeed your younger baby in public, but then reserve nursing your toddler for an “at home only” thing. BUT you can talk about the fact that you are breastfeeding your toddler. That helps too! I was very happy to talk to people about breastfeeding my toddlers even though I didn’t like to breastfeed them in public. I was often surprised to hear that the person I was talking to also nursed their toddler when at home. When we open up, it allows others to do the same. You might also breastfeed your toddler only in certain situations. For example, it might feel ok when you’re at a friend’s house or out at a park, but maybe not at a busy restaurant.
• Keep it to yourself. You might decide that it’s nobody’s business but your own whether or not you choose to breastfeed. This is true! It’s a very personal choice, and can definitely feel like an intimate part of your family life. It’s also very reasonable to keep it in the family.

Things to know

Breastfeeding a toddler will be different. This is so important to recognize. If you are breastfeeding a newborn, it can be so daunting to consider having to do that same thing for a year… OR MORE?! I can assure you that you won’t be doing that for very long. After the newborn period, breastfeeding gets easier. How?

• You will no longer be newly postpartum and recovering from pregnancy and birth. Your physical and emotional recovery is a big complicating factor and can make breastfeeding feel like more of a chore.
• Your baby will get better at it. They have to develop some strength, endurance, and skill for breastfeeding. It’s just like exercise. It’s harder at first, but once the strength is there, the endurance and skill increase too. When they are better at breastfeeding, things go more smoothly and more comfortably for you.
• You will get better at it. Breastfeeding is learned. You’ll figure out new and more comfortable positions that work best for you and your baby. You’ll find a routine and a rhythm and things will feel easier.
• You will do it less often. On day 1 of life, a baby’s belly is only the size of a cherry and can hold about a teaspoon of milk. Their bellies fill and empty very quickly so they eat often. By the time the baby is one month old, the belly has grown to the size of a large egg and can hold almost half a cup! That means the baby will stay full longer and need to eat less often.
• They will eat more quickly. As the baby gets better at it, they will be able to get the milk out more quickly, and once a baby is eating solid foods well, their breastmilk meals might be more like snacks. They can get what they need in less time, so you spend less time breastfeeding.
• Your milk supply stabilizes. At first, your milk supply will be very sensitive. It’s critical to stimulate the breast often and consistently to build and maintain a good supply. After a couple of months, it matures and stabilizes and you can be more flexible. By the time a baby is a toddler, most people can nurse a lot less often and be less consistent without losing the milk supply. You will also likely stop leaking!
• When your baby is not completely dependent on your milk for their nutrition, it gives you more flexibility for child care and more time that you don’t have to spend nursing or pumping for bottles.
• When your baby starts eating solid foods, it can be really stressful. They won’t always eat all the right things. They’ll have days when they seem to just throw everything on the floor, or days when they’ll only eat blueberries. If you are still breastfeeding, you can relax knowing that your baby is still getting everything they need.

It’s so hard to describe what it’s like to breastfeed a baby to someone who has never done it before. It’s also so hard to imagine what it will be like when you never have. It’s also hard to imagine that it will be different as your baby gets older, when you’re in the middle of newborn confusion and chaos. It truly is a completely different experience to nurse a toddler, and can be very easy, special, and sweet. I encourage you to remind yourself of that when things feel really hard or even painful. You can get help, and it will change.

Resources

Weaning from the breast – PMC

An Age-Old Question: What is the Natural Age of Weaning?

Infant and young child feeding – WHO

Cultural Motherhood: Weaning Part II

Tandem nursing refers to breastfeeding more than one child at a time when they are also different ages. Feeding twins or multiples is a little different. Tandem nursing is not a common practice in our modern culture, but it happens more than a lot of people think.

Should I stop breastfeeding when I’m pregnant?

If you struggle with the idea of weaning, know that there is another option. You DO NOT have to stop breastfeeding when you get pregnant again. Especially for low risk pregnancies and for people who are able to maintain good nutrition, it does not appear to be harmful to your body or to your pregnancy to continue to breastfeed your older child. It also does not seem to negatively affect the quality of the milk that your newborn will get. The milk you make for your older baby is different, but your body is incredibly sensitive and intuitive. It will understand that there is a newborn baby needing colostrum and a different kind of milk, so it will provide it. These newborns tend to do very well, and there seems to be no difference in health and weight gain for newborns of parents who are tandem nursing.

Why tandem nurse?

If you’re successfully breastfeeding a toddler or older baby when you get pregnant again, it can be a really hard thing to consider weaning for the sake of the pregnancy and the new baby. A lot of people think it has to be done, but when things are going well with breastfeeding, it’s often not something that people want to give up. It’s excellent nutrition that is very affordable. By this time, it might also be very easy and even enjoyable for you both. The babies get very efficient, and breastfeeding can be quick and easy with no mess to clean up! When older babies and toddlers are exploring solid foods and deciding what they do and don’t want to eat, it’s especially helpful to have breastmilk as a backup. It feels good to know they’re still getting complete nutrition with breastmilk if they just play with their food or throw it on the floor today. It’s normal for older babies to explore textures and tastes when they’re starting solids, but not get much actual nutrition from it. It’s great to keep things positive and continue to offer breastmilk.

Some people get pregnant again pretty quickly after the last birth, and in this case may want to continue to breastfeed for the recommended amount of time. The current recommendation from the American Academy of Pediatrics is to provide breastmilk exclusively for at least the first six months, and to continue to offer breastmilk in addition to solid foods “for at least 2 years and beyond as mutually desired”. Many other sources have published similar recommendations. So, if you have a baby that is just a few months old, and you are trying to adhere to these recommendations, it can feel like weaning during pregnancy would be too soon for your baby.

You also might feel a very strong bond with your baby through breastfeeding, and it can be very hard to consider giving that up, especially knowing that another baby is coming and you’ll have to divide your attention. You might worry about how your baby will handle it, but it can also be really hard for the parent. People often choose to tandem nurse because breastfeeding is working very well for their family.

Some parents worry that a new baby will change their relationship with their older baby. If breastfeeding has been a point of strong connection for the two of you, it can be comforting to continue breastfeeding. That might help ease some of those worries. You and your older baby can continue to share that kind of bonding and that might help make the transition a little easier for both of you.

Tandem nursing can also help make those early days and weeks of feeding a newborn a little easier. You are less likely to experience engorgement and the discomforts that go along with that transition. The older baby can be a great help in balancing the milk supply.

Is there a downside?

Tandem nursing can be fantastic for some families, but it’s not for everyone. Some people end up feeling very tired and “touched out” when they’re trying to breastfeed a baby and a toddler at the same time. It might seem like there is always someone wanting to be at the breast. Your breasts might get sore from frequent use. And some people end up experiencing some difficult emotions. Some people feel resentment towards one or the other of their children when things feel very difficult. You might feel like you can’t give enough of your attention to one of them and resent the other for that. You might have feelings of doubt or insecurities about your ability to breastfeed two children. Some people don’t have community or family support for their choice and feel rejected or judged. There are even cases where their OB and/or pediatrician express concerns or judgments about the choice. This is usually just a lack of information on their part, and not because it’s a bad choice, but it can still feel very difficult to receive that kind of reaction from a health care professional.

Also, even though it’s not harmful, it might not be the same to breastfeed throughout your pregnancy. Your milk supply might drop in one breast or both, and the composition of the milk changes due to the hormones of pregnancy. The milk might taste different to your baby. Because of these changes, some babies decide to wean themselves. When I became pregnant with my second baby, I was still breastfeeding my daughter who had just turned two. I noticed that breastfeeding started to feel painful on one side because the supply was gone. My daughter definitely noticed that there was no more milk in that breast and would get frustrated and only choose the other. At that point, I felt ready to try weaning, and my daughter agreed. It was easy because of those changes in the milk supply, and it turned out to be the right thing for us.

How to transition away from breastfeeding

Luckily, my daughter did not struggle with weaning at all. She wasn’t nursing much at that point anyway. It was mostly a comfort and an easy way to get her ready for naps and bedtime. I offered her a little bit of juice and extended snuggles instead, and she was very happy to take it. She’s very snuggly, and juice was a special treat for her, so that’s all it took!

If things had been different, I likely would have continued to breastfeed through my pregnancy, because it was a very easy and sweet thing that my daughter and I shared. I did worry that the new baby would create more separation for my daughter and me, especially without our shared experience of breastfeeding. I worried that she would feel neglected or jealous of the new baby. Luckily, we had many months for our relationship to shift, and we still had a very strong bond when my son arrived.

When the baby came, she had mostly forgotten about nursing and it didn’t bother her as much as I thought it would that he was breastfeeding. If your older child does wean close to the time that your new baby arrives, I recommend building in some things that will help your older child with the transition:

• Find new special bonding rituals for the two of you. Maintain those when the new baby arrives so they can see that they still have their own special relationship with you. You might start doing some infant massage at bedtime, or storytime if you haven’t done that yet. You might make a cup of sleepytime tea together and play a favorite game before bedtime, or take a daily walk around the neighborhood. My daughter loved to act out her favorite scenes from storybooks, so we did that everyday. Her favorite was pretending to be Curious George when he broke his leg and had to go to the “hoshtable” (hospital). We would wrap her leg with a scarf and put it in traction using the side of her crib.
• If you start out tandem nursing, and then it starts to feel overwhelming to nurse both babies, it doesn’t have to be an abrupt or dramatic loss to stop breastfeeding your older child. You can gradually remove some feedings. It’s a great idea to replace that time with something else special. You can use that time to do something else that will maintain your bond. What many parents want to avoid is their older child feeling neglected or replaced by the new baby.
• Toddlers sometimes like to be involved in the baby care, and that can help them feel included and important. You might ask them to help you when you’re feeding your newborn. They might be able to bring you a burp cloth or help hold the baby’s head or feet. They can start to understand that they have a new and very special role in the family as a big sibling.

How to tandem nurse successfully

If breastfeeding continues to go well during pregnancy and you would like to tandem nurse when your new baby arrives, here are some tips that might be helpful:

• The more experienced baby can probably nurse well under any circumstances, but newborns are still developing their strength and skill, so latch the newborn first, then allow the older baby to latch at the other breast if you’d like to nurse them both at the same time.
  If you prefer to nurse them separately, you might set up ‘special’ nursing times just for you and your older baby when someone else can be with your newborn.
• Make sure to feed your newborn “on demand”. It’s important for them to get as much milk as possible in those early weeks especially. They usually lose some weight at birth, and getting plenty of milk is important for their growth, and also for health concerns such as jaundice, digestive health, and immunity. Their meals should be prioritized. The older baby can nurse after the newborn and still get some milk.
• Your older child can be fed “on demand”, but many parents decide to set up regular times to nurse the older baby. It’s a personal preference, but a schedule can be helpful for many people.
• If you’re experiencing engorgement, it can be helpful to allow your older baby to nurse a small amount from that breast to relieve the symptoms. It can be difficult for a newborn to latch on to an engorged breast and can sometimes cause frustration and refusal. The older baby can ensure that the engorgement is relieved and that the breast is soft. This can make it easier for the newborn to get a good latch.
  If you have a very powerful milk ejection or “letdown”, a newborn might not be able to keep up with the amount of milk that is spraying out. When this happens, they can choke and gag and get upset at the breast. This can even lead to rejection of breastfeeding. If you have an older baby, you might let that baby nurse for a short time until the flow slows down, and then allow your newborn to nurse more easily.

The most important thing to take away from this is that tandem nursing is great for some families, but not for everyone. I encourage parents to listen to their own intuitions when it comes to parenting decisions like this. Tandem nursing has been done throughout our history and across many cultures, so it’s definitely something that our bodies are capable of. It can be a really good thing. It’s also true that it doesn’t work for everyone, or that it doesn’t feel right for everyone. If you feel a strong intuition to continue to breastfeed your baby and tandem nurse, you can tune out the voices that tell you it’s not healthy or wrong or weird. If someone thinks it’s unhealthy, that’s because it’s something they don’t understand. If someone thinks it’s weird, it’s just because they haven’t been exposed to it. For other people, it seems like the most reasonable and natural thing to do. I hope that you can find your own path in parenting. It doesn’t have to look like what you’ve seen before. We all have different bodies and different circumstances. There are SO many right choices!

References

Tandem Breastfeeding: A Descriptive Analysis of the Nutritional Value of Milk When Feeding a Younger and Older Child – PMC

Tandem Nursing – La Leche League GB

Pregnant and Breastfeeding – La Leche League GB

Breastfeeding During Pregnancy: A Systematic Review of the Literature

(Trigger warning: discussion of maternal and infant mortality rates)

Or maybe you’ve heard this one, “Healthy baby, healthy mama. That’s what counts.” Are these platitudes true? I think they are absolutely true. But are they really all that matter?

Do Birth Plans Work?

Many people go into birth with a plan. You might have preferences and intentions that you and your care team work to make happen, but the reality is that in birth there are detours. Birth plans are a great way to get you prepared for labor and birth, and have many benefits, but they can not guarantee perfect outcomes.

Sometimes the detours are simple and easy to work around. Other times, they can be very scary and some people have an experience that feels not only like one that is not what they originally planned for, but one that can feel traumatic. Some people end up feeling like birth became a rip current that pulled them off their feet and underwater only to spit them out 50 yards down the beach. I’ve heard many women describe feeling out of control, confused, sad, overwhelmed, and guilty. They might be wondering, “What if I had done something different…”

Am I Wrong for Feeling Like This?

I want you to know that it is absolutely normal to be feeling and thinking ALL the thoughts and feelings you are having—the guilt and sadness, the confusion and feelings of being totally overwhelmed. It’s all so very normal, and it’s also specific and highly personal. It’s a very big thing that your body and brain and emotions are trying to process.

Even more, you might compare your situation to those of others and try to talk yourself out of some of these emotions by thinking, “Well, at least we are safe and healthy now.” That might be true, but it is also very true that a big thing happened and that your feelings are totally valid.

Those feelings, especially the guilt, do not mean that you deserve blame for anything. You did the best you could in each moment on this journey with the information and support that you had. You are here just because you are here, and NOT because you did anything wrong.

You may never know the reasons for everything, so it’s important to feel those feelings, let them move through and out, and then move forward knowing that difficult things just happen sometimes, and you are going to keep doing the next right thing as you know it. No one can do any better than that.

You might also be made to feel that you are ungrateful if you share that you’re not OK about your birth experience as long as everyone is healthy. You might feel pressured to shut up, shake it off and move on, ”At least I have a healthy baby.” When someone makes you feel bad about the feelings you are having, it’s usually not about you. They have their own issues that are coming up for them. They may have had a traumatic experience that ended badly, or maybe they never did and can’t understand what you might be feeling.

Use it for Good

Hopefully you can find some compassion for those people who aren’t able to sympathize. And hopefully you can find plenty of compassion for yourself. Compassion is a very positive feeling!

And remember that you’ve gone through difficult things before. For me, it helps to remember those times and recognize that I did get to the other side of it. I also like to remind myself that, in many ways, I am now better, stronger, and wiser for having lived it. This is one of those moments. You are already stronger and wiser, and you can get to the other side of this too.

Racial Disparities

The difficult emotions might be felt even more in certain racial communities. There are big disparities in care in the United States. The risks of pregnancy and birth are higher for black, brown, and indigenous people, and especially for black women. This is caused by a combination of factors, with systemic racism and implicit bias being the foundation of it all. This should not be happening. This is preventable.

For many of these families, finding out they are pregnant can bring an even greater range of emotions. They might be very happy to be pregnant and expanding their family. They also might feel afraid for their lives or their baby’s. So many more black families fear death as a result of birth than any other racial group, and with good reason. In this case, when they survive the experience, they might feel especially relieved and grateful. But does this mean that they received excellent care and feel completely positive about their experiences?

What to Do?

I encourage all families, and especially black families, to find a supportive care provider, maintain good prenatal care, hire a doula, take birth classes or educate yourself about labor and birth, and make a birth plan. I want everyone to feel empowered going into their birth. That should help you feel less afraid. It’s important to understand your body and your options, and it’s important to have support and an advocate.

It’s About More Than Just Survival

I also want ALL families to have the expectation that they will more than just survive their birth experience. You can and should expect more. Birth can be a positive experience, even when things don’t go exactly as planned. When it’s not a positive experience, it is your right to question that, remembering that it was not your fault. What went wrong? Were there missing pieces in your care? Were you given true informed consent at every step? Do you feel like you were not just a patient, but a true partner and leader in your health care? It’s important to ask those questions out loud. I recommend talking to your providers, and also using the Irth App to share your experiences, good and bad.

And please try to remember this. While there can be other complications, most everyone does survive pregnancy and birth. It’s true that the United States has some of the highest maternal mortality rates in the world compared to most high resource countries. And mortality rates are more than doubled for black families than for white non-hispanic families, and this is unacceptable.

But for your peace of mind, remember that the absolute risk for mortality is still very small. For black women, the risk of death is .05%. For white women, it’s .019%. So, while there is some risk, and there is increased risk for black women, it does not mean that you are most likely to have a bad outcome. You are most likely to have a good outcome.

It’s important to maintain this perspective, so that you can enter your birth time with more confidence and peace. High levels of stress can contribute to complications, and that is definitely not the goal. Keep this perspective while you educate yourself and build your excellent care team. This kind of preparation will help you navigate your labor and birth with more presence and resilience and will also help lower your risks.

We all want healthy bodies and healthy babies, and we all deserve that and more. You deserve to survive and to feel good about your experience.

References:

• Timing of maternal mortality and severe morbidity during the postpartum period: a systematic review
• Maternal Mortality Rates in the United States, 2022.
• Systemic racism: individuals and interactions, institutions and society | Cognitive Research: Principles and Implications
• Systemic Racism
• American Black women face disproportionately high rates of maternal mortality | PBS News
• What is the difference between absolute risk and relative risk and why on Earth should I care?
• Relative vs Absolute risks: Why Relative Risks Are Misleading, and How To Communicate Absolute Risks