Monday, November 25, 2013

Coming Home with Baby: What to Expect on Days Three and Four Postpartum

Assuming you had an uncomplicated, vaginal birth in a hospital, you'll be going home on day two or three postpartum. Legally, in the United States, insurance is required to pay for 48 hours postpartum in the hospital, and it's up to you, your family, your doctor, and your baby's doctor whether you want to stay for that long or if you want to go home sooner. This will depend on your health, your baby's health, and how confident you feel about taking full responsibility for your care and your baby's care weighed against how much more comfortable you'll be at home compared to the hospital environment. Many first-time parents prefer to take the full 48 hours in order to have assistance with breastfeeding, diapering, and general baby care, while more veteran parents are often in a hurry to get home to the older kid(s) and back into an already-established routine. (On the other hand, if you have several children, you may enjoy the relative quiet of your hospital room!)

Leaving the Hospital
When you're getting ready to leave the hospital, make sure you collect everything you brought. Don't forget small things like your cell phone charger, eyeglasses or contact lenses, jewelry and watch, and so forth. Go over the room a few times and collect everything that belongs to you.

Then, collect everything that the hospital gave you. Sanitary pads, ice packs, peri bottle, mesh underwear, diapers, alcohol wipes, bottles, pacifiers, thermometer, bulb syringe, breastpump parts, baby wipes, samples of baby shampoo, water bottle - anything they gave you that's consumable, they have to throw away when you leave. You're paying for it, one way or another, so you may as well take it with you. The only things they'll ask you to leave behind are typically the hospital gown, the baby shirts, and the receiving blankets (although we've ended up with more than a few hospital receiving blankets over four kids, so somehow quite a few of those have slipped through...). Often the nurses will offer to bring you more of anything you might need, such as another pack of diapers. Accept it! The less you have to worry about running out to buy the minute you get home, the better. (The only thing I'd recommend leaving behind, if offered, are formula samples if you're breastfeeding. See my "Just One Bottle" post for more on that topic. Or, take them with you but don't make them easily accessible.)

Have your partner or whoever is taking you home bring up the infant car seat (if you're using one) from the car so you can take your time buckling your baby securely. See my videos (here and here) on properly buckling your newborn in the car seat for instructions on keeping your precious new baby safe on his first car ride. (If you're starting out with a rear-facing convertible car seat, obviously you'll have to carry the baby down to the car and buckle her in there. I'm not suggesting that you wouldn't be using a car seat at all!)

Baby Blues
Whether you're still in the hospital or back home, days 3 and 4 postpartum will be very difficult. There's a major hormonal plunge at three days postpartum, which usually coincides with your milk supply increasing dramatically. Your progesterone levels, which were kept high by the placenta, finally plummet, now that the placenta has been delivered. Progesterone inhibits milk production, so when the placenta is delivered and progesterone levels fall, milk production suddenly increases. This is when you'll see the changeover from small amounts of colostrum to a much larger volume of milk.

While a welcome change as far as feeding your baby, this increase in milk production can cause new problems. Even if breastfeeding was going well up to this point, your milk volume increase may result in engorgement, making your breasts bigger, hard, and painful to the touch, which can make it difficult for your baby to latch, even if there were no problems with her latch before. The speed and force with which your milk may emerge from your breasts may confuse or upset your baby, who was used to the slower, thicker flow of colostrum. These combined issues may cause frustration for you, adding to the hormonal and emotional roller-coaster of the first week or so postpartum.

The result of this perfect storm of hormonal and physical changes is often inconsolable, irrational sobbing. Many newly postpartum women find themselves crying over nothing. I remember dissolving into tears because I couldn't figure out what to do about feeding my two older kids lunch when my third was three days old. Sometimes, your crying may be triggered by nothing at all, while other times small stressors can result in big sobs.

It's important to know to expect these "baby blues," because at least if you know it's coming, you can be prepared to ride out the crazies. Make sure your partner and other support people know about this phenomenon so that they'll know that your crying is not something they did wrong and so they can remind you that it will pass. You may feel overwhelmed, incompetent, or confused. Having someone there who can remind you that you're doing great, that this will pass, and to help you with all the little things that suddenly seem monumental will be vital. And if you do need to cry, go cry. Let it out. Crying releases toxins and is very freeing and cleansing, even if it's not much fun. Better to sob it out than try to hold it in.

Ask for Help
Ask for help. Ask for help. Ask for help. If you need assistance with breastfeeding, with housekeeping, with meals, with shopping, with simple baby care, a ride to the doctor, a cup of coffee, or someone to keep you company, ASK FOR HELP. If someone says, "What can I do?", tell them. If they offer, accept the offer. Be kind to yourself. Don't expect to be able to do everything yourself, even if you're used to being in charge and handling it all. You cannot handle everything at three days postpartum, and no one, including yourself, should expect you to. Your postpartum time is just about universally accepted as a time to rest, bond with your baby, and learn about parenthood (even if you're a parent for the second or third or fourth time!). Your body is healing, your brain is changing, and your life will never be the same. Lie down and let someone else take care of the mundane stuff.

Postpartum Depression
Baby blues should not last more than a week or two and should not be accompanied by severe anxiety, thoughts about harming yourself or your baby, hallucinations, or extreme paranoia. If you experience any of these more severe symptoms or if your "blues" last more than two weeks, contact your OB or midwife immediately. These are signs of postpartum depression, postpartum anxiety, or even postpartum psychosis, which are serious but can be treated with therapy and/or medication. Many psychotropic medications are compatible with breastfeeding and can help you feel like yourself again. Don't be afraid or ashamed to reach out for help if you suspect there's something more than hormonal changes going on.

Uterine Cramps and Bleeding
Especially if this is not your first baby, the cramping caused by your uterus shrinking back to its prepregnancy state can be fairly painful. If you were prescribed pain killers, take them! Ibuprofen (Advil/Motrin) and acetaminophen (Tylenol) are both compatible with breastfeeding, and even narcotics such as Percocet and Vicodin used sparingly are relatively safe (although narcotics may make your baby sleepy - if you don't need them, it's probably better to avoid them). If you are in pain as well as having emotional symptoms, you will find it hard to enjoy your baby and your rest. Your postpartum bleeding should have slowed but will still be relatively heavy. Don't overexert yourself. If you soak through a maxipad in less than an hour, see clots larger than the size of a golf ball, or have a fever, contact your provider, as these may be signs of postpartum hemorrhage or infection.

Vaginal Symptoms and Hemorrhoids 
If you had a vaginal delivery and tore at all or had an episiotomy, this will still be healing. Don't squat or try to lift anything heavy, as this may tear your stitches and cause additional damage. If you're still experiencing swelling or any external pain, using ice packs and witch hazel on the area may help. Also, taking a sitz bath may speed healing and relieve pain and swelling. If you were given a cooling or numbing spray or foam, use it as directed. Drink plenty of water and avoid constipating foods to keep your bowel movements soft and help your hemorrhoids heal. Hemorrhoidal creams can be soothing as well. Use your peri bottle to clean your perineum after using the bathroom so that you don't have to wipe too aggressively with toilet paper.

After a C-Section
If you had a c-section, you'll likely still be in the hospital at three days postpartum. After my c-section, on day three, I woke up in the middle of the night crying. My nurses insisted that I was in pain and brought me more pain pills, but I knew that wasn't it. It turned out it was the aforementioned baby blues, which I had no idea existed! I was resentful that the nurses also didn't seem to know what was going on and that no one had warned me to expect them. A c-section will also cause different physical issues as well. Your incision is still very new at three and four days postpartum, and laughing, sneezing, and coughing will be painful. Hold a pillow against your middle if you need to do any of these things to help support and protect your incision. Watch for signs of infection such as smelly discharge from the incision site and fever. Follow your doctor's and nurses' instructions for keeping the incision site clean and dry. Some of the treatment will depend on the type of incision and the type of sutures used. You will still experience postpartum bleeding and cramping, and if you had the c-section after pushing for any length of time, you may also experience some perineal swelling and hemorrhoids.

Breastfeeding Help
As alluded to above, day three and four may present new breastfeeding challenges, as your milk volume increases and you experience engorgement for the first time. If you are so engorged that your breasts are hard and painful, or the engorgement causes your nipples to flatten out such that your baby cannot latch, it may be helpful to express some milk prior to feeding. Use warm compresses or take a warm shower to help start the milk flowing, then use hand expression (NSFW video) or a breast pump to remove some milk. If you are in severe pain, taking pain medication can sometimes relieve some of the pain so that you can express. Pump or express just enough to soften the breast so that the baby can latch and to relieve the rock-hard feeling. Removing more milk than necessary will signal your body to produce more milk, which will perpetuate the cycle of engorgement. You want to train your body to make the amount of milk your baby needs, so feed the baby on demand and let him nurse as long as he desires, and pump only enough for comfort. (Do save whatever you pump, either for later bottle-feedings or to donate.)

If you are having any breastfeeding difficulties, contact a lactation consultant, La Leche League Leader, or an experienced breastfeeding friend for help. Many breastfeeding issues can be solved with a little intervention, but if they are not addressed, they can become big problems. Some techniques that can help in the meantime are making sure your baby is latching well, keeping baby skin-to-skin as much as possible, and trying different breastfeeding positions to see if any of them are more effective or more comfortable for you or your baby.

For a proper latch, make sure baby's lips are flared outward, that his mouth is opened very wide, that his tongue is over his lower gums, and that your nipple is far back in his mouth; some of the areola should be in his mouth as well - he should not be sucking just on the nipple.

Follow these four rules to help with positioning:
1. Tummy to tummy: Keep your baby facing you, with ear, shoulder, and hip in a straight line.
2. Nipple to nose: Align your baby's head so that your nipple points to her nose. Brush your nipple down across her lips to her chin, then drop the nipple in when she opens her mouth wide.
3. Allow the baby to tilt his head back slightly: Don't crunch your baby's chin down toward his chest, and don't put your hand on the back of his head. Instead, support his head at the base of the skull so that he can tilt his head back slightly. This will help get a deep, asymmetrical latch.
4. Bring the baby to your breast, not your breast to the baby: Don't be afraid to pull your baby in close. Support your arms and back with pillows if you need to. You don't want to be hunched over and stretching your breast toward the baby's mouth. Rather, pull the baby close to you and straighten your neck and shoulders.

See my "Breastfeeding a Newborn" (here and here) and "Breastfeeding Positions" (here) videos for more help.

If your nipples are damaged, talk to a lactation consultant about using a nipple shield to protect your nipples and help your baby latch. Also, you can use lanolin to help them heal. Hydrogel pads can assist with pain and healing as well.

What surprises did you encounter in the early days postpartum? What other tips or advice would you add?

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