It's December which means the year is coming to a close. This year has been a journey, just like the years before. I like to sit back and reflect on what the year has brought and what changes have come as a result. I decided this year I want to share the changes in my practice I've implemented as I continue to learn and grow as a midwife..

I created two new informed consents, one for ultraound, and one for hospital transfers. After hearing about a birth experience a midwife who practices in a different region had, I decided I needed an ultrasound informed consent to explain the risks and benefits of ultrasound. Having clearly spelled out information about what to expect in a transfer, what I do, and what my assistant does, makes transfers smoother and less stressful when they do happen.

I purchased ultrasound equipment and completed a course to gain a basic understanding of how to do ultrasound. I wanted to be able to do a quick check to confirm if baby is head down when I was unsure from palpating. I am not a sonographer, so I am not doing any other evaluations or assessments with ultrasound. If we need or want more information, I refer clients to a sonographer.

I have totally revamped how I chart. I feel more comfortable with my new charting. It gives a clearer picture of what was covered and discussed during prenatals, and it helps with being consistent with the care I offer clients during prenatals.

I now have multiple blood pressure cuffs, stethoscopes, and pulse-ox sensors so I don't have to remember to shift them from bag to bag, or use them in my office.  It's nice to know my bags are always ready and I will always have access to equipment I need wherever I'm at while doing midwifery work.

I am doing more initial prenatal labs. I now check thyroid levels, Hemoglobin A1c and Vitamin D levels.  Thyroid function can impact pregnancy if it is outside of normal ranges. Hemoglobin A1c gives a picture of what blood sugar levels have been in the past 90 days. This is helpful for evaluating if we want to do gestational diabetes testing or blood sugar tracking. Vitamin D is essential for both baby and Mom during pregnancy. I was surprised when I began checking Vitamin D levels that over 90% of clients were deficient.  

I have made all these changes and additions to how I provide care to help clients have the healthiest, most amazing pregnancy possible. These changes help me in providing better and more consistent care as well as making life a little smoother for me as a midwife.  
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Postpartum depression in mothers is a serious issue and we are making strides in helping mothers who may have it. We now know Dads can get postpartum depression. In my opinion, we are not paying enough attention to or providing adequate support for Dads, and recent research agrees.

Some Dads try to keep home life going at the same pace it was before baby's arrival. Some Dads try to keep the house spotless and make sure all meals are homemade. These things are great goals, but when everyone is sleep deprived and adjusting to the changes a new baby brings, it can be too much. Unfortunately, some dads might get a few days off work and then have to go back to work which can bring Dad some stress and maybe guilt that Mom is having to take on more while she is recovering from birth than if he was at home to help.

I have seen everything I mentioned above. And I've seen Dads struggle. The symptoms of postpartum depression in Dads is very similar to Mothers. I want to know Dad is doing well so I check in with Dad when I'm doing a postpartum. I want to know that Dad is getting at least 6 hours of sleep in a 24 hour period. I want to know that Dad is eating well. I want to know that Dad is taking care of himself. I also want to answer any questions Dad may have.

I might make suggestions like using paper plates, ordering food in, or going to the store and picking up a few frozen pizzas for meals. I might suggest Dad take naps or get a few hours of sleep at night in a different room than Mom and baby. I might suggest Dad see a therapist if I am seeing signs he is heading into postpartum depression.

I want Dad to thrive when baby arrives. I want Dad to be empowered and equipped to support Mom and baby well. Because I want the entire family to thrive, I ask questions and talk to Dad about postpartum depression. I want Dad to feel respected, valued and heard. I do not want Dad to be forgotten in the busyness of life with a newborn.

Newborns spend a lot of time with Mom in the first few' days and weeks after birth. This helps Mom and baby connect well or bond. While Dad isn't the one who can nurse baby, there are still lots of things Dad can do to bond with baby.  

• Dad can be the one to read baby a story every day.
• Dad can be the one to bathe baby.
• Dad can be the one in charge of getting baby ready for bed for the night.
• Dad can be the one who puts baby to bed.
• Dad can be the one who gets baby out of bed in the morning.
• Dad can be the one who is in charge of getting baby dressed and ready for the day.
• Dad can be the one who snuggles baby at dinnertime while Mom gets to have both hands free to eat.
• Dad can be the one to take baby out for a walk everyday, whether it's going through the neighborhood or driving to the mall, store or other indoor space and walking there.

I recommend that Dad should have some area of baby's day that is his special time with baby, that only he does, and does how it works for him and baby.  It may be different than how Mom would do it, but that's okay. Babies are smart, and they know Mom and Dad aren't clones of each other. Babies benefit from having Dad only time to support and increase bonding, and Dad only time shouldn't wait until baby is older.  It should start the day baby is born.

What is jaundice?  
Bilirubin is a yellowish substance that is a byproduct when red blood cells are broken down. Red blood cells are always being broken down and replaced by the body. Bilirubin is normally broken down by the liver.  Jaundice occurs when bilirubin builds up faster than the liver can break it down and eliminate it from the body. Newborns are transitioning from fetal red blood cells which have a slightly different form of hemoglobin to normal red blood cells. That process begins right after birth. Their liver is just beginning to function so that makes them more susceptible to jaundice.

How common is jaundice in a newborn?
It is pretty common, 60% to 84% of all newborns born at term will experience some level of jaundice in the first week of life. It even has a name, physiologic jaundice because it is considered normal.

How will I know if my baby has jaundice?
​The newborn will start to get a yellowish tinge to the skin. It starts at the top of baby’s head and travels down the body through the torso. The whites of baby’s eyes may start to take on a yellowish tinge.  Jaundice usually peaks between 2-5 days after birth, and  lasts 1-2 weeks.

What can I do to minimize jaundice?
Bilirubin is eliminated through the digestive system. The single most helpful thing you can do to minimize jaundice is to nurse baby frequently. (Supplementing with formula does not clear out bilirubin any better than breastmilk so formula supplementation is not beneficial.) Light therapy can also be helpful since sunlight breaks down bilirubin. Place baby where natural sunlight will shine with just a diaper on, or completely naked.  Do this for 20 minutes 3 times a day. You could also consider having baby under a SAD (seasonal affective disorder) light if there isn’t a lot of sunlight in your home.  

When should I be concerned about jaundice?
In between postpartum visits, these are things that would indicate baby may need some help:

• Baby has yellow skin within the first 24 hours after birth
• Baby becomes jaundiced around 3 weeks old
• Baby has yellow skin below the knees
• Baby is lethargic
• Baby is not having wet or soiled diapers.  Baby should have wet diapers equal to how many days old they are, and should have some soiled diapers as well.
• Baby has lost more than 10% of birth weight.

Can jaundice be a problem?
Yes, in rare cases, jaundice can be a problem. There is breast milk jaundice, and pathological jaundice, often caused by blood type issues. These types of jaundice are typically recognized by when they appear, or how long they last. Both types are easy to treat if they are recognized and treated early.

Summing up
Jaundice is pretty common in newborns. It is also pretty easy to address with frequent nursing, and some sunlight exposure or other light therapy. There are some recent studies that indicate jaundice may actually have some benefits as an antioxidant in the first few days after birth, as well as protecting baby from Group B Strep infection. As your midwife, I will help you monitor and address any jaundice your newborn may develop, and advise you when it might be necessary to seek medical help.

Other sources not linked in post:
Thureen, Patti. Deacon, Jane. O’Neill, Patricia. Hernandez, Jacinto. (1999) Assessment and Care of the Well Newborn. W.B. Saunders Company.

Recently, a client decided during labor to transfer to hospital care for birth.  Shortly after we got there, the OB asked me why I "let" my client continue to labor. That got me thinking about what I see as the biggest difference between midwifery care and obstretric care.

There was nothing happening with the labor I was at that would indicate an immediate trip to the hospital was needed.  As I've written before, hospital transfers can happen for benign reasons like a client wanting pain medication, or because the client is tired and wants the tools hospitals offer to get contractions stronger to get finished. The client is in charge and if they want to go to the hospital, it's my job to facilitate and support them in that.

In the past the American College of Obstetrics and Gynecology has had wording to include "allow a trial of labor after cesarean"  as well as "allowed to push" in their provider guidelines. I was asked why I "let" someone continue to labor at home. The connotations those words have is the difference between midwifery and obstetrical care. 

To allow or let means someone is in charge, or has control over what another person is doing. My clients are adults who have taken the time to educate themselves on the risks and benefits of home birth, and they have also educated themselves on the risks and benefits of hospital births and interventions that are offered at hospitals.  

My clients are the ones making decisions regarding their care. My role is to facilitate and offer education so they understand what is happening and understand fully the risks and benefits of the options so they can decide what is best for the individual situation and for them. I don't "let" or "allow" my clients to do anything!!  My clients are fully capable of making decisions without my permission and I wouldn't want it any other way.