The Modern Midwife's Guide to the First Year

About the Author

Marie Louise is a midwife, adult educator, hypnobirthing teacher and author of the bestselling The Modern Midwife’s Guide to Pregnancy, Birth and Beyond. You can find her on Instagram @the_modern_midwife or at themodernmidwife.com for informative and evidence-based guidance.

Also by Marie Louise

The Modern Midwife’s Guide to Pregnancy, Birth and Beyond

Marie Louise

THE MODERN MIDWIFE’S GUIDE TO

THE FIRST YEAR

Contents

Introduction

Part 1: The First 48 Hours After Birth

Clinical observations post-birth

Birth experiences

Meeting your newborn

Feeding your baby

Caring for your newborn

Part 2: Newborn to Three Months

Birth’s the hard part … right?

The first 42 days

Postpartum nutrition

Common symptoms

Mental health in the fourth trimester

Safer sleep for babies

Supporting your baby’s development

Crying

Getting set up at home

Part 3: Three to Six Months

What to expect

What’s happening with your baby

Routine and finding your flow

Returning to exercise

Sleep

Relationship difficulties

Part 4: Six to Nine Months

What to expect

Weaning

Your baby’s personality

Illness

Mama self-care

Part 5: Nine to Twelve Months

What to expect

Putting your needs first

Going back to work (or not)

Happy birthday to you

A final note

My top tips

Helpful resources

References

Acknowledgements

Index

Introduction

WELCOME TO THE wonderful world of motherhood. If you’re reading this, I am sure you’ve already been on a huge journey and are about to embark on another one – the first year of your baby’s life. You may be reading this book during pregnancy, shortly after birth or several months later. Wherever you are on your journey, it’s great that you’re here – feel free to dip in and out of the book as you need to.

Becoming someone’s mother is one of the greatest and hardest transformations life has to offer. We are all unique individuals and there’s never one way of doing anything. Yet there are many questions, decisions and opinions. It can be really tough for new mums to know who to take advice from, where they fit in within mum groups, and to settle into themselves as mothers. You are a different person after becoming a mum. There are many changes within the first year and I want you to know now that if you find this hard at times it’s because motherhood, whether it’s for the first or fifth time, is hard. Especially in today’s world with all its pressures on so many areas of our lives – from social media and careers to our identity. More often than not, you can trust your gut instinct to guide you, especially once you build confidence as a mother.

As a midwife for many years, I assumed I would cope with motherhood well. I thought I knew what I was doing, at least at the beginning. I thought motherhood would come naturally to me and I would be able to trust my intuition and instincts as a mum. Part of this was true, but much of it never really became reality. My intuition seemed to get lost in my emotions, self-doubt crept in and it was hard to think straight. At times I didn’t know who to listen to or even the best place to turn. Some of those difficulties are normal, such as the extreme emotions you feel, and may serve a purpose, but the confusion and self-doubt can be mitigated with the right support, science and a little guidance. Eventually I managed to reach a healthy balance of being able to listen to advice and pick what I wanted to take away and what I wanted to leave.

My aim in this book is to offer you some guidance during the first year of your baby’s life and your life as a new mum. I have highlighted what to expect at different times, with a constant yet important reminder that all babies are different and you will know what’s right for yours. When I wrote my first book – The Modern Midwife’s Guide to Pregnancy, Birth and Beyond – I had not had a baby. Now that I have joined you and become a mother to the absolute love of my life, Georgie, I am able to share some of my own experiences as well as offer you support that is backed by research. Along the way you’ll find ‘honesty boxes’ where I have shared some deeply personal experiences which I hope you’ll find helpful. I have purposely chosen not to sugar-coat things because I think real-life experiences and raw emotions help mothers more than glossing over or making light of a tough situation. Your journey will be unique and different to mine, but I’m sure you’ll find yourself nodding along in agreement in a few places. I hope you find comfort in knowing you’re not alone. Writing about my emotions and difficulties has been a healing experience. I laughed and cried many times, and I thought of you reading this and how amazing we parents really are.

You deserve to feel confident and better able to care for yourself as well as your baby, and I hope this book enables you to do just that. There’s a lot to cover and a lot to talk about, as ever so much happens within that first year: from recovering from birth, to teething, weaning and sleeping, to supporting your baby to learn and develop (their brain doubles in weight within the first year of life), your relationship, if you are in one, and then you, mama. It is going to be okay.

We cover each section chronologically. Take it slow and try not to think too much about how you’ll cope with the next phase. Some light planning and awareness will do, but focusing on what’s happening now, in the present moment, may be best; we can often overthink things as mums or beat ourselves up if we don’t get it ‘right’. We all make mistakes and we learn – motherhood is all about adapting and learning on the job, so to speak. Whether this is your first baby or not, all babies are different and come with their individual ways.

Throughout our journey through the first year I have a few experts joining us. I am an experienced midwife and mum, but my main expertise is within the first eight weeks after birth. That’s why, as well as incorporating my own research, I have discussed different areas relevant to you with experts I trust or who have personally helped me.

HOW TO USE THIS BOOK

To keep it simple, I have divided the book into parts based on three-month intervals, the exception being the first part, where we focus on the initial 48 hours – this time warrants a separate section, as I hope you’ll agree after reading through it:

The first 48 hours after birth

Newborn to three months

Three to six months

Six to nine months

Nine to twelve months

This book is a natural progression from my first book and I hope you find it just as supportive and nurturing, which is an intention I always set out with when I start writing. There are inevitably a few crossovers between the two books in a couple of places, but if you would like to know more about pregnancy and birth, please do have a look at my first book which is full of information about these topics. Once again, you’ll find key points at the end of each section. Mums are super-busy and I appreciate you may not always have time to read the whole section, so the key takeaways are there to help set reminders. You may also want to use them as a prompt, to see if that section is relevant to you at the time.

Because many of my readers highlighted these key points as a helpful tool in my first book, I wanted to expand on them here and thought you might find a special section with my top tips helpful too (see pages 235–40). These are little bits of information I have gleaned along the way, notes to myself and quick reminders. This section is intended to support you to take what you find helpful and leave anything that doesn’t feel authentic to you. We all have different ways of approaching the same situation and that’s okay. I hope you find something helpful in and among those tips to implement on your journey.

There’s also a final note to you on page 233. You may want to come back to this and read it if you’re having a tough time, or difficulty crossing from one stage to the next and need some reassurance or a reminder.

No matter what happens on your journey through motherhood you will learn that you’re stronger than you ever knew, and that sometimes the toughest times lead to real personal growth and make you a better version of yourself. Watching your baby grow and learn about the wonders of the world is one of the most beautiful miracles life has to offer. This is such an exciting and huge chapter in your life.

You’ve got this! x

THE FIRST 48 HOURS AFTER BIRTH

A very warm welcome to the wonderful world of motherhood, mama. In the early hours after birth, feelings are difficult to put into words and are likely to be bigger than you ever could have imagined. This is very normal for all mums. You’ve just experienced one of the biggest events life has to offer. Allow yourself to go through all of these powerful emotions: the scary love, worry, tiredness, amazement, vulnerability, pride, relief, fear … (I’m sure you’ve got a few more to add).

The first 48 hours will look different for everyone and depend on a few things, such as the type of birth you had, what happened during the birth and immediately after, who was with you, where you gave birth, how many weeks your baby was born at, and how well you are both recovering from the birth. These will all be unique to you and your new baby. In addition, there are so many aspects that have an effect on your individual experience – your birth experience, any medication you had, and the length of your labour, to name a few. There’s no right or wrong way to feel. Some mums get that instant rush of love; others don’t. There’s nothing wrong with you if you don’t get this right away. Your birth experience will impact those very early feelings and emotions. If your experience differs greatly from what you were expecting or had heard about, this may make you feel alone. I can absolutely promise you that someone somewhere in the world is experiencing exactly the same situation as you.

In this part we are going to start with some of the things you may experience soon after birth, including the clinical checks and wound care. We’ll then move on to birth experiences and how to manage them. We will run through a few types of experiences and hopefully you will finish this section with more understanding of why you may feel a certain way and have confidence to ask questions. Lastly, the focus shifts to your newborn baby, starting with caring for their skin and cord, initiating breastfeeding, normal newborn behaviour, and the role of healthcare professionals – once you’re home. I’ve created a little list of places and organisations you may find helpful in the resources section on page 241.

Whether you’re a first-time mum or have given birth several times before, this will be a new experience and will change your family dynamic. It’s important to know from the start, this early on in your journey, that there will be things that throw you, make you feel vulnerable, and you may even question everything you thought you knew about yourself. All mums go through a huge transitional phase and transformation when they have a new baby. It’s going to be okay. You’ll work through the hard times and you will be an amazing mum. In these first 48 hours I’d really recommend you carefully carve out some protected time for yourself and time to bond with your baby – uninterrupted. For those of you with babies in the special care baby unit (also know as SCBU or NICU), you can still recreate this bonding time once your baby is ready. You haven’t missed out – it’s a little delayed perhaps, but you’ll have this moment and it will be blissful.

Clinical observations post-birth

WHEN YOU ARE moved to the postnatal ward, or if you are being discharged home from a midwifery-led unit, the first check you can expect during the postnatal care pathway is often referred to as a ‘full postnatal check’. It is a thorough top-to-toe assessment of you. At the same time your baby will receive a ‘neonatal check’ – should you consent to these, of course. Your midwives will document everything in a checklist-style table either on paper or digitally, depending on whether or not the hospital you receive care from has gone paperless.

After taking into account the type of birth you had and any additional concerns or risk factors (most commonly due to infection, meconium, blood loss or any complications during pregnancy), you may be offered more frequent checks or blood tests. If this is the case, it is important to ask all the questions you have so that you can make an informed choice about whether or not you would like to accept the recommendations or tests. I want to be really clear here: I am not suggesting you decline recommendations from your healthcare providers. Instead, I am encouraging you to ask questions to ensure you have a full understanding of what is happening medically and why. We all have different perceptions of risk and the hospital may have a particular policy due to extensive research and reliable statistics, a previous case that led to a poor outcome, or a clinician’s expert opinion. That does not mean to say that their risk assessment is in line with yours or that you have to do or administer anything to yourself or your baby that does not seem appropriate to you. Only you can decide what you think is necessary. And you won’t be able to make that judgement until you ask those questions. That said, some people are happy to follow every recommendation because following all recommendations is what makes them feel safe. We are all very different – whatever works best for you is fine.

‘HOW ARE YOU?’

Your midwife will likely start by asking you how you are feeling. Speaking to you directly is the number one way many clinicians assess your individual needs, so please give your midwife as much information as possible and always be honest. So many mums say ‘fine’ when I ask this. It’s okay not to feel fine and it’s best to let your midwife know if that is the case so they can really support you to heal or address any of the concerns you have. The majority of further tests or diagnoses I have made in my career usually start with what a woman tells me, not by completing my checklist. That’s not to discredit the list – it’s helpful when you have a lot to remember – but the information you tell us takes priority. You’re the expert when it comes to your own body and you know when you don’t feel right. Please use this question to address any concerns you have about yourself. And try to focus on yourself here. The number of times mums reply with something like, ‘So, the baby wouldn’t settle in the cot last night …’ Yes, it’s important we address every concern and question you have about your baby, but try to think about your needs here. Even just for that one question, your health, healing and wellbeing matter.

OBSERVATIONS AND ADDITIONAL TESTS

After your midwife has covered your concerns, answered questions or concluded whether you need further tests/referrals, they will undertake a full set of clinical observations – this is nothing out of the ordinary so try not to worry. Generally, that’s your blood pressure, heart rate, respiratory rate and temperature. If you’re in hospital or have had a heavier bleed, your midwife may want to check your oxygen saturation levels too. There are some additional checks or blood tests that you might be offered, but that is completely dependent on any current medical condition and symptoms. You should also be asked about your breasts, whether you are breastfeeding or not. Don’t hesitate to remind your midwife or doctor of any follow-up tests that have previously been recommended to you. It’s unlikely these will be missed, but it’s always good to ensure there’s good communication and that your expectations surrounding what was to come are in alignment with what is being recommended/undertaken.

WOUNDS AND BLEEDING

Once the observations have been taken, next they will want to assess any wounds, either from a C-section or due to perineal trauma – we’ll go into more detail about this in just a moment. Your midwife will closely assess the wound and ensure there’s no excess bleeding, oozing or unexpected smell coming from the wound site. I know this doesn’t sound very pleasant, but please don’t feel embarrassed; we’ve seen and smelt it all before and will do again and again after you.

It’s normal to bleed after birth for up to a few weeks. Your placental wound site (the size of a dinner plate) needs to heal and the lining of your womb sheds. Some women are quite surprised at how heavy the bleeding is after birth and are alarmed by clots lost. You do need to let your midwife know if you’re passing clots, but this is very common and usually nothing to worry about. Your midwife will assess any clots and be looking for placental tissue, so don’t be surprised if they’re having a rummage around in your blood clot. It may look odd, but we want to ensure there’s no tissue left inside your uterus.

Tip: If you have any concerns over your blood loss, keep whatever is on your pad for us to have a look at! It’s much easier for us to see rather than hear about.

Assessment and repair of any wounds

Between 85 and 90 per cent of first-time mums who give birth vaginally will have some form of perineal wound following childbirth. Of these, 70 per cent will require suturing after birth. If you have had a tear, remember just how common it is, even if women don’t talk about it or you were not forewarned. Lots of mums tell me they had no idea about tearing and the process of suturing or wound healing. Part of what I campaign for, and have been for a while, is better education for women in general but especially in relation to the postnatal period. There are hundreds of thousands of (self-proclaimed) experts handing out birth preparation advice on every forum going, but there’s not enough about what happens after birth. Therefore, when women have babies there are many surprises and taboos – tearing being one of the top ones.

Some mums have asked me how common tearing is because no one ever told them about it and they really thought they were among the few to sustain a tear to their perineum (the skin between the vagina and anus). The reason tearing is not discussed prior to birth is likely due to concerns over scaring mums, but withholding information can be more damaging in the long run. There are many ways to have difficult conversations with pregnant women that empower them and leave them feeling informed rather than scared.

There are very small and simple things that you can do to prevent perineal trauma, such as the choice of your place of birth (research shows that mums who give birth in a midwifery-led unit or at home have significantly reduced chances of perineal trauma). Birthing position and hydration of tissues are also important, both externally – such as with water immersion – and internally via drinking water prior to and during labour. Sometimes, no matter what you do to prevent a tear, it may still occur. But many mums don’t know they have torn until midwives or doctors have a look and diagnose the type or grade of tear after birth. Please don’t blame yourself.

It had been 150 years since a midwife invented a tool especially for perineal repair (stitches, also known as sutures, to repair tearing after birth). But an incredible Danish midwife, Malene Hegenberger, thought that was far too long and invented a device called the Hegenberger Retractor – the first and only device in the world designed by a midwife for perineal repair. It improves visibility for midwives and doctors while stitching and reduces pain for women undergoing the procedure. Malene is a true expert when it comes to suturing and has been a midwife for more than 22 years. I thought it would be good for her to share some of her advice around this topic too:

‘Please speak up if pain relief is not working properly, and if the place you gave birth has gas and air you can supplement the local anaesthesia with this too. Just make sure you’re still okay to hold the baby if they are with you or let someone else take over. If a tear has been stitched it is normal to have perineal pain for three to five days, but it is important that you feel a slow improvement. If the pain continues or increases, you need to be checked by a midwife or a doctor. I would recommend that you have a look at home with a mirror – it almost always feels different to how it looks.’

Malene Hegenberger, midwife

As Malene says, it’s common to have perineal pain for up to five days after having stitches, but thereafter the pain should be slowly but surely improving (see page 14 for tips on managing pain). If, however, the pain persists or worsens this is a very clear warning sign and possibly indicates infection or the need to reassess the suturing. Unfortunately, the wound will need to be reassessed as soon as possible. Early-onset infection is quite common and will usually need medicating with antibiotics. To prevent this, and also help manage infection, after having a shower wait a little before putting on underwear and maternity pads. Airflow helps to dry out your skin and therefore aids healing. It may not feel or look like it now, but you will heal; the vagina has a wonderful blood supply and tends to heal beautifully given the right environment.

YOUR BLADDER

During pregnancy, your organs become displaced to accommodate your growing baby. Your bladder is affected by the weight of your growing uterus, alongside hormones, and causes you to feel the urge to pee little and often. The usual wee window is between two and a half and four hours in a non-pregnant woman, although this will vary depending on how much you’re drinking. Your bladder may have become used to more frequent urination. That’s why it is important to consider retraining your bladder after birth and to remember that window, not immediately but as the weeks go by.

When it comes to passing urine after a vaginal birth, lots of mums report a stinging sensation if they have a wound or grazes (see page 14 for managing this). Your perineum can also be sore and swollen, and it may feel weird – almost like your perineum doesn’t belong to you. This is quite common and usually resolves itself quickly. If ever you’ve got any concerns over the healing of your perineum or what it looks like, then, once again, talk to your midwife or ask for an assessment.

Postpartum urinary retention (PUR) is common in varying degrees and often means you can’t wee within six hours of giving birth and, if you do, you may only wee a tiny amount. PUR is poorly researched and understood, but most often occurs if it’s your first baby, you’ve had an epidural or spinal anaesthesia, you had a long labour or assisted birth, you had a tear or needed stitches, or you had a UTI or previous experiences of bladder problems. For this reason, your first urination post birth should be measured by your midwife. This is really important so please remind your midwife if you feel the need to go but they have not provided you with a jug. If you required a catheter during your labour or birth, then your midwife will usually request to measure at least your first three urines. There may be need to measure more should you not pass enough urine within these. PUR usually resolves itself within a few days, but please speak to your midwife about any symptoms you experience.

CATHETER CHAT

If you’ve had an epidural, spinal or general anaesthetic you would have had a catheter sited – this is a thin clear tube that’s inserted via the urethra and remains in the bladder, draining your urine during the time you’re less mobile and unable to take yourself off to the loo.

The catheter will need to come out after you’ve had your baby, and as mentioned previously, your midwives will assess your urine output to make sure you’re emptying your bladder properly and look out for any signs of infection. Simply put, anything that goes into your body has the opportunity to cause infection, especially around that area. In case you’re wondering, catheter