A visit from an International Board Certified Lactation Consultant, or IBCLC, can and will look different for each breastfeeding mother-baby dyad. Depending on the current, or past, issues the focus may be on the baby or the mother, or we may be working with both.
Here is a list of things that happen at visits with me:
I will listen to your concerns
I will take a current medical history for both mother & baby
I will ask about your social history (diet, any drugs of abuse, alcohol, exercise, etc.)
I will ask about your birth story (interventions or medical concerns that occurred during birth)
I will ask about your current feeding history (including frequency, diaper counts, and any supplementation)
We will assess your baby’s weight, a weighted feed is often done, but not always
I will observe an entire feeding, specifically looking at:
evaluation of transfer
evaluation of nipples after feeding
I will look at your baby from head to toe (structural assessment)
I will perform a functional oral assessment of your baby
If needed, I will palpate and assess your breasts
Next we will review, and I will ask any clarifying questions if needed
Finally, we will make a plan that works for you and your situation
Most of our time will be spent talking and I will work to educate you (and any present family member or support people) about whatever comes up. Typically while your baby is eating we can address any additional concerns about sleep (including sleep arrangements), dietary questions, pumping, returning to work, even partner intimacy and breastfeeding. I am not shy and will happily address any and all concerns I can in the time of our visit. After we finish getting the big picture, I will explain what I see and what my recommended plan of action is to meet your feeding goals. I want you to succeed and will do my best to ensure that nothing I recommend feels like “too much” or is overwhelming. We will make the final plan together.
I also don’t want your baby to feel overwhelmed, so here is what it looks like when I do an oral exam on an older baby. This process is similar for a newborn.
How can you prepare for a visit?
Schedule a time when you baby is most likely going to be hungry. Observing a normal feed is important for me to make the best recommendations possible.
Have a change of clothes for your baby and diapers, as needed
And change of clothes for yourself if you think you might need it
If you are supplementing, have either pumped breastmilk or infant formula available
Have a log of diaper counts and feeding frequency available, I know you are sleep deprived, either a written log or an app is great for this.
If you have concerns about pumping, have your pump available for me to troubleshoot and assess
A list of questions that you want me to address
Don’t worry if you forget something, you can always email me!
Thank you for supporting my birth doula client with me through transition, your words were supportive and kind. You honored my client and her innate ability to trust her body. You spoke softly and gently, you gave words of encouragement and affirmations. I could see how supported my client felt. It gave me a renewed faith in your hospital.
After about 20min of my client basking in the glow of her newborn, something changed in you. Your hospital was recently designated as Baby Friendly, which as both a doula and International Board Certified Lactation Consultant, I applaud the systematic change that took! You and your hospital see the value of ensuring breastfeeding starts within the golden hour after birth. What I didn’t expect for you to do was suddenly and forcefully decide it was time for my client’s baby to latch. You came over and said, “it has been about 20min, I think we should get her to latch.” You raised the bed nearly upright and then you took my clients fresh pink and healthy newborn and began forcibly shoving her face to my client’s breast. Her baby then started fussing and was not happy, and you said “don’t worry, we’ll get her on.” I stood there, next to my client watching you and wondering what on earth was going on. After a minute or so I calmly suggested we try repositioning. I changed the angle of the bed to allow my client to lean back more, I then talked my client through moving her baby over a bit so when baby came to breast her airway would be nice and open. I guided my client, with my words, on how to move her opposite arm across her baby’s back to support her head and neck. I explained how to use her other hand to hold and support her breast. Then without a fuss, her baby latched on for the first time. I did not physically assist at all. It was beautiful and my client was glowing with pride. This only took a few minutes. I did not rush, I was not concerned.
After a minute or so of a beautiful latch, on IBCLC Day no less, my client’s husband thanked me to being there and helping be sure breastfeeding got off to a great start. Maybe you didn’t know how hard breastfeeding was for their first baby? Maybe you didn’t know how medicalized and disempowered my client felt postpartum with her first child, as she was diagnosed with postpartum preeclampsia within minutes after birth? Maybe you didn’t know how important this postpartum time was to her? I did. I knew she could do it. I knew she wanted to do it. I continued to believe in my client and her ability to mother and latch her baby on her own, just as I had known she could birth without pain medication.
Our actions are powerful and a women who is still in the beautiful mind space of the golden hour does not need to be forced, she can be guided and, more importantly, empowered. I encourage you to take all the wonderful knowledge you received in the course of your facility’s Baby Friendly designation, and find ways to continue to honor the journey of motherhood. Just because you know how to do something, doesn’t mean you should. Find those words of empowerment you gave in labor and apply them to the immediate postpartum. Take a moment to use your words to guide the mother through the first latch. It may take some practice, but that is okay. Empowering a mother to latch her baby for the first time on her own is hugely powerful! You will imprint on her that she can do it, and that she can do it without physical help! Observe and commentate on the latch. Explain what you see and let her know! If adjustments need to be made try to talk her through them first. I promise this does not take a lot of time. I know your time is rushed and you have so many things to do and other patients, but I am telling you, taking this extra moment will save you time and empower your patients. You want to be remembered for giving the gift of empowerment, not for being the one that did it for them.
The us versus them of IBCLCs and CLCs has been going on for years. I admit that I felt the same way many IBCLCs do about CLCs too. It is hard to see someone take a one week course and see themselves as equal, but I also don’t feel that is how most CLCs are. All lactation care providers have been continuously undervalued in healthcare and not given credit for their expertise. Not all breastfeeding dyads need the level of care an IBCLC can and does provide though. Many families simply need encouragement and education about the normal course of breastfeeding, including normal newborn behavior, which CLCs are well equipped to provide and should be providing. Even minor corrections in positioning and latch are well within the scope of a CLC. After careful consideration, and heated conversations (thank you to my friend and ally Lissa for challenging me to look at this issue through a health equity lens), I believe that the biggest issue in the minds of many IBCLCs is that there is no current place for CLCs in our healthcare system in regard to the currently used Current Procedural Terminology (CPT) codes and billing. I believe CLCs do have a place in our healthcare system, and I believe I have a solution.
CLCs are counselors, they are well equipped for counseling and should be reimbursed. CLCs know normal and know to refer when things are not normal. As IBCLCs we should embrace this and network with our community CLCs and support them.
The rest of this discussion gets in to some of the nitty gritty of billing and coding, which while not fun is part of this solution. So try to stay with me! I know when I starting looking at all of these codes and terms when I first started I felt like my head was going to explode!
We are about to celebrate this little man’s first birthday in early September! He is such a joyful child and I am honored to be a part of his story that Kasie so beautifully wrote and has allowed me to share. I will always welcome his little hugs and am excited to watch him grow up!
The Doula I Needed – A Birth Story
by Kasie McCoy
I turned the alarm on my phone off, and continued to lay in bed. The silence of a morning before even the sun is awake was pressing on me. My due date had come and gone. I had tried it all- walking, dancing, bouncing on an exercise ball, sex, evening primrose oil, membrane sweep, reflexology… Yet my contractions didn’t pick up, my water never broke. I wasn’t going to go into labor naturally.
I was 41 weeks to the day. Due to a condition called polyhydramnios, I had more amniotic fluid than usual around my larger-than-average baby. These two things combined meant Induction. One of those things that other people had to have, but I wouldn’t. Yet, here I was. Starring at my wall. On induction day.
The sun had finally risen to meet us at the hospital a few hours later. Even though I was yet to be induced into labor, Sandra, my doula, was there, smile on her face, doula bag on her shoulder. Her familiar face and own comfort with our surroundings helped to make everything seem just enough friendlier. She stayed while the nurses inserted the IV I hadn’t wanted, and hooked my belly up to the restrictive monitors I had asked on my birth preferences sheet to avoid. She stayed while the nurses got me settled and I met the midwife on duty.
My heart was heavy with the understanding that the ‘natural’ birth I had so adamantly and desperately desired was not to be. But there was Sandra, and somehow her presence and attitude helped keep me present, instead of dwelling too immensely on my disappointment of the circumstances. It was nearly 12 hours later that the Pitocin they began earlier in the day jolted me into labor.
I never got the labor I wanted. I hadn’t been able to tell my husband the exciting ‘I think I’m in labor’ at home. I didn’t get to move freely around the hospital room due to the numerous cables, cords, and tubes attached to me. I wasn’t able to labor in a tub. There was no electricity in the air, no excitement. And because of that, I never got the doula I wanted, either.
I never got the doula who used a rebozo to help with discomfort because of the monitors attached to my belly. I never got the doula who came to our house to stay with me as labor progressed and intensified. I never got the doula who used massage or hip compressions to help with each contraction because I was mostly confined to a hospital bed. I didn’t get the doula I wanted; however, I got the doula I needed.
I got the doula that washed out the bin I just threw up into, for the umpteenth time, while my husband held my hand and helped wipe off my face. I got the doula that got me new towels to sit on while on a birthing ball because my contractions were so intense and close together I couldn’t release my grip on my husband’s shirt. I got the doula that helped keep all the cables and cords I was connected to out of the way while my husband helped me change positions. My doula didn’t do what I wanted, she did what she saw I needed, which was far more valuable.
Sandra kept us grounded in unfamiliar territory, both with labor and the hospital. She brought me things I needed before I even knew I needed them. She provided help without us having to ask or give permission. She never waited for us to call upon her, but instead stayed actively involved in both our experiences. She even helped me to see past what I wanted in order to focus on what I needed: pain relief.
After endless hours of weathering intense contractions, she helped encourage me to consider getting an epidural. Knowing my strong desire for a natural and medication-free birth, she was hesitant to broach the topic. But she knew what I hadn’t admitted even to myself: I couldn’t continue on the way I was until my baby was born. While the Pitocin had helped me progress initially, my progress stalled when I was 7 centimeters dilated. I endured hour after hour of contractions that didn’t get me any closer to meeting my son.
Sandra talked calmly with me, while my husband was by my side, and helped me to see the option not as a failure, but a tool. She knew I wanted a medication-free natural birth, but helped me see that if I kept going the way I had been, without any rest, that my fatigue could have resulted in me not being able to birth my baby vaginally- one of the few things left that I wanted and hadn’t yet been taken away from me as an option. She helped me to understand that pain relief would be my best chance at still having the energy to have my baby the way I wanted, even if the circumstances were not how I always envisioned they would be.
Due to a variety of concerns about both myself and my baby, I had over a dozen people in my labor room by the time my baby was born. My husband told me later that he grew increasingly concerned as person after person filed into our room. He kept glancing anxiously at Sandra, but her calm, focused demeanor helped him to relax and know there wasn’t any perceived danger to the baby or me. I pushed for nearly four hours before my son was born. A retained placenta and hemorrhaging after our son was born meant a manual removal of my placenta, which was painful; even with an epidural. Somehow amongst the chaos of the room Sandra managed to take care of both my husband and I simultaneously; helping him have skin to skin time with our baby, helping me breastfeed my newborn for at least a few minutes before he was whisked away for tests.
Once my placenta had been removed, my bleeding stopped, and my tearing had been stitched up, one by one everyone left my room. My husband was gone, with my baby; the doctors and nurses had all taken their leave, and I was alone, naked, and in pain now that the epidural had been stopped. I had no idea where everyone had gone, or if they were coming back. I didn’t know how my baby was, or really, how I was. But for the next few hours of being alone in that room, Sandra stayed with me.
I cannot imagine the intense loneliness and fear I could have experienced had she not been there, especially after such a long and eventful labor and delivery. She had been with us constantly for more than 28 hours, and it had been 38 hours since she first met us at the hospital. Still she stayed. We were both exhausted. We sat together in silence, and she commiserated with me without words. It was only when my husband, son, and I were settled in our recovery room that she took her leave- nearly 40 hours after I was first admitted to the hospital.
Hiring a doula to be with us for the birth of our son was singularly the most important decision I made during my pregnancy. Sandra helped me process so many choices and challenges that arose, even prior to my labor and delivery. Her presence, knowledge, and experience helped to guide us through much more than just my long, induced labor. Sure, I didn’t get the doula I wanted, but I got so much more than I could have hoped for: A compassionate, empowering birth partner and, even greater, a friend.