Friday, May 10, 2013

Avoiding Mismanagement: Why you should see an IBCLC for lactation challenges

I cannot stress the number of times I've seen breastfeeding parents -- exhausted and at the end of their rope -- come into my office after perhaps weeks of troubleshooting and self-diagnosis. Often these are issues that, if caught early on and properly managed, would be fairly easy to fix. However, the delay between the onset of the problem and the point at which they arrive in my office often means the treatment will be longer and more involved.

We are very fortunate to have a wealth of breastfeeding resources. Not too long ago, new parents that struggled with breastfeeding literally had nowhere to turn, and the bottles of formula offered up by their pediatricians became necessary. Today, we have La Leche League, WIC Peer Counselors, and a variety of moms groups and doulas that specialize in breastfeeding support. While I cannot sing the praises of these resources loudly enough, occasionally a lactation challenge requires more than simple remedies and old wives' tales. And while La Leche League in particular has a protocol for referring parents to a qualified clinician, social mom's groups and meetups often do not.

A recent case in particular comes to mind. It was a first-time mother who had struggled from the beginning with a suppressed milk supply. She was hardly at risk for such a deficiency: healthy pregnancy, natural birth, and great support at home. But something -- for the life of me I could not figure what -- had thrown a wrench in the gears very early on.

So she sought advice from several very knowledgeable resources: her childbirth instructor, her doula, some friends, her mother, and the internet. But these remedies were to no avail, and by the time she got to me she was providing less than half of what her baby needed in breastmilk, the rest supplemented in formula.

It was truly this mother's determination to breastfeed her baby that got her through what had become a very serious milk supply issue. The individualized plan of care I provided combined with her willingness to do all the legwork brought her supply back to a level she felt good about, though I can't help but think she'd be off the supplement completely if I'd had the opportunity to work with her sooner.

Again I want to emphasize the appreciation I have for lactation-knowledgable support persons, be they nurses, doulas, childbirth educators, friends, etc. Time and time again this support -- and lots of it -- keeps new parents focused on achieving their infant feeding goals even in the face of difficult roadblocks. However, what has inspired me to sit here and write this today is my observation that sometimes these support resources keep parents from seeking out clinical support when it's needed.

Why does this happen? I do not think anyone intends to keep a breastfeeding mother from seeking proper care. I think it's just that we all want to help. It's the nature of birth workers, of nurses, of care-giving family members, of friends... we see a problem, we want to help. And it is very difficult, especially for us doulas with multiple certifications, to admit an issue might be beyond our management capabilities.

I do wish to point out, however, that there are people out there who provide services that they are not appropriately credentialed to provide. There are a number of non-IBCLCs in particular that advertise "lactation consultation", and while they likely offer invaluable support to many new parents, they may very well be operating beyond their scope. This often creates the very delays I describe above.

I listed breastfeeding certifications in a post several months ago. I encourage you to check out what those letter combinations mean, and most importantly, check the scopes of practice for each.

Many doulas and childbirth educators in particular also have the CLE, CLC, or CLS credential. This makes them valuable support resources. Folks who hold these certifications are qualified to tell you when things are going well and when they are not, to offer support and encouragement, and to teach basic troubleshooting techniques. However, they are in no way qualified to provide clinical management of any major breastfeeding challenge.

Which brings me to my original point: the IBCLC is the only credential recognized the world over to provide proper clinical management of all breastfeeding challenges. Though even us IBCLCs refer to more advanced clinicians when necessary; sending a patient to her midwife or obstetrician for a fluconazole script comes to mind here.

A quick note on accessibility: it is true that lactation consultation from an IBCLC is more expensive than an assessment from a doula (and it's certainly more expensive than the free advice found on Google). You should be aware, however, that lactation consultation and supplies are now covered under most health insurance plans when it is provided by an IBCLC or higher. Most hospital-based clinics will file for you, and my private practice provides a form for reimbursement. I am fortunate to work as an IBCLC at Peaceful Beginnings of the Triad, a private practice small enough to make sure you see the same lactation consultant for each of your visits. We pride ourselves on following up with you personally and offering continuity of care. We also host a weekly Breastfeeding Clinic for minor challenges and reassurance.

In other words, when you seek the support of an IBCLC, not only do you receive care provided by someone who's qualified to provide it, your insurance is more likely to cover the visit. And when you get proper support at or near the onset of a problem, the challenge will be more easily overcome and require fewer appointments. It's a win-win, and the best way to ensure you and your little one are receiving the care you deserve.

Monday, February 18, 2013

What's In The Bag?

A lot of folks ask me what I carry in my birth bag, so I thought I'd share this image from today as I was packing up for my upcoming birth.
 Now I'm not the kind of doula that spends the entire labor pulling tools and tricks out of my bag, but because labor can be so unpredictable, I find it's important to carry a lot of this stuff with me just in case. What I have includes (in no particular order):
  • Massage tools: Nukkles, an Omni ball, several sizes of balls inside of socks, heated "stones", a foot roller, and a hollow rolling pin.  
  • Bath pillow, fully sterilizable.
  • Stress ball and comb for accupressure/hand rolling
  • Covered kneeler pad (also washable)
  • Flip flops and a change of clothes for me (just in case)
  • Microwavable brley pack - both scented and unscented depending on client's preference
  • Massage oil, lotion, peppermint spritz, and several essential oils for light aromatherapy
  • A compact fan (a client favorite for transition and second stage)
  • Hair clips/pins and ponytail elastics
  • 5 Hour Energy (disgusting but effective)
  • Battery-lit LED candles
  • Extra lip balm for mama or me
  • Sustenance for me (I never want to look at a granola bar after a birth)
  • Extra toiletries for me
  • Birth ball (not pictured) and air pump
  • A "pull toy" for 2nd stage... this was an idea given to me by another doula several years ago
  • Medical gloves in case of roadside delivery (hasn't happened so far)
  • The Labor Progress Handbook (aka, cheat sheet)
  • Client file and numbers for me to call if I need to reschedule appointments
Again, I don't use 90% of this stuff during a single labor, but you never know!

....and it all fits into one bag!!

Saturday, February 16, 2013

To Encapsulate or Not To Encapsulate?

Placenta encapsulation has become increasingly popular in the natural birth community. Claims of lower postpartum depression, the replenishment of vital nutrients, even increased milk production permeate discussions in both mainstream and "crunchy" circles alike.

Placentophagia (the eating of one's placenta) is found in many mammalian species, though interestingly has not been recorded in human history and is only occasionally observed in the reproductive behaviors of our closest cousins. Anthropologists have failed to nail down the specific drive behind placentophagia, however, the hypotheses have become the mantras of today's placental encapsulation enthusiasts.

I'll say this: I'm a huge supporter of the practice. Not only do I believe it can potentially replenish your body's nutrients, I also believe in every person's right to do what they will with their bodies whether or not they're giving birth. If you have spent the better part of 40 weeks growing the organ that sustained your child in utero, it is understandable that you wouldn't want it to just be hauled off to the incinerator. Many families opt to take it home, bury it, save it in a freezer, or have it encapsulated. Encapsulating parents take the capsules like vitamins, and indeed the placenta is home to a number of beneficial nutrients that may aid postpartum recovery.

On just about every placenta encapsulator's website, you can find the following claims:
It is believed that consuming your placenta can:

  • Help to balance your hormones
  • Replenish depleted iron levels
  • Assist the uterus to return to its pre-pregnancy state
  • Reduce post-natal bleeding
  • Increase milk production – this has been proven in a study
  • Make for a happier, more enjoyable post-natal period
  • Increase your energy levels

Sounds pretty good, doesn't it?

As much as I hate to be a buzzkill, I must interject here that there is absolutely no methodologically sound research to back many of these claims (or demonstrate how consuming one's placenta would, say replenish iron levels better than a diet rich in heme iron). I wish there was such research, but unfortunately, the evidence of any of the above benefits remains largely anecdotal.

Deena Blumenfield at Shining Light Prenatal Education breaks down the issues with some of the commonly-held beliefs about placentophagia, noting specifically the questionable claims surrounding oxytocin and postpartum bleeding:
Yes, oxytocin is present in the placenta… but how much of it is destroyed during the cooking or dehydrating process.  No one knows because there are no studies on this.  How much of any of the hormones or nutrients are destroyed during cooking or dehydrating?  Again, no one knows.
Placenta is also used to control postpartum hemorrhage ... by cutting off a small piece of placenta and asking mom to suck on it, or eat it, as her care provider is trying to control the bleeding.  However, this is used in conjunction with other techniques, such as uterine massage, to control bleeding.  So where is the bleeding control coming from?
As a lactation consultant, I wish to specifically address the commonly-held belief that consuming your placenta can combat low milk supply because of its high levels of prolactin. It's shocking to see a number of people citing "a study" on placentophagia and prolactin levels when in reality no such study exists.  Let me rephrase... no such methodologically sound study exists.

The "study" put forth by most supporters of placentophagia is Soykova-Pachnerova et. al, Placenta as Lactagagon. The first thing I noticed about this study is that you can't find it anywhere... I sifted through page after page of placenta enthusiasts citing it, but couldn't locate a primary source at all.

The second thing I noticed about this study, once I found a reliable source with more details about it, is that it was conducted in 1954. It had an extremely small sample size, it was not performed with any kind of single- or double-blind method (in other words, participants knew whether they were being fed placenta or the placebo), and it did not control for outside factors (first gestation vs. subsequent, overlying health issues, etc). It has yet to be replicated. From those issues alone I am prepared to dismiss this research as bunk. Moreover, I am concerned with the number of folks claiming increased lactation from placentophagia has been "proven in a study."

Still, I find that the rationale deserves a closer look. While it is true that placenta contains lactogens (human placental lactogen, or hPL), hPL is slightly different from the prolactin (PRL) responsible for milk production. In fact - to totally nerd out on endocrinology for a moment -  it appears that the similar hPL molecules, along with progesterone, keeps the body's prolactin levels at bay until the placenta is delivered.[1]

Which brings me to my next point: even with lactogens present in placenta, can taking them orally cause one's prolactin levels to increase? For this to happen, lactogens (prolactin, etc) would need to have some sort of oral absorption capabilities.  Do they?

Unfortunately, the evidence seems to suggest they do not. While the body of research on this topic is also lean (and decades old), a well-controlled experiment conducted in 1979 found that the serum prolactin levels of lab rats were not effectively raised by the oral administration of prolactin. This study has also not been replicated, however, the conclusive nature of the results may contradict the need for further study.

Lastly, anecdotal evidence of better breastfeeding success and lower PPD is suspect in that it leaves many socioeconomic factors out of the equation. Consider location alone: the provider listings at show that most placenta encapsulation specialists are localized to metropolitan areas, areas where there are also likely to be lactation consultants, peer support groups, friends close by, etc.

Now consider the economic factor. To my knowledge, placenta encapsulation is not covered by any insurance company (and definitely not Medicaid), with out-of-pocket costs ranging from $200 and up. If someone has the ability to pay that fee (especially after having a baby), they probably also have the ability to pay for a lactation consultant, a doula, a therapist, etc. They are more likely to be partnered and have well-paying jobs (which would denote higher education levels). These factors play major roles in breastfeeding success and postpartum depression risk alike; therefore, without research on placentophagia that controls for these factors, there is truly no way of knowing whether the placenta - not socioeconomic status - is what's lending these great results.

Regardless of all the suspicions I have about placentophagia being a "miracle cure," my opinion is that there are probably many benefits (mostly nutritional), and it is likely not harmful. There has been some concern over the 2011 study that found heavy metals present in placenta and cord blood, but those levels are likely a reflection of what the body has been exposed to anyway. I am not clear on whether or not re-consuming those metals will do any more damage, however, I would encourage you to speak with your midwife or doctor if that is a concern.

But unfortunately, the claims involving lower PPD and better milk supply seem to be anecdotal. I'll echo Blumenfield that I would love to see actual research. As someone who works with new parents as both a doula and lactation consultant, it would be great to find out that placentophagia does in fact have these miracle properties. In other words, I would love to be proven wrong.

Lauren Guy

[1]Jan Riordan, and Karen Wambach, Breastfeeding and Human Lactation Forth Edition, (Sudsbury, Massachusetts: Jones and Bartlett Publishers, 2010), 88-90.

Wednesday, February 13, 2013

Hiring a Doula: A Doula's "Stats"

This is Part Three of a series on choosing the best doula for you and your family. Are there other topics you'd like to see addressed in this area? Email me at, or visit my Contact Form.

I always encourage my clients and friends alike to research their care provider's stats. As in, how often do they induce, what is their cesarean rate, etc? (This is also helpful to learn about their place for birth, which has fortunately become easy to find out.) 

In the past year or so, I have been asked more and more about my rates as a doula. As in, what percentage of my clients have epidurals? What percent have cesarean births? And so on.

There's really nothing wrong with this question, and I happily answer as I keep decent records of the births I attend. But what you may not realize is that these "stats" don't necessarily tell you anything about the person you're interviewing. It may give you limited information about the kinds of births the doula has attended, but seeing how medical decisions are 100% out of our hands, you may be surprised to learn that stats don't dictate how effective a doula will be for you.

Now granted, if a doula has attended 10 births and 8 have been cesareans, I would want to know a few more details as there are many factors that may influence this kind of rate: does she regularly assist in higher risk labors? Does she get a lot of referrals from care providers with high c-section rates themselves? Did she just have a string of strange outcomes that required the surgery? Regardless, are you comfortable with her limited experience with vaginal birth?

I would be less inclined, however, to inquire about her epidural rate, as this really tells you nothing at all about how "good" a doula is. The vast majority of women giving birth today plan on having an epidural at some point during their labor, and while a person hiring a doula is less likely to plan for that option, families hire doulas for many different reasons. In other words, there is no reason to assume that a doula with a 70% epidural rate is a "bad doula." You may, however, have questions about her lack of experience supporting folks through natural births, which is a legitimate concern.

One thing to remember when hiring a doula is that no topic is taboo. It's your birth, and you deserve to find a doula that you are comfortable with! But keep in mind what questions tell you and what they might not, and if you want additional detail, just ask!  We're always happy to offer some insight, even when you haven't hired us yet.

Speaking of sharing... in the interest of transparency, my stats:

(As of 2/13/13)
In the births I have attended:
  • 58.8% were first time mamas
  • 33.3% opted to have epidurals
  • 25% were induced
  • 8.3% were cesarean births 
  • 16.6% were born in water
  • Shortest gestation was 38w 0d
  • Longest was 42w 2d
  • Shortest labor was 2.5 hours from start to finish (45 minutes with doula in attendance)
  • Longest was 30+ hours (27 hours with doula in attendance)
  • Smallest baby was 5lb 14oz
  • Largest was 8lb 15oz
  • All babies healthy
  • All mamas an inspiration

Monday, January 21, 2013

Hiring a Doula: Certified vs. Not Certified

This is Part Two of a series on choosing the best doula for you and your family. Are there other topics you'd like to see addressed in this area? Email me at, or visit my Contact Form.

A common question I get at interviews is the question of certification. What is the difference between a certified doula and an uncertified doula?

The answers to this question are as varied as doulas themselves. First off, there's a difference in certifying organizations. While each organization has similar requirements and scopes, they may have slightly different focuses. The larger certifying organizations include:
I am certified through DONA International, the largest of the above organizations. My certification process included the following:
  • Attend either a series on childbirth education or a day-long seminar on the process of normal labor and birth.
  • Attend a weekend-long training (minimum 16 hours) on labor support.
  • A self-study of a minimum of five books.
  • Attend a breastfeeding class (minimum 3 hours)
  • Attend a minimum of three births as the primary doula, totaling at least 15 hours of provided labor support, receiving evaluations from the parent, nurse, and midwife/obstetrician.
  • Create a comprehensive resource list for expectant/new parents.
Entangled in this process is a whole host of workshop fees, membership fees, material costs, etc. That being said, the monetary expense of certification alone may be prohibitive to many. Some doulas choose instead to just pay for the labor support workshop and leave it at that, or even learn skills on their own. Others certify for a period of time, but they choose to let their certifications expire when they no longer see the value in maintaining them. Some communities (Greensboro included) have volunteer doula programs with lower-cost trainings, such as the one provided by our local YWCA. Some organizations provide scholarships to minority groups who will be creating low-cost doula networks in their areas; still, I have heard these scholarships are difficult to come by.

This is the key difference between "uncertified doulas" and "doulas working towards certification." While uncertified doulas may have all the training and experience of one who has certified (and therefore similar fees), doulas working towards certification are less experienced but generally offer their services at a much lower rate.

In other words, a doula who chooses to forgo the certification process is as capable of being a strong supportive presence at your birth as one who is certified. Certification does provide a certain "authenticity," there is a clear scope of practice as dictated by the certifying organization, and maintaining certification requires us to stay abreast of new research and techniques. If this is important to you, you might want to choose a certified doula. If this is not as important to you, you trust your doula to be honest about her training and experience, and you find an uncertified doula that really clicks with your family, then hiring an uncertified doula may be the right option for you.

I have chosen to maintain my certification with DONA because I personally value the credential. But others may not (or they may not have the means to get it). No matter what the reason, there is no doubt in my mind that you could receive wonderful labor support from an intentionally uncertified doula just the same as one with letters after her name.

Sunday, January 6, 2013

Hiring A Doula: How To Interview A Prospective Doula

This is Part One of a series on choosing the best doula for you and your family. Other topics you'd like to see addressed in this area? Email me at, or visit my Contact Form.

I've been to several interviews recently where I was the first doula the family had ever spoken to. While they obviously knew what a doula was and what we do, they were unsure of additional questions to ask. Listed below are several things you might want to ask a potential doula during your initial consultation.
  1. "Tell me about your training/education." An easy starting question, this will give you an idea of your potential doula's expertise, plus a look at how we came to call ourselves Doulas.
  2. "Are you certified?" Less important than you might think (see a more in-depth look at certification next week), a lot of families desire a doula that holds a certain credential.
  3. "How many births do you attend per month?" This is a very important question because obviously, babies don't always come when it's convenient! If your doula takes on more than one client per month, be sure to ask if she has a backup in case of overlaps. If continuity of care is important to you (i.e., you definitely do not want her to send her backup), you may choose a doula that has a smaller client load.
  4. "Do you offer anything besides labor support?" While this is not always important to expectant families, a growing number of doulas have multiple areas of expertise. If you would prefer a doula that also specializes in massage therapy, belly casting, placenta encapsulation, breastfeeding support, or one who rents birth tubs, this is a good question to ask. Many provide these services at a reduced rate to their birth clients.
  5. "What is your fee, and how is it paid?" A doula's fee varies by experience, credentialing and location. Many require a deposit to be paid at the time of hire. Be sure to ask about reimbursement in the event that she fails to provide services. Lastly, if her fee is prohibitive to you, don't be afraid to ask for a reduced rate; many doulas take on lower-cost clients when they can, and can at the very least refer you to someone who may be able to meet your needs.
  6. "Do you have experience with _____?" Do you have special considerations that would narrow your search? Some expectant parents want a doula that has experience with specific scenarios such as VBAC, waterbirth, multiples, pregnancy after loss, or just attending births with a specific care provider. Any special consideration that you would like your labor support person to know about, just ask.
  7. "Why did you decide to become a doula?" This is a favorite topic of conversation, as all answers will vary slightly. While nearly all of us got into it because of our passion for birth, we all come to the table with different backgrounds that influence how we'll answer this question, giving you a better idea of who we are on a personal level.
  8. Anything else you think is important! Have them clarify what, exactly, they do prior to and during labor. Will they accompany you in the event of a c-section? An epidural? How will they work alongside your significant other? Ask about their personal experience giving birth, if that is important to you. Very few topics are off limits for your average doula.
If at any point you feel your interviewee does not meet your specific needs, don't be afraid to ask for referrals. Our area has a vibrant and diverse doula community that is generally non-competitive and desires the best fit for all expectant parents.