The EngagED Midwife
The EngagED Midwife
From Placenta to Production: Understanding Lactation
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Milk supply can feel mysterious when you’re tired, sore, and staring at a hungry newborn. We sit down and make lactogenesis practical by walking through what’s happening in the breast during pregnancy, what flips hormonally right after the placenta delivers, and why “milk coming in” usually peaks around days 2 to 5. Along the way, we translate the science into the questions we hear every week: Is leaking in pregnancy a good sign? Why does engorgement happen? When should we worry about a lump, redness, or nipple discharge?
We also get honest about the lived experience of feeding in the real world. We talk delayed lactogenesis and the common culprits like retained placental fragments, postpartum hemorrhage and pituitary effects, PCOS, cesarean timing, and edema from heavy IV fluids that can make latch feel impossible. Then we shift into lactogenesis 3, where supply becomes locally regulated and milk removal drives production, including the role of the feedback inhibitor of lactation. If you’ve ever panicked because your breasts suddenly felt soft or you stopped leaking around week 3, we explain why that can actually be a sign your body has calibrated beautifully.
Letdown is its own puzzle, so we dig into oxytocin, what blocks it (stress, fear, pain, cold), and simple tools that help, including warmth before feeds, cold after, and the “three Ws” that support pumping and letdown: warmth, water, and watching. We wrap with fast myth-busting and one of our favorite postpartum interventions: teaching partners and families how to protect the “oxytocin bubble” so the feeding parent can focus on rest, baby, and recovery. Subscribe for more evidence-based midwifery conversations, share this with a friend who’s feeding a newborn, and leave a review with your biggest milk-supply question.
#TheGoldenHour #Breastfeeding #ChestFeeding #NourishingNewborns #DemandAndSupply #Lactogenesis #BreastfeedingJourney #ProtectTheOxytocinBubble #Support
Welcome to the Engaged Midwife podcast. This is Missy. And this is Kara. Pardon the interruption of us being off by a week.
SPEAKER_00Yeah. You know, spring has sprung in parts of the Midwest. And what did you tell me on the phone the other night? What did I tell you?
SPEAKER_02That I sounded like a man.
SPEAKER_00Well, yes. You're not you're still not at your ideal, but we needed a break. We needed to cut our sinuses a break.
SPEAKER_02I sounded like a like a man who'd been like chain smoking for like you did. Like 10, 20, 30 years.
SPEAKER_00Yes. So we took a break. We took a much needed break.
SPEAKER_02For a week. For a week. Because I couldn't talk before that. Yes. And now I'm only talking with the helps of my friend Allegra, Claritin, and Flonase.
SPEAKER_00God bless Flonase. I am telling you, spring, the spring exacerbation. I have to take allergy medicine to function on a daily basis, year-round. 365. Correct. Me too. Yes. And so the flonase comes out in the spring when my eyeballs feel like I'm going to scratch them out of my head. And they're drippy and gooey and nasty. So thank you, Flonace.
SPEAKER_02I don't ever have the eyeball thing. It's literally like my nose is like a is like a faucet. Ugh, I hate it. But I don't have like eye pressure, my ears don't hurt. Like it's nothing weird like that. It's literally just this face thing. And my voice turns funny because of I get all raspy and sexy because of post nasal drip. Sexy, that's a word for it. I mean, could be like a little Jessica Rabbit situation. Sure. Sure. Do your children, if you said Jessica Rabbit, would your children know who that is? Probably not. I made my children sit down and watch that movie. Um, and they were like, Mom, this is really good. And I'm like, yeah, this is before computers started doing all the animation for you. That was a big deal at the time. Yeah. It's a really big deal. A really big deal. Anyway, we digress. Hey. So um we're back. And oh, by the way, if you didn't know, we're like sitting next to each other too.
Why Lactogenesis Matters For Care
SPEAKER_00We are. Um, we are also in the city. So if you hear some background noise of traffic and horns honking and sirens, we're in the big city. Welcome to Chicago. Well, what are we doing in Chicago? We are teaching a workshop for UIC.
SPEAKER_02Yay, Moodworth Free students.
SPEAKER_00So fun. Yes, it's one of our favorite things is doing live workshops.
SPEAKER_02Yeah, we're happy to be here and be in front of a room with some students tomorrow. So, um, but here we go. Yeah. What are we gonna talk about?
SPEAKER_00Lactogenesis.
SPEAKER_02I love this topic. I know. I will tell you why I love this topic. One, I teach the postpartum in newborn content. Yes. Two, it's something that I don't feel like I had a great handle on when I was a student, but have learned so much more about like throughout my years in midwifery. Yes. And three, if you understand this, it makes such a difference with all kinds of different like breastfeeding complications, milk supply issues, right? All kinds of like complications of the postpartum period.
SPEAKER_00Yeah. I mean, I think I was excited to have this topic for discussion. And this is one that students, I think, asked us about. And mostly because of the exact same reasons that you said, of this was not something that I really remember learning a lot about. You know, we were always taught supply and demand. And there's more to it than that.
SPEAKER_02Yeah, and I also think that like when you think about lactogenesis and the changes that happen in the breast and the physiology, and we're gonna get to that. It's also ties back into gynecology and primary care when we think about breast screening, because we know that well-differentiated tissue likely is less is less likely to get cancer. And so, as the tissues differentiate through lactogenesis, we know women who've breastfed for a certain, even not even for a certain amount of time, but at all, have more differentiated tissue than somebody who's never breastfed, right? Or been pregnant even.
SPEAKER_00Right.
SPEAKER_02So the physiology, I think, of this topic like ties into so many other aspects. It's one of the reasons, like if you're doing a cancer screen, they ask you, have you ever been pregnant? They ask you how many live births you've had, right? Because that's when differentiation of breast tissue happens, right? Right. And then um, if you breastfed. And so there are reasons that they ask those questions and it ties into the physiology of lactogenesis. Absolutely.
SPEAKER_00Absolutely. So, you know, we have long believed that breastfeeding is the best thing that you can do. It's a physiologic process, but not everybody is able to master it or achieve it, or nor does everyone want to. But for those that do, we want to talk about ways that we can help support breastfeeding, help support lactogenesis, good milk supply, and really understanding all of the different components, like what's happening during pregnancy, what's happening in the initial postpartum, and then what helps us maintain the breast milk supply later on. Yeah. Okay. I'm actually kind of pumped about this.
SPEAKER_02Pun intended. Um, I also want to tie this back to an episode that we released not that long ago on social determinants of health and how breastfeeding can be very like polarizing in some instances because women who don't have the resources to either be home postpartum or resources to stop their jobs and pump, yeah, or be lucky enough to be home and be breastfeeding on demand. Like, I think there are so many things that we pushed breastfeeding really, really hard in the past where we're like breast is best, breast is best. And now we know it's more like fed is best, and we're not providing guilt around the idea that some women are not set up in life to be able to breastfeed effectively.
SPEAKER_00I still think there's way too much guilt. Um, but yes, hopefully we're moving away from that. And as midwives, hopefully we can support them. Yeah.
Breast Changes During Pregnancy
SPEAKER_02All right, let's start with physiology.
SPEAKER_00Okay, so the physiological adaptations that happen in the breast really begin during pregnancy. Yep. And we're gonna talk about mammogenesis, and that's when the breasts undergo the changes like growth and development of mammary tissue during pregnancy. And we said we were also gonna talk about lactogenesis, and lactogenesis is the milk development.
SPEAKER_02Correct. So mammogenesis is the part that helps the breast tissue differentiate, yeah, like I was just talking about before.
SPEAKER_00Yeah. So estrogen causes the milk ducts to branch out like limbs on a tree. So that's one of the changes that happens. And then we also have um progesterone that triggers the growth of the leaves on the tree. And those leaves are the alveoli, and they're like grape-like clusters where milk is actually produced. And so estrogen creates the branches, and progesterone causes the leaves on the tree to develop.
SPEAKER_02And I think when all of those things happen, you also have to increase the vascularity of what's happening in the breast. So the blood supply to the breast actually doubles.
SPEAKER_00That's yeah. Think about those, you know, in pregnancy when the women have those really prominent veins on their breasts. That part of it is because we need that blood supply for all of this to happen.
SPEAKER_02And then I think other physical changes that happen during this period are the changes to the um, to the areola, um, and they get darker, right? Yep. And we form those Montgomery tubercles that get bigger, right? During this sort of physiologic phase.
SPEAKER_00I saw the funniest TikTok the other day where a girl was like, Did you know those bumps on your press have a name? I was like, I did know that actually.
SPEAKER_02Like, did you know that that pain you have mid-cycle has a name? It does. It does.
SPEAKER_00Um, it was so funny. We did know that. We did know that. Yeah. So I always thought of the darkening. I remember one of my instructors once told me that's so the baby could find your nipple.
SPEAKER_02That's just terrible.
SPEAKER_00I know, it's kind of more of a bullseye, I guess.
SPEAKER_02I also think that there are varying, just like everything else, there are varying degrees of this. Because like not everybody's nipples get darker when they have babies.
SPEAKER_00Well, some of us don't have enough melanin in our body to create dark anything.
SPEAKER_02From the two whitest girls you know. You're way you're whiter than I am.
SPEAKER_00I'm fair skinned.
SPEAKER_02You you're transparent.
SPEAKER_00I am fair skinned.
SPEAKER_02So, okay, so some of the complaints that women experience in pregnancy have have to do with physiolog with the physiology.
SPEAKER_00Yes. Uh-huh. So one is like the tenderness and tingling that they'll have in their breasts, and partly that is just the tissue expansion and growth, but also that increased blood flow, and that's putting pressure on those nerve endings in the breasts. And then they can also have extreme heaviness because the breasts increase in weight by about one to one and a half pounds during pregnancy, just due to that new glandular tissue development. And itching. Oh, yeah. Growth.
SPEAKER_02Yeah, it's this, it's like just like any other stretch mark or stretching area. You get itchy from the striate.
SPEAKER_00Yeah. And do you remember um when you started leaking in pregnancy? Leaking milk? Uh yeah, I do. I feel like mine was like literally at 20 weeks. And then, you know, they say it can start that early. Um, but some people don't have any leaking, and it doesn't mean that you're gonna either produce good milk or not produce good milk. I it's just that it can happen.
SPEAKER_02Yeah, I don't think it was like till really late, like 36 or 37 weeks, when I was like working on pulling my inverted nipples out, like I was wearing like a shield. Yeah. And then I noticed it. But I also think that had something to do with like a nipple stimulation from wearing the shield all the time.
SPEAKER_00Well, and I think I would notice it, and this makes sense. I would notice it when I had my bra off. And it's probably because my t-shirt worked up or that sort of thing. Yeah.
SPEAKER_02So when you hear your patients who have what we would call normal discomforts of pregnancy, right? That would be like, I feel like my breasts are burning, or they feel really heavy, or I'm my breasts are really sore or tender. Like we can attribute a lot of those normal discomforts kinds of complaints to just normal physiology.
SPEAKER_00Yeah, yeah. And helping normalize it and know that they're not alone and feeling. I think that's what a lot of people just need to be heard and let them understand why those changes are happening.
unknownRight.
SPEAKER_02So, what kind of advice are we giving to patients when they're experiencing those things?
SPEAKER_00Well, as I was just mentioning, a good supportive bra could be helpful. How much have we learned about bras since I've had breast cancer? A lot. A lot. Um, it's fascinating.
SPEAKER_02We're on a whole new bra journey.
SPEAKER_00Yes. Yeah. I'm also at the age where I feel like my clothes shouldn't hurt me. So I have moved away from probably as much support as I should have to just comfort. I don't I don't want to feel like I'm being squeezed.
SPEAKER_02Yeah.
SPEAKER_00My new thing is like I need to wear a bra, but I don't want to feel like I'm wearing a bra. Yes. Um, in pregnancy, one of the things that I really liked, more so postpartum, but the sleep bras. I loved wearing a sleep bra. I probably could wear one of those all the time. It wouldn't give me any shape or support.
SPEAKER_02But and I think that bras in general have come so far, like we are of the underwired generation. We are, and I have moved away. I don't, I don't think I own any anymore. Well, I can't, yeah, post-mastectomy, but um, I was still of the underwire generation until I got breast cancer.
SPEAKER_01Yeah.
SPEAKER_02And literally, I think one of the letting go things for me was like letting go of all those bras.
SPEAKER_01Yeah.
SPEAKER_02But also then like walking into a store and like looking at the new, I I hesitate to call it technology, the new like styles of bras and how they can not look like grandma bras, but still be really pretty, but not have a wire in there.
SPEAKER_00There's some on TikTok that I really, really like that are gel bra, like they've got gel supported them. I got a gel one.
SPEAKER_02I like it. No, you like it.
SPEAKER_00Okay, it's nice. It's nice.
SPEAKER_02So the bra thing is important.
SPEAKER_00Yes. And then I have told so many people in my life that I feel like a bath is healing and it's the hydrotherapy that can be really helpful for your breasts too. So not just a bath, but also being in the shower, you know, it could be cool or warm, whatever that is, that can help that tissue feel more comfortable for you. Yeah.
SPEAKER_02I like the idea of maintaining skin integrity too, right? So vitamin E can be helpful, coconut or almond oil. I will also tell you, and I don't, I would have to like look more into it because I don't know who makes it, but dandelion oil, and it's usually like dandelion in something in some other sort of emollient, but it is actually good for like all different kinds of skin issues and is good on stretch marks. So that would be another like thing for itching and discomfort from stretching.
SPEAKER_00Yeah, that sounds comforting. Um, I think you know, avoiding really harsh soaps and different products, um, a lot of scented products, that kind of stuff, just you know, helping to make sure that the sensitive tissues aren't getting dried out or irritated.
SPEAKER_02Yeah, one of the things that is so funny to me thinking about like we've had this conversation about showering before. Like, how much soap do you really need to put in some places? It's really, it really is pits and privates. Your whole body does not need as much soap as we use every day. It's actually not great for your skin.
SPEAKER_00I wouldn't even say you don't. I mean, water, water, so I mean, yeah, like not a ton, right?
SPEAKER_02Like, yeah, and if you do like wash parts of you, you can just let the soapy water run over things versus like actually soaping things. Yeah. So um just remember like not to make sure that your patients aren't like drying out their skin. You you know what I mean? Washing vigorously, there's no reason to do any of that. Yeah. And then sleep positions. Oh my gosh, sleep position is like everything in pregnancy, especially like breasts, belly, everything's growing, right?
SPEAKER_01Yes.
SPEAKER_02And so finding a way to sleep on your side, um, something that can help support your breasts too.
SPEAKER_00You know, I often still sleep with like hugging a pillow, but I've seen people put a pillow between their breasts, even I would have said I didn't ever have big enough breasts to do that, but but you can certainly imagine that putting pillows in different ways to help support your chest can be helpful. I recently had a massage and I was so uncomfortable throughout the whole massage laying on my chest. And I remember getting pregnancy massages where they had that cutout for your belly and they had cut out for your breasts. I think I should start requesting the cutout for the breasts, like if I go get a massage. Because laying flat on your belly is not comfortable, right? But it was so, but that also just that idea of like support at your chest level, but letting the breasts be more free, like if that makes sense. Be free, be free. Be free, breasts, be free. Well, they're just always being so contained.
SPEAKER_02Well, yes. So when when are we worried? So, if in terms of like normal breast changes in pregnancy, we would be worried if that there was some change that was unilateral. Yes. So redness, heat, streaking, yes, anything that looked like infection.
SPEAKER_00Bilateral generally is reassuring to me.
SPEAKER_02Yeah. Um, lumps or bumps, just like outside of pregnancy, are also concerning.
SPEAKER_00Yes, I will say that I do feel like the ducts can become more prominent, and you can, but you can almost trace it like it is a duct. And so, but if it was more of a I always kind of describe it as three-dimensional uh mass, then that's concerning.
SPEAKER_02Um, and then nipple discharge. I'm not talking about colostrum, I am talking more about like bloody discharge from the nipple, yeah. Um, or even that weird green, yeah, gray, sticky discharge.
SPEAKER_00Yeah, like a cotasia almost. But I feel like a lot of times in pregnancy, it is a sticky colostrum. It may look yellowish if as it dries on your bra or something like that or on your clothes. But um a little bit of blood tinge once you've started breastfeeding, like if your nipples are a little irritated, wouldn't be shocking to me. Um, but anything that looks like it has blood in it, I would be concerned.
Lactogenesis One And Colostrum
SPEAKER_02Yeah. So that kind of covers the like normal brush changes that happen during pregnancy. Should we move on to lactogenesis? Yeah, let's start with lactogenesis one. I love that. So this starts like mid-pregnancy, usually like 20-ish weeks, and continues through the first few days postpartum. And it is very much driven by the endocrine system. Yes. Everything's if I told a student the other day, if you know the HPA, if you know the HPO axis like really well and you know all of the hormones of what they're able to control, yes, there are so many things you will understand.
SPEAKER_00Yes, absolutely agreed. So the big role of hormones in lactogenesis one is progesterone, and it develops the milk-producing cells, which again are those leaves or those alveoli. Um, and it helps to prevent full milk secretion while the baby is still inside. Amazing. Yeah. And colostrum is, I mean, we've always said this. I feel like people have talked about it's like liquid gold. It really is. It's so full of, you know, the antibodies and all of those different things, but it's that pre kind of pre-milk.
SPEAKER_02Well, it's also more condensed. It's right, a condensed version of mature milk that's got all of the things that the baby needs in it. Yeah, absolutely. Um, all right, so the hormones, right? There, let's talk a little bit about what happens like in the immediate postpartum period, which is as soon as the placenta delivers, we have a sharp decrease in estrogen and progesterone. Yes. Right? And as soon as that happens, we have an increase in. So estrogen and progesterone have been suppressing prolactin and oxytocin. So when the placenta comes out and we get rid of our estrogen and progesterone, then we have an increase in oxytocin and prolactin. That's the physiology in the immediate post-proturnum period. Yep. Now, there are a million things that could go wrong there. There are. And we'll get there. Sure. But let's talk about the hormones that have to do with lactogenesis.
SPEAKER_00Yeah. So I already mentioned progesterone, and we can consider it the break. Um, it's progesterone during pregnancies produced by the placenta. And progesterone inhibits that full secretion of milk until it's time for, you know, like once the baby's delivered, that sort of thing. But it also keeps the factory, kind of your milk production factory, in a low production state so that the body doesn't become engorged while the baby is still in utero. But let's talk about prolactin, because you mentioned how important it is. It's really the gas. If we've got the brakes with progesterone, prolactin is a gas.
SPEAKER_02Right. So when we take the when we put the brakes on, right? The brakes are on during pregnancy. Yeah. We pull off the brake because we get rid of all the progesterone. We take that placenta out and we gas the prolactin. Yes.
SPEAKER_00So prolactin is made by the anterior pituitary, and it tells those LVLR cells to pull nutrients from the blood and turn them into milk. And prolactin levels rise steadily throughout the pregnancy. And then once that break is released, once that placenta is delivered, then it's full go. Let's produce some good amounts of milk. And we don't have that down regulation caused by progesterone. And then we have HPL too. Yeah, human placental lactogen. What? Yep. Yep. Yeah, we like a hormone that tells us what it's doing. So that hormone coordinates the growth of the breast and ensures that the mom's metabolism is redirected to provide enough glucose and amino acids to make milk, to milk synthesis.
SPEAKER_02So then, so we know now, like if you're ever asked like a test question, like HPL, progesterone, prolactin, yes, are the power trio.
SPEAKER_00And they are the ones that create milk. You mentioned another hormone that we're going to talk about in a minute, that really is how we get it out of the body. Correct.
SPEAKER_02So, what do we expect during lactogenesis one? So, one of the things that we expect is colesterol production that we've talked about. Yep. Right? Yep. And that includes all that IgA. IgA is how moms pass antibodies to babies. Yep. So um that's like gut immunization. Yep. Right? Yep. They could leak. We just talked about this. Some women leak, some women don't. Right. They could have either.
SPEAKER_00But that doesn't tell you whether or not you're going to be able to go on and breastfeed. Right. Because some do.
SPEAKER_02We have changes in like size and sensitivity of the breast, which we knew. Right. And then that does skin changes from the alveoli.
SPEAKER_01Yep.
SPEAKER_02So I really like this like analogy. With the placenta and the brakes. Yeah, the placenta is the brake.
SPEAKER_00And then once we pull that break, it's like all gas. All gas.
SPEAKER_02So let's go to lactogenesis too. Okay. Sounds good. Because that is like when the milk is coming in and we're like full on the gas.
SPEAKER_00Full on gas, copious milk. This is when sometimes it can feel like things get a little out of control.
SPEAKER_02Right. So if we're sticking with our break mechanism, the idea is the placenta is the break, placenta comes out. Yep. We lose our estrogen or progesterone. We increase our prolactin and oxytocin. This happens. It doesn't happen immediately. The hormone shift happens immediately. Right. But the milk supply does not become like really good until like two to five days postpartum.
Lactogenesis Two Milk Coming In
SPEAKER_00Right. And that's usually, I mean, everyone will produce some milk just from the placenta being, you know, delivered and that prolactin increase. But to actually formulate a supply and to get a good amount of milk, we really do need that suckling process and that um additional hormone release. Yep.
SPEAKER_02Um, so we're still like talking through what's happening in that first like 30 to 72 hours, right? Postpartum. Yeah. And if a mom's milk doesn't come in, is when we start to think about the problems that I was alluding to earlier. Yeah. So one of the biggest things that I think about is retained placenta.
SPEAKER_00Which makes sense.
SPEAKER_02We've still got some break going on. Yeah. And if they're still circulating estrogen and progesterone, we don't get the spike in prolactin and oxytocin.
SPEAKER_00Right. The other things that we could have is someone could have like PCOS. And so maybe their normal HPO axis could be a little out of whack. So they don't get that same feedback system that they're used to. And so maybe with PCOS, they don't go on to produce as good of a milk supply. And the other thing could be like a significant hemorrhage.
SPEAKER_02Oh yeah, people often have delayed lactogenesis too if they have a delayed, if they have a hemorrhage, a big hemorrhage.
SPEAKER_00Yeah, I would even say a day or so slower, even in patients with C-section.
SPEAKER_02Yep. I would agree with that too. Okay. So what happens to our patients? These are phone calls we get when moms go home.
SPEAKER_00Yeah, because I mean you don't, you just don't expect like the sudden change. So one of the things that you can have is as that milk comes in, some people will experience engorgement. And I remember, you know, their breast may feel hard and firm and tight. I remember my sister telling me, she's like, I didn't realize I had breast tissue that wrapped around my shoulder blades. Because we're in your armpits, you know, as as whatever mammary tissue you have, as it becomes full of milk, you could just get really uncomfortable in all kinds of places. One of it is the milk, but also we could have a lot of edema, right? The fluid shifts that we have, postpartum, if someone got a lot of IV fluids in labor, those kinds of things. I remember being taught that engorgement was meant that you did something wrong. And I think that there is some level of that fullness and discomfort that can be normal and it will even itself out with good feeding.
SPEAKER_02When I had my first baby, I literally remember my mom going and buying me a different bra every day for like a week. Because my breast just kept getting bigger, bigger, bigger. And I was like, I don't have anything to wear.
SPEAKER_00I remember going for my first bra fitting um at the lactation store at the hospital where I delivered. And I remember walking out and being like, Well, I'm no member of the itty bitty titty committee anymore. Correct. And then menopause. It's a shifting and changing. Things have shifted and changed throughout life. Oh goodness. Okay. So engorgement can be, I feel like, pretty common. There are ways that we can help to prevent it or to at least lessen it, but it can be a very uncomfortable time. Also, people will notice more leaking. And then they may notice that while they're feeding, they feel that letdown response. And it can be pretty intense for some people.
SPEAKER_02Oh, yeah. No, like if somebody else's baby cried when I was breastfeeding, yeah, I was done for.
SPEAKER_00We'll talk more about it as we talk about lactogenesis three, but I remember that if I even thought about pumping, like I like I need to go pump, I would start to like let down a little bit. Like I it's not fun that you like let down to your pump, but um, just knowing that it was gonna like be a chance to relieve that pressure felt was like something to look forward to. Some people also have significant mood shifts with their breastfeeding. And so it really like lactogenesis two again is related to hormones, like we talked about with lactogenesis one, and those hormonal shifts that are happening in such profound ways can also mean that they have really profound mood shifts with letdown or with breastfeeding.
SPEAKER_02That's that also tracks like mood changes with all the hormones that are happening, right? Yeah, absolutely. So there's all kinds of like I think patient education that we have the opportunity to do with our postpartum rounds. Yeah, right. Anticipatory guidance as to what's gonna happen when you go home. That is the key midwifery intervention, I feel like, is anticipatory guidance. Well, honestly, like the the thing about it, like I used to say, like, I have a very specific script postpartum, and one of them has to do with like, you will be engorged. It's going to happen, whether you're breastfeeding or not. If you're breastfeeding, this is how you deal with it. If you're not breastfeeding, this is how you deal with it. My other thing was about like in seven to ten days, you're also gonna have significant swelling. It's not gonna get better until seven to ten days. That is normal physiology, it's protective hypervolemia, right? Yeah. Um, and so like I just had a like a speech about this. And I know like it's probably oftentimes really intimidating for midwifery students to think like, I've got to go do all of these rounds and I've got to get all these teaching points in. But if you sort of have like a checklist of how you do your like what you say on your rounds, you won't forget anything.
Engorgement And Early Feeding Support
SPEAKER_00Well, we've talked about it in so many different ways about your script. And you're right, you want to make sure that your script is very similar. Now you obviously want to adapt it to people's needs, but if you have the similar script that is what you do with every postpartum patient, then you won't miss it.
SPEAKER_02Yep.
SPEAKER_00Yep. Yeah. So things we do to really promote um and help support those early days of breastfeeding, the golden hour, skin to skin, as early as possible, and then frequent suckling at the breast.
SPEAKER_02Yeah, frequent suckling is the number one way to increase milk supply as well.
SPEAKER_00Yeah. So that's when we want at least eight to 12 feedings in a 24-hour time frame. And you know, in those first few days when baby may be kind of sleepy and they may be kind of spitty, just getting the baby skin to skin, getting the baby to the breast to attempt is going to be better than not attempting at all or just letting them sleep. You want to try to get the breast stimulation as much as you can in those first couple of days.
SPEAKER_02And that's also the prime time for babies to want to cluster feed. Yeah. And so cluster feeding means that they want to like eat for 20 minutes or eat for 30 minutes and then be done for 30 minutes and then do it again. Right. Um, it's pretty common over this like period of lactogenesis too. Um, so I wanna I don't want to skip over patient education for like engorgement and lactogenesis too and like the expecting things. Yeah. Yeah. So um, like there are reasons that we use heat and cold for different things. So warm before, cold after. Warm before promotes um like letdown reflex, right? Um, and it can help the the vessels to vasodilate. And then cold after can reduce swelling and pain.
SPEAKER_00Yeah, absolutely. I think understanding the warmth before the cold after is really, really important. Then the other thing is that you can do enough like hand expression. I've even had a patient that pump just enough to relieve the pressure and soften the nipple so the baby can get latched on. Because sometimes when the breast is so full, it's hard for the baby to differentiate the nipple from the rest of the breast tissue around it.
SPEAKER_02Yep. Yep. So we talked some about what happens when lactogenesis 2 is delayed, right? Yeah. We talked about retained placenta is probably one of the most common things. Yeah. So even a little tiny bit of placenta can leave just enough estrogen and progesterone. I've seen it. I mean, literally a teeny tiny little fragment. Correct. Yeah. Um, and that for certain certainly can block milk production. Um, uh, Sheehan syndrome or postpartum hemorrhage um can have some impact on the pituitary gland. Yeah. And that affects the prolactin level of a mom in the postpartum period. And then, like you were saying, a lot of IV fluids, right? Can cause edema that mimics engorgement, but actually makes the it really difficult for babies to latch.
SPEAKER_00Yeah, absolutely. So, really good discussion about lactogenesis 2, but now lactogenesis 3. Yes. So lactogenesis 3 is everything after five days, really, two to five days. And the really interesting part of this is that it is autocrine driven rather than endocrine. And what that means is it's locally driven. We and we always say uh supply and demand, but I almost think of it more as demand and supply. Okay. We need the demand, we need the suckling. Yeah. And that triggers the body to make the supply. Correct.
SPEAKER_02Yeah. It's also really interesting, as I've like had my own breastfeeding journey and watched lots of my friends breastfeed and my sisters, right? Yeah. That I'm like, your body knows how much milk to make. Yes. And like I know moms who get frustrated because they're like, oh, I'm going back to work. I need X number of ounces of milk in the fridge. Yeah. You really don't need a huge surplus of milk in the freezer. I felt like if I was a day ahead of my baby, I was good. Dude, that's what my sister's saying right now. She's like, I have a couple days worth in the freezer, and that's like enough if we have a sitter or I don't get to pump. Yeah. Or like if I got sick or I mean, just anything. She's also just like, I'm pumping and like, but now she's eating so much regular food that she needs to nurse less. Like, yeah. Um, anyway, it's just amazing to me how your body like reacts to exactly what your baby needs.
SPEAKER_00Yeah, I know I've mentioned this before too, is I feel like so many people get so focused on filling the freezer that it, you know, they feel like they're like behind, or we have these like overproducers or all of those different things. Good on you if you have a great supply. Good on you even more if you can donate your milk to a breast bank. Like, yeah. But the most important thing is to feed your baby and your body will make what they need. I was not someone that ever, my baby never took more than four to five ounces in a feeding, even as they got close to a year old. Yeah. Where other babies would easily take eight ounces at that age.
SPEAKER_02I remember having a lot of surplus with Brooks and then not having hardly anything in the freezer with Rory.
SPEAKER_00Yeah.
SPEAKER_02And that was just how it was. I didn't do anything differently.
SPEAKER_00Yeah. Yeah.
SPEAKER_02I certainly was not like, yeah, encouraged.
SPEAKER_00But even at my like fullest, you know, like you know those people that like go pump and they have two eight-ounce bottles from one pumpy. And you're mad about it? Well, I don't know that I was ever mad about it. I'm like, that's just not me. Like, if I was at my fullest and I pumped, I might get eight ounces between my two breasts combined. Right. Like it just everybody produces what's right for their baby.
SPEAKER_02Um, when we talk about um like nutrition and hydration and all of those things that go with postpartum, like and la people think that lactogenesis is really like linked to nutrition and hydration, and it's not because women in countries that are low resourced still produce breast milk even if they're not eating and drinking appropriately. Yeah, yeah. Now, do they produce the best breast milk that they could if they were, you know, fed and watered regularly? Probably not. Yeah, I think, but women still breastfeed without any problem, and that has it's very there's very little like um, there are very few lines that can be drawn between hydration and nutrition. Yeah. For the mom.
SPEAKER_00Yeah, absolutely. So we talked before about the gas and the brakes and all this, but we can kind of think of this stage as cruise control. And another word that we're gonna throw out here is galactopoesis, and that basically is that maintenance of milk supply. So we talked about mammogenesis, we've talked about lactogenesis, now we're saying galactopoesis, and that's that maintenance of supply.
Delayed Milk And Common Causes
SPEAKER_02The biggest difference, I think, as you're thinking about one and two versus three, is that what you were saying was that shift between endocrine and autocrine. Yes. Right. And so whether or not like that lactogenesis free continues for however long it is that you decide you're gonna recipe, right?
SPEAKER_01Right.
SPEAKER_02So it's from day five or day 10 to whenever mom decides that she's gonna wean that we are in this lactogenesis three area. Yeah, and it's really all about removal of milk from the breast, emptying the breasts. Yes. If they are not empty, the signs and the signals that need to go to your brain to produce hormones will not be there. Yep. What's really important is emptying of the breast. Yes, and ensuring that they're empty either by your baby or by your pump, because if you are not adequately emptying, that feedback mechanism in terms of the autocrine system is not going to work properly.
SPEAKER_00Yeah. So there's this really interesting small protein that is in breast milk and it's a it's basically feedback inhibitor of lactation. And if the breast is full, then that inhibitor sits against the milk-producing cells and tells them to stop that they're at capacity. But then when the breast is emptied and the baby has emptied the milk from the breast, then those cells wake up and start producing milk again because that feedback inhibitor is removed. So, so interesting. I know, agreed, agreed.
SPEAKER_02So, what do we like? Do you want to like maybe finish up this episode with some like misconceptions about breastfeeding and like breast issues in the postpartum period?
SPEAKER_00Yeah, sure. So some patients around weeks three or four will feel like their breasts are really suddenly soft and they've stopped leaking. So they feel like they're losing their milk supply. And the main thing to know is that that is a sign of success. It means that their body body has started to calibrate and figure out exactly how much their baby needs. Now, I will say babies go through gross spurts, and we talk about their sleep patterns and when they have sleep regressions and all those different things, but I think those are also tied to gross spurts. And so if you've been doing really well and you're, you know, you've stopped leaking as much and things are feeling soft, and then all of a sudden your baby is like ravenous and eating all the time, it's probably because they're getting ready for a gross spurt. Yeah. Doesn't mean you've done anything wrong or that you're not producing enough. Yeah, babies don't just eat for now.
SPEAKER_02No, no, they're uh pre-ordering their doorblash.
SPEAKER_00Uh-huh. They are. They're Uber Eats. They are. They they know when they need more, and so their little bodies will just demand it more, and then that will build your supply.
SPEAKER_02Yeah. So the role of, I think it's important also to differ differentiate the prolactin is the one that helps you make the milk, but without the oxytocin, you don't get the milk let down. And oxytocin can be inhibited by pain, yeah, by fear, by emotions. There's all kinds of things that can inhibit oxytocin, which is like the love hormone, right?
SPEAKER_00It's our feel-good hormone, but it is the milk ejection hormone as well.
Lactogenesis Three Demand Drives Supply
SPEAKER_02And it's important that we're talking to patients about those oxytocin blockers, like I was just saying, that are like stress, cold, pain, right? And if you're having trouble with letdown, there's these three W's. They're warmth. We talked about that, increased vasodilation, yeah, water, have a big glass of water, and watching. Like looking at pictures or things that would like give you a surge of like happy.
SPEAKER_00Yeah. I remember in my pump bag, I had one of those backpacks. Um, you know, back before they had all the hands-free stuff. I'm so mad that we had babies before hands-free. I'm not mad about it, but it wasn't a good enough reason to have a baby now. No, absolutely not. But I'm like, dude, you know how much I could have gotten done with a hands-free pump? I did have a hands-free boustier and a car adapter, and I felt fancy, but back in the day, there was a little slot in my little backpack where you could slide a picture of your baby in, and it was so you could look at your baby while you were pumping.
SPEAKER_02Well, that's cute.
SPEAKER_00Yeah, it was cute.
SPEAKER_02So we hear a lot from moms when they're supply drops. Yes. And there are all kinds of things that you're gonna read. They can take fenugreek, they can, there's herbs that you can do, but really like it's are they latched effectively? Yep. Is the breast emptying appropriately? Yep. Right. Um, or like, did you introduce something different? Right. Did you give them a formula bottle? Have you introduced solid foods or different foods? Right. So there are definitely reasons when supply drops. Um, but also like some of that can just be the body adjusting to the amount of milk that the that it needs to make versus when your baby is exclusively breastfeeding.
SPEAKER_00I'm glad that you mentioned those oxytocin like kind of blockers, but I'm also really glad that you mentioned appropriate latch. So we should be quick to include our lactation specialists, our lactation consultants. Um, they might be found at your pediatrician's office. They might be at the birthing facility where you delivered, they might be at your OB office and your midwife's office. There are many midwives that are also lactation consultants, but we should be quick to make sure that we're getting good assessment of latch and good assessment of the breast tissue and so forth.
SPEAKER_02All right. I have five like one-sentence myths that I want to bust. Okay. So I'm gonna say what they are, and then you're gonna tell me why it's not right.
SPEAKER_01Okay.
SPEAKER_02Um, my breasts are too small to breastfeed.
SPEAKER_00Um, that is not true. Your breast size is mostly determined by fatty tissue and not your milk-producing glands.
SPEAKER_02Amazing. Yeah. Um, I if I feed my baby too much, my breast won't have a chance to like make milk.
SPEAKER_00That's actually not true at all. That your breasts are never really truly empty and they're constantly producing. And in fact, milk production is fastest when the breast is empty and slowest when the breast is full. So actually getting them empty more frequently is what actually makes you produce more. Pain's okay. Oh no, I so I'm supposed to say um nipple tenderness or a few seconds of discomfort at the initial latch can be normal. Yes. Here's when I tell people most of us are not used to having somebody suck on our nipple every one to three hours throughout the day. Correct. So around the clock.
SPEAKER_02But I I mean, I had a baby who was tongue-tied. Yeah. And so every feeding hurts.
SPEAKER_00So sharp, toe curling, cracking, bleeding, pain throughout the feeding is not normal. Yes. Initial laps, maybe a little bit of discomfort.
SPEAKER_02Before I figured out that Rory, I mean, I knew he had a tongue tie, but I was literally like sobbing over him, yeah, holding him. Yeah, feeding, I didn't want to give him a nipple because I was still in this like nipple confusion thing, which we know is really not a thing. Sure. Um, and I was feeding him, pouring milk into his mouth like a baby bird with a little medicine cup.
SPEAKER_00Yeah. Yeah.
SPEAKER_02This is what I did to myself.
SPEAKER_00No, I know. I know we can have a whole episode about our own breastfeeding troubles.
SPEAKER_02What or just like how much things have changed? And I would have been so much if I would have known more then, I think I would have been kinder to myself.
SPEAKER_00If that is not the story of every woman's life, shown myself a little bit more grace. If I had known then what I know now. Yeah, right.
SPEAKER_02Yeah. I even think I wasn't a very good midwife to myself either, but that's also a whole nother episode. That's a whole nother thing. Yeah. So yes. Okay. If my baby cries a lot, it means that I don't have enough milk.
SPEAKER_00No, it's almost always a cluster feeding. Um, and they're again placing that order early for their delivery. Um, they're probably a gross spurt, cluster feeding, getting more milk supply. All right.
SPEAKER_02And I can't eat uh Indian food, broccoli, asparagus, garlic.
SPEAKER_00Interesting. Um, our our milk is not made from our gastric uh contents, our stomach contents, it's made from our blood. And so um the concentration. Contents of your stomach are not really involved. Now, some babies are sensitive to specific proteins, like cow's milk or something like that. But most babies, if your varied diet is going to help them to have a varied diet in their lifetime.
Soft Breasts Are A Good Sign
SPEAKER_02So this last part before we finish up, I feel like is one of the things that I specialize in in terms of postpartum, which is preparing the partner. Yes. I look at husbands and partners all the time and I say, this is where I need you to pay attention.
SPEAKER_00I love um the the the idea of this is your little oxytocin bubble.
SPEAKER_02Yes, protect it at all costs. Yes. Um, because I think this there is a um a Venn diagram where lactogenesis overlaps with postpartum blues, yes, overlaps with like the first day of being home. It's all of those sudden changes. And that middle section is when like the meltdown thing, the tears, the I'm not doing anything right situation happens.
SPEAKER_00So helping to have some anticipatory guidance about that timeline, but then what are some of the things that we can do and promote to help that as well?
SPEAKER_02Well, I think like having the right help. Yes. If that is available, like having that.
SPEAKER_00And things that can make the lactating person most comfortable, if that's getting them some water at the start of a feeding, if it's rubbing their shoulders because they're tense, if it's, you know, making sure the room is the right temperature or the lights are dim. Similar to labor. It's the psyche in labor, right? So this is that that fourth P when we're talking about lactation.
SPEAKER_02I always say to like, um, my sister would tell her husband, like, I'm going upstairs to feed the baby. Will you put a glass of water on the nightstand? Yeah. And I was like, that's so helpful because you're so thirsty. Yes. Yeah. So, you know, encouraging hydration and nutrition. I know I just said you don't have to have hydration and nutrition to make breast milk. That's not my point. My point is, is like this is a comfort for the lactating person.
SPEAKER_00Yeah.
SPEAKER_02While they are breastfeeding.
SPEAKER_00Also taking everything off of that person that isn't lactation. So if it's, you know, the household chores, if it's laundry, if it's whatever, like you, the partner becomes the administrator for the next few days because it's such a stressful time.
SPEAKER_02I honestly say to dads a lot, like the only thing your partner should be doing is sleeping and taking care of the baby and feeding the baby. Exactly. And everything else can be done by somebody else.
SPEAKER_01Yes.
SPEAKER_02Now, I I fully recognize that that is not possible in every household.
SPEAKER_01Yes.
SPEAKER_02However, if it is possible, it should be the norm.
SPEAKER_01Yes.
SPEAKER_00So I remember when Julia was, I think that would have been four days old. The day after Christmas in 2004. And we were hosting Christmas because then everybody could come to us instead of us having to go anywhere. That was supposed to reduce my stress. And I remember my mother-in-law asking me if I wanted red plates or green plates to serve the barbecue on. I did not need to be making that decision at that moment. And I let her know that.
SPEAKER_02Sure, that went over so well.
SPEAKER_00But it's just, I mean, it really was a good point of like that was not something I needed to be worrying about in that moment. Someone else could make that decision.
SPEAKER_02Yeah. Yeah. Honestly, like there's so many things. There's also like I just from my own recent experiences, I'm like, I don't, there are things that I don't need to be making decisions about.
SPEAKER_00Yeah. Yeah. So protect that oxytocin bubble.
Letdown Oxytocin Blockers And The Three Ws
SPEAKER_02Protect it at all costs. Yeah. Um, all right. So things that like in terms of wrap-up, right? Yeah. I think it's important for midwives to understand their role in anticipatory guidance for mammogenesis as well as all three phases of lactogenesis. Yeah. Understanding like how we can be helpful and supportive with latch and engorgement and those kinds of things that are normal that might need tweaked.
SPEAKER_00I think it's really important for us to help people to trust the process and the physiology, but also know when are things that I should alert you about.
SPEAKER_02Yeah, I also think the midwives should be like the connectors. Yes. And that's the connector to like who are your lactation services? Who, what's in your community? I'm so lucky in Cincinnati. We have a center for breastfeeding medicine. That's awesome. I would have never survived breastfeeding a tongue-tied baby without those people. And but if you don't have that, what do you have? Who who are the telehealth resources that you have for lactation support? Who um can somebody see outpatient?
SPEAKER_00Yeah.
SPEAKER_02And every single patient, if they're breastfeeding, should have a lactation um consultation, even if you think that they're like not a first-time mom or they've been breastfeeding for a very long time. Right. Everybody should have a consult.
SPEAKER_00Yeah, you know, I was not successful with breastfeeding in my first with my first child, and she turned out fine. We're all okay. We've survived. But I was extremely successful the second time around, but people were shocked that I would even try. And I just think it just goes to show that every baby and mom, every breastfeeding experience, every everybody's different.
SPEAKER_02Like and the same mom from pregnancy to pregnancy is different.
SPEAKER_00Yes, yes. And um, you know, the my parts were the same. Well, as much as anything stays the same. We never go back to a pre-pregnant state, we just have a new normal. But it it really, there's so many variables at play, just like we talk about in labor. We talk about the powers, we talk about the pelvis, we talk about the passenger, is so true in all of these different things. There's different players involved, there's different life circumstances involved, there's different emotions involved. So it can just be a completely different experience.
SPEAKER_02Our job is to be supportive and protect normal and recognize when it's not normal. Yes. So such a good conversation. I told you I was super excited about this topic.
SPEAKER_00Yeah, I we were pumped. We are not generally people that are pumped about postpartum.
SPEAKER_02No, and it's not even that. It's like I just think that like a good example of this is when you are a young midwife. I was a young midwife, I was a midwife before I had kids. Yes. You were a midwife before you had kids?
SPEAKER_00Um, not really in practice. I mean, I was graduating from pigmentary school when I had my first baby, and then I didn't practice until she was about six months old.
SPEAKER_02There were so many things that I didn't understand though, because I hadn't done them myself. I hadn't done pregnancy, I hadn't done breastfeeding, I hadn't done postpartum, I didn't know what any of that stuff looked like. And then now I have a whole different perspective on like now I understand menopause so much better, and I understand what this is and what that is. And it's so interesting. It's all about like life circumstances and like where you are in your life at that time when you're practicing. Yeah. But I think you just get a whole new perspective. And it's why our our, you know, grandmothers of midwifery were like, oh, they're so smart. It's because they've now lived all the stages.
SPEAKER_00That's true. I had the most fascinating conversation with Max, who is now 18. And he was, you know, in his infinite wisdom telling me that he felt like, you know, every lawyer should like have to go to court for a misdemeanor so they better understood the experience. And we were talking about those kinds of things. And I'm like, so, oh, every midwife needs to have a baby. And he's like, No, mom, midwives do so much more than catch babies. And I was like, Oh, I can retire now. Well done. I work, all done. It's true, yeah. But I do think our life experiences certainly have give you a different perspective on things, but people can be really good at what they do without having gone through it.
SPEAKER_02Yes. And for me, it's just set me up for a whole different level of understanding.
SPEAKER_01Yes.
SPEAKER_02But I do love some breastfeeding.
unknownYeah.
SPEAKER_02Yeah, I don't ever want to do it again. But um nope, but I love to help other people do it. Yes. So, well, amazing. So thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again. Take care.