Postnatal Instructions: the "Owner's Manual" to your New Baby
Top tips from a midwife on what to watch out for once you take your newborn home from the hospital.
Most new parents report feeling one thing as they take their first baby home from the hospital: when do the grown-ups arrive who are going to keep this child alive? Many parents today have little or no experience at all with newborn babies right up to the moment we are handed our own and are expected to be fully responsible for him or her. We usually feel completely out of our depth and often feel terrified that we will not be up to the task.
The good news is that your baby is going to teach you everything you will need to know to take care of him or her, as long as you give yourself some time to get to know your baby, practice a little trial and error, and trust your instincts. The bad news is that here in the UAE there is very little postnatal care and follow-up unless you yourself set it up, and it is easy to fall into the gaps in the private medical system. There are just a few basic things you will want to know about now to help your new baby thrive and a few things to look out for so that you can call in some expert help quickly when it is needed.
14 things a midwife would want you to know about your new baby:
1. Feeding: Babies should nurse at least 8-12 times in a 24-hour period, and newborns will usually want to feed almost constantly in the early weeks. This will ensure adequate calories and nutrition for baby, and will establish an adequate milk supply for mum. Feeds can take between 20-40 minutes each time, and both breasts should be offered at each feed. Colostrum, the first milk, comes in small quantities but is very nutritious and high in immune factors and is all that your newborn needs until your milk volume increases. Your baby’s stomach is tiny and will fill and empty quickly. Feeding schedules are not healthy or helpful--watch your baby, not the clock. New babies may sleep for one 3-4 hour stretch in a 24-hour period, but other than that should be feeding every 2 hours or more often, “on demand” or “on cue”. It is not normal for a baby to be uninterested in nursing or eating, or to be too sleepy to wake up and feed. This is not a sign that you have a "good baby"--it may be that you have a baby who is "happy to starve." You should call your midwife or lactation consultant immediately if this happens. You can read more about how to know when you need breastfeeding help in an earlier post.
2. Spitting up and wind: Most new babies will experience gas and wind and will find having to digest their own food and pass their own waste upsetting--you did all of that for them when they were in utero! For most babies simply holding them or wearing them in a sling or wrap, gently bouncing or rocking and giving them love and support will be enough to help them cope. Many babies will find tummy massage or gentle cycling of the legs helpful while they are learning to manage their own digestive processes. Some babies benefit from burping or winding during and after feeds, others will not require such help. Spitting up is normal for many babies and is not necessarily a sign of reflux. If a baby spits up or possets but is gaining weight and and is not in any pain, than it is a laundry issue, not a medical condition. A baby who is clearly in pain while spitting up, especially if not gaining weight well, should be assessed by a pediatrician.
3. Breathing: Infant breathing is often irregular, especially during sleep. This means a baby takes 30-50 breaths per minute, but the time between breaths can vary--which often worries new parents when there is a long pause between breaths. It is also normal for newborns to cough and sneeze and sound stuffy for a few days as they clear their air passages (nursing helps them do this). If the baby is able to nurse well, then s/he is probably not having any difficulty breathing. A baby who is struggling to get enough oxygen, will not be able to feed, Infant breathing should never be labored or difficult. A baby who is struggling to breath will be making "grunting" noises with every exhalation, will have flaring nostrils, and/or will be working so hard to bring in air the muscles between the ribs will be visibly moving with every breath. They will also have blue/gray coloring in the lips, face and/or body (blueness in the hands and feet is normal.) If you notice anything like this, contact your doctor and get your baby to the hospital immediately.
4. Temperature: Newborns are not able to regulate their own body temperature well so you will need to help. The general rule of thumb is to dress a baby in one light layer more than you feel comfortable in, but different babies can have different "thermostats," so touch the baby to see how they feel--hands, feet and face will usually be cooler to the touch than the torso. If the hands are hot, the baby is probably too warm--unwrap them or take off a layer and check again in 30 minutes. If the torso is cool, add another layer of blanket or clothing. We used to advise parents to keep a hat on new babies to keep them warm, but recent research shows that the pheromones that make your baby's head smell so irresistible are really important for early bonding. The best way to regulate your baby's body temperature is to hold him or her skin-to-skin against your chest. Mother's breasts in particular will adjust to stabilize your baby to the ideal temperature (you can even have 2 breasts with 2 different temperatures if you have twins!) You can place a sheet or blanket over both of you if you feel cool. If you are ever in doubt, check baby's temp with a thermometer. Normal body temp is 36 C or 98.6 F. If a baby's temperature continues to go up and down, or if a baby younger than 3 months ever has a temp of 38 C/100.4 F or higher, call your doctor or take baby immediately to a hospital for evaluation. Fever in young babies can get serious very fast.
5. Cord care: The less you do to the cord stump, the quicker it will fall off. If you leave it alone (do not use alcohol, hydrogen peroxide or herbs) it should fall of in 5-7 days or less. Make sure it stays outside the nappy so it can dry. The cord stump can get goopy and stinky as bacteria cause it to decay and fall off, but the skin surrounding the belly button should not be red or have noticeable swelling. Call your doctor or midwife if there is more than a spot or two of bleeding, pus or redness on the belly around the base of the cord.
6. Hands and nails: Baby fingernails, though very soft, can be sharp and many parents worry about baby scratching his or her face. Cutting those tiny nails is very stressful--some easy solutions are to nibble or peel the nails with your teeth or fingers (while nursing is a common time for mums to do this) or gently file them with an emory board (after a bath when they are extra soft can work well). Resist the urge to cover your baby's hands with mitts as research has shown that babies need their hands to find the breast and trigger mum's milk to let down, and they feed better when their hands are free, They also may be used to sucking on their fingers or hands in utero and may find it soothing.
7. Urine and stool: Baby's first meconium stools are dark and tarry in the first couple days but they should transition to a bright yellow color by day 4. If they are not yellow by day 4 it can be an indication that feeding is not going well--see a lactation specialist right away to solve the problem early. The normal consistency of breastfed stool ranges from curd-like to runny. After the breastmilk volume increases between days 3-4, baby should have 6-8 wet nappies in 24 hours and may have a bowel movement as often as every feed. Any addition of formula will change the consistency, frequency and odor of baby’s stool. Urine should be plentiful and clear, but in the early days you can sometimes see some orange crystals in the urine. This is uric acid from the kidneys just starting to do their job, and is normal in the early days. It is also normal for girl babies to have a little menstrual period (blood from their vagina) as they come off mother’s hormones. Sometimes you will also see a little mucus plug in a girls’ nappy. When diapering boy babies, aim the penis down to avoid the urine coming out of the top of the nappy. Be careful when removing a nappy as the cold air will often trigger a baby to urinate (right into your face.)
8. Eyes: It is very common for babies to have excess discharge from one or both eyes. Your baby’s tear ducts are very small and may not drain efficiently. If your baby has lots of discharge from his eye, clean his eyes gently with a soft, clean, wet washcloth/flannel. You may also put a few drops of breast milk into his eyes to protect against infection. If the eye is crusted shut or the discharge is not clear, then check with your doctor or midwife to make sure there is no infection.
9. Skin: Your baby’s skin is very sensitive and is going through many changes as baby adjusts to life in the air. Newborn skin may become dry and peel in the early weeks, especially on the hands, feet, and in creases. You do not have to do anything, but if you would like to moisturize with natural oil such as coconut oil you can. There is some evidence that oils such as olive oil and sunflower oil may increase the risk of eczema in babies, so proceed cautiously. Most babies do develop normal newborn rashes, spots, and acne that come and go around the face and body—these usually are not anything to worry about. Your baby does not need daily baths, and bathing too often can further dry sensitive skin. The only 2 areas that need daily cleaning are the nappy area and the neck and chin. Sponge baths or “tops and tails” baths can work just fine for this. Do not use cotton swabs in baby’s ears and do not use powder on babies as it can cause breathing problems. Another little tip is that when you do bathe your baby, be extra careful to dry well in the armpits and all the little creases and rolls of skin and fat which never see the light of day in chubby babies. If this skin remains wet inside the creases it can start to cause soreness and a foul smell.
10. Jaundice: Yellowing of the skin and whites of the eyes is very common, and usually is not a problem if it develops between days 2-7 after birth. This physiological jaundice is caused by the normal build-up of bilirubin in the blood as baby transitions from fetal red blood cells to adult-type cells. Excess bilirubin is excreted in the stool; nursing stimulates pooping, which will lower bilirubin levels. If jaundice develops in under 24 hours, or if it continues to get worse after day 3, or if baby has become too sleepy to wake up and eat enough (see above) it is a problem and you should notify your doctor or midwife immediately. The concern about excessive jaundice is that it can lead to brain damage, so get it checked out.
11. Weight: It is normal for a newborn to lose no more than 7-10% of their body weight in the week after birth, possibly more if you got a lot of IV fluids during labor. By 2 weeks most babies should be back to birth weight or higher. If baby loses more than 7-10% or is not gaining it back quickly enough, see a lactation consultant or other breastfeeding specialist quickly to figure out what is going on with feeding. After 2 weeks baby should continue to grow along their growth curve on a World Health Organization growth chart.
12. Danger signs: Call your doctor or midwife IMMEDIATELY if your baby has any of the following:
Has fever, unstable body temperature, or breathing difficulty (see above for details).
Develops a high-pitched cry.
Is unable to nurse or has a poor suck.
Shows any skin bruising or unusual bleeding, especially ANY bleeding from a circumcision.
Is lethargic or has seizures: Difficult to rouse (won't wake up, won't eat) or has seizures (possible signs include eyes rolling upward or fluttering; stiffening of the body; movements of the tongue, lip smacking or excessive sucking; uncontrolled jerking movements or body twitching; staring spells or periods of unresponsiveness.)
13. Follow-up medical care: Even if you think everything is going well ALL BABIES should be seen between days 3-5 to make sure they are feeding well, have not lost too much weight, and are not overly jaundiced; and all babies should be weighed around 2 weeks to make sure they are back to birth weight. More visits may be necessary if there are any complications or breastfeeding struggles
In the UAE you will have to make your own arrangements for these visits with a midwife or lactation consultant--pediatricians usually will not have much expertise or experience in assessing or helping with breastfeeding. Pediatricians are great if your baby is sick, but a midwife or lactation consultant will be the expert when it comes to well-baby visits. In Dubai, Cooper Health Clinic, Healthbay Polyclinic and Babies and Beyond all offer midwifery home or clinic visits for both mother and baby and are highly recommended. In Abu Dhabi you can find similar care from BAYTI Baby home healthcare. Midwives may even be able to provide your baby's vaccinations and other well-baby care through the early months and beyond. If you are wondering what sort of postnatal care you as the mother will require, read out other blog post on 15 Things Nobody Tells You About Recovering from Childbirth.
14. Cranio-sacral therapy, osteopathy or chiropractic body work: If your baby is struggling with feeding, colic, reflux, or has any asymmetry or flatness in the head, getting some bodywork from someone who specializes in infants can be very helpful. Long labors, forceps, ventouse or cesarean deliveries, or being in a funny position in utero can all affect a baby's head and neck. Pain and/or tension in the neck or jaw, and mis-alignment of the bones of the skull can affect feeding and digestion in many significant ways. Treatments for infants are very gentle but can be very effective.
Caring for your newborn is exciting, exhausting, and often over-whelming in the early days and weeks, but it is all part of the process of becoming a parent. Ask for help from family members, friends and professionals and seek out the company of other new parents both on-line and in person. It does indeed take a village to raise a child so you might as well start to gather your tribe right from the beginning.
What was most surprising for you about taking care of a newborn? What do you worry about the most if you getting ready to have your first baby? I would love to hear from you!
Good luck and Take Care!
Amy is a Licensed Midwife (Washington state, USA) and an International Board Certified Lactation Consultant. She currently works in Dubai as co-founder of Love Parenting UAE, teaching antenatal and parenting classes and workshops. For more information and tips like this plus lots of community and professional support, join our facebook groups Informed Pregnancy and Birth UAE and Love Parenting UAE support group.