The majority of expectant parents focus on their birth plan, and oftentimes planning for their life after birth is more of an afterthought. The baby shower and preparation for the new arrival generally centers around the baby, with minimal focus on the myriad needs of new parents as they care for a newborn. As a therapist who specializes in Perinatal Mood and Anxiety Disorders (PMADs), my work involves tending to the birthing parent in one-on-one sessions and in support circles. Much like a wedding planner would be for a bride-to-be, I often discuss birth preferences and postpartum planning with expectant parents. I provide education and expertise on how to plan for this period of time so that each parent feels as prepared and supported as possible.
In the time of COVID-19, postpartum planning is more critical than ever, but looks drastically different. Something to keep in mind is that during these uncertain times (and really any time) it is essential to remain flexible and learn to accept that plans can change. Dr. Sarah Oreck, reproductive psychiatrist and my frequent collaborator, works closely with many OB/GYNs and notes that in birth planning with her patients, she likes to use the terminology “birth preferences” as plans can so quickly change when we are talking about childbirth. She notes that it is often the disappointment of experiencing a birth other than the idealized one that can trigger birth-related Post-Traumatic Stress Disorder (PTSD). She adds that it is essential to keep in close contact with your provider to ask about the changing protocols at hospitals, including birth supporters and visitors allowed. We know that mothers and babies have better outcomes with support throughout the entire labor and delivery process.
Now with hospital restrictions due to COVID-19, having a birth doula at your side currently is not an option in many hospitals, however, your partner and/or perhaps a nurse at the hospital could serve that purpose. Alternately, those who are good candidates for a home birth may opt for that, but it is important to mention that this requires months of planning and should not be a last minute decision made only in the context of the current pandemic.
For at least the first 40 days after birth (but likely much longer than this), support is vital. Typically a family member or, if resources allow, hiring a postpartum doula and/or night nurse is ideal to support the recovering birthing person and allow parents to get sleep; however navigating all this in the time of COVID-19 is complicated. Some may elect to have a healthy family member move-in, or hire “live-in” help if they are able to afford it. Dr. Oreck emphasizes the importance of support during the postpartum period in decreasing the risk of PMADs and strengthening attachment between new parents and infants. If having family support and/or hiring your proverbial village is not an option, then it’s important to negotiate night feedings and naps between partners. In addition, being open to supplementing with breast milk alternatives (i.e. formula) for some of the feedings in order to prioritize sleep and subsequent mental health should be taken into consideration.
Build Rapport Before You Birth
Although pregnancy is generally seen as a joyful time, depression and anxiety can begin while gestating according to Dr. Oreck. She notes that around 50% of perinatal mood and anxiety disorders start in pregnancy and continue into the postpartum period. She adds that the factors that may put a birthing parent at risk for developing PMADs include a personal or family history of anxiety or depression or PMADs, severe mood issues around the time of your menstrual period or premenstrual dysphoric disorder, financial or relationship stressors, limited support, medical complications during the pregnancy or birth and a history of infertility treatment or miscarriages.
If you have any of the aforementioned pre birth risk factors or you’ve had a personal history of PMADs in prior pregnancies, then it is crucial to plan ahead for care in case you need it. Establish a relationship with a psychotherapist and psychiatrist who specialize in PMADs prior to giving birth. Dr. Oreck and I work together to support the birthing person’s overall well being. She and I can both treat patients virtually in California since that is where we hold licenses and practice; and she holds an additional license in New York so she is able to do bi-coastal virtual sessions.
When helping patients resolve birth trauma, I incorporate Somatic Experiencing into my work and Dr. Oreck includes EMDR as part of our therapeutic offerings. These techniques can be done to a degree virtually, however, they may have better outcomes when done in-person. Dr. Oreck and I encourage massage and acupuncture from preconception through the perinatal period, and once these in-person services are available and safe, we urge you to take advantage of them. Although we have an integrative, east-west approach to treatment, we are proponents of medication when needed. According to Dr. Oreck, there are a number of medications that have a large body of research supporting their safety in pregnancy and breastfeeding.
Life After Birth Support
A significant component of postpartum planning is connecting with other birthing persons during and after pregnancy (albeit virtually) to commiserate and support one another, especially during this global pandemic. Although Mommy & Me groups can be educational, they are more didactic and focused on the baby (their development, sleep schedule, etc.) so there is not always much time and space to talk about what is really going on with being a new parent. Also, it may be challenging for those experiencing acute symptoms of depression and anxiety since the people who attend those groups may be higher functioning.
When I was suffering from postpartum depression, I felt alienated in the mom group I went to because I felt like, “Everyone seems to be functioning well…what’s wrong with me?” which exacerbated my depressed mood. As a result, I created my postpartum support circle, Life After Birth™, as a counterpart to Mommy & Me groups in order to provide emotional support for the birthing person. My group tends to those who identify as mothers and provides connection and community. During this time of COVID-19, I have translated my signature offering to a virtual platform until I am able to resume once again in person. Another way to connect with those who have a “guess” date around the same time, is to participate in a group fitness class such as prenatal yoga, which are also available online currently.
La Rééducation Périnéale
A tremendous part of education during pregnancy is understanding the delicate mind-body connection. Pregnancy puts a huge strain on the pelvic floor, so even if you do have a cesarean birth, pelvic floor work after the baby comes is still important. In France, their government has subsidized la rééducation périnéale, (perineal re-education, i.e., physiotherapy that helps strengthen a birthing person’s pelvic floor.) Unfortunately, while this should be a routine postpartum appointment for everyone who gives birth, the United States is behind in standardizing this offering, therefore most birthing people wait until there is an issue to seek out treatment. Dr. Oreck reports that perineal tears secondary to vaginal births can result in sexual dysfunction, pain and incontinence, which she has seen connected with developing perinatal mood and anxiety disorders. Therefore, it will be supportive to connect with a Physical Therapist (PT) prior to giving birth. This way, you will have already built rapport, so you can easily call on them in the 4th Trimester (the three months post-birth). If you’re not sure where to find a reputable PT, Origin, is a leading provider of women’s health physical therapy in Southern California. Like most practitioners in the time of COVID-19, they offer virtual sessions and can walk you through exercises to restore pelvic floor health.
Knowledge is Power
Even though there is no way to fully prepare for the drastic transformation of becoming a parent, education can of course help lower anxiety and empower new parents. From birth preparation to baby CPR to breast- or chest feeding classes, they’re all–wait for it–available through online video platforms. In my practice, I see feeding issues contribute to the development of PMADs. Dr. Oreck reports that around 60% of patients do not breastfeed for as long as they intend to due issues of lactation, infant nutrition, concern about taking medications while breastfeeding, and unsupported work policies according to the Centers for Disease Control and Prevention data.
Oftentimes the dissonance between fantasy versus lived experience can be devastating. The primal need to feed your baby from your body and immense community pressure can create a fixation on producing milk, so those with low supply, for example, pump around the clock to increase supply, but at the expense of bonding with their baby. One of the first things I ask a patient who is having feeding issues is, “Have you talked with a Lactation Consultant about this?” That is why I suggest getting some education and establishing a relationship with a Lactation Consultant and examining your expectations prior to giving birth. Similar to thinking of your birth plan more as birth preferences as mentioned above, feeding should be looked at through that same supple lens. In addition, credible podcasts and well-respected books are another form of education. Here are a few of Dr. Oreck and my favorites:
- Transformed by Birth by Britta Bushnell, Ph.D. (pregnancy & beyond)
- Mindful Motherhood by Cassandra Vieten, Ph.D. (pregnancy & year-one of motherhood)
- Ina May’s Guide to Childbirth by Ina May Gaskin (birth prep)
- The First Forty Days by Heng Ou (postpartum)
- Buddhism for Mothers by Sarah Napthali (motherhood)
- Whole Brain Child by Daniel J. Siegel, MD & Tina Payne Bryson, Ph.D. (parenting)
Before closing out this article, here some quick pro-tips on products. Although a bit controversial, there are advanced bassinet technologies that can help soothe your baby back to sleep, which can be a great investment, if resources allow. Some baby gear can be rented or gently used items are available as well if on a tighter budget. Also, forget all the origami-inspired swaddling–when you’re sleep deprived and overwhelmed it is best to invest in a Velcro swaddle.
Hopefully this will help some of the overwhelm you might be feeling and serve as a guide for you as you plan for the postpartum period in the time of COVID-19. The upside of stay-at-home life is that it is much like the postpartum period, so you’ll already have experience of what it’s like (e.g. less showers, anxiety about leaving the house and eating copious amounts of peanut butter). And if we’re still all quarantining when you have your baby, then at least there won’t be any fear of missing out.