Maggie McKay (Host): Meaningful Medicine is a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm your host, Maggie McKay. And today, our guest is certified nurse midwife Sharon Varner to discuss being a certified nurse midwife. Thank you so much for being here today.

Sharon Varner, CNM: Thank you for inviting me.

Host: Absolutely. So to begin, what exactly is the fourth trimester? I've heard of that, but I don't know what it is.

Sharon Varner, CNM: So, the fourth trimester is 12 weeks post-delivery. It starts after you deliver the baby and then the 12 weeks after delivery.

Host: What do you wish every expectant mom knew before entering the fourth trimester?

Sharon Varner, CNM: To listen to their bodies and to rest and feed their babies. Rest and feed. Rest and feed.

Host: What should moms expect physically during the first six weeks after birth? Because your body is going through some changes.

Sharon Varner, CNM: So for the first two weeks, there's a lot of exhaustion. Two to six weeks, the body is going back to the normal functioning. So in pregnancy, there's a 30% blood volume increase, and there's an overworking of the heart, the kidneys, and that all goes back to normal within six weeks.

Host: And how long does postpartum recovery really take?

Sharon Varner, CNM: A year. We have 12 weeks for the fourth trimester. But in reality, your body is still feeding a baby for six months to a year. So, that's a lot of drain on a physical body.

Host: Sharon, what are some postpartum symptoms that should not be ignored?

Sharon Varner, CNM: Postpartum depression should not be ignored. It's normal to have baby blues for one to two weeks where you're happy, sad, happy, sad. But if that lasts longer than two weeks, you need to contact your provider because that could be postpartum depression. If you're having fever, chills, red spots, hot spots on your breast, that should not be ignored. You need to contact your provider, because that could be mastitis. And mastitis needs an antibiotic to help with that. If you're running a temperature greater than 100.4, you need to be seen because that's a sign of infection post-delivery. If you're soaking more than a pad an hour times two pads, then we worry something's going on with the involution of the uterus, so you need to be seen.

Host: What about if you're—I mean, we know your sleep's disrupted, of course, but what if you're not sleeping at all?

Sharon Varner, CNM: So in the first week, you need to feed the baby every one to two hours. So, you want to sleep when the baby's sleeping, up when the baby's up. If you're not sleeping at all, then you need to be seen. That could be a sign of anxiety or depression, and that needs to be addressed.

Host: How does midwifery care continue after birth?

Sharon Varner, CNM: So, midwife means with woman. So, we listen to the woman's concerns. We try and incorporate and do shared decision-making, where we help the woman make healthful decisions for her life and her family and for the baby. So, we focus on the full body—body, mind, spirit, and what she needs.

And every woman is different in what their needs are. Some women don't have any struggles with breastfeeding, so they don't need the assisted guidance with breastfeeding. Some women don't struggle with depression, so they don't need information about that. So, you throw out the information at the six-week appointment, and you also just discuss it before they ever leave the hospital. That way they know, is this normal? Is this abnormal? And I like the partner to be available when I'm giving them information before discharge so that the partner knows what to expect post-delivery.

Host: Isn't that the truth? When we were trying to get discharged after my son was born, my husband was there and they gave a questionnaire to see about your mental health. And I thought—

Sharon Varner, CNM: And we still do that.

Host: Do you? That's a good idea.

Sharon Varner, CNM: Yes. It's called Edinburgh.

Host: And it's to guard against people who might have postpartum depression already before they even leave the hospital, right?

Sharon Varner, CNM: Yes, it's a screening. So if somebody's score is greater than eight, then we follow up at two weeks postpartum and we don't wait till six weeks postpartum. So dependent on that Edinburgh score, we will see them sooner or call them and reach out to make sure she's doing okay with her emotions and her moods.

Host: " And don't fudge on your answers," as my husband said, because he was watching me fill it out. And he's like, "You need to be truthful." And I said, "Then, they won't let me go home, and I want to go home." But you need to be truthful, because obviously for your benefit and the baby's. So, what can somebody expect during a postpartum visit with a midwife?

Sharon Varner, CNM: During a postpartum visit, we do a full body physical. We discuss the birth what their perception of the birth was, what they're wanting to do for contraception to prevent pregnancy for at least two years. We'd like for the woman to give herself a two-year break just to allow the body to heal and to allow that six to 12 months of breastfeeding.

We do a pelvic exam to make sure everything's healed from her laceration to her uterus going back to pre-pregnancy size. We do a weight to see where she's at with weight loss depending on what she had gained during her pregnancy. We do a breast examination, and we go over self-breast exam so that she knows what to look for in case of a clogged duct, in case of mastitis, in case of breast issues. Women that are struggling in the postpartum period with breast issues can come in and see us, and we'll do a lactation visit also with the patient.

Host: It sounds like you've got all the bases covered. You've thought of everything. That's awesome. What concerns do moms most frequently bring up during postpartum appointments? What do you hear from them?

Sharon Varner, CNM: They are worried about intimacy with their husbands, especially if they've had a laceration. Sometimes when they're breastfeeding, they don't understand the makeup of the vagina, that it could be dry post-delivery and up to a year if they're breastfeeding because of breastfeeding. So, we discuss lubrication. We discuss all the different types of birth control that fits into their lives. So, they get concerned about body image issues. They're concerned about bleeding and what's normal and what's not normal. They're concerned about their going back to work and re-entering the work force after having a baby and what that looks like. And some of them, when they have other children, they're concerned about how do we integrate a new child into the family, and how does that function out in our lives?

Host: That going back to work one is a big one, because a lot of people are still pumping, and you have to have a room for that. And you're already exhausted, and you're at work. And with that in mind, how do midwives support emotional recovery, not just physical recovery?

Sharon Varner, CNM: We give them resources. We can't be everything, but we'll give them resources to counselors. We'll give them resources to what to expect. There's a lovely pump. You discussed pumping. Here at our office, we've had many of our colleagues that have delivered babies, and they have these pumps that they put in their bra and they're still working while they're pumping. And it is amazing. You don't even know what's going on unless you hear the pump going on. But I mean, it's like a backpack. They wear a backpack while they're pumping their breasts every four hours while they're working. So, it is amazing the things that technology has come up with to where we can still support breastfeeding mothers.

And then, we also have a room if a colleague doesn't want to pump in front of people, even though it's discreet, we have rooms and we put on the app for the work restrictions or work, an adjunct, to allow the new mother to nurse every two to four hours. So, you need at least 20 to 30-minute break every two to four hours in order to excrete the breast milk.

Host: My son's turning 23 tomorrow, and I wish they had that pump that you talked about back then, because at work in the state I live in, it's the law. You have to have a room for women to breastfeed. And luckily, another coworker was in the same boat. But do you know what—you're not going to believe it, Sharon. Do you know what room they gave us? It was sort of like a closet—the fire department room. It all the switches and stuff for when the fire—it's a big high-rise. And we're like, "Seriously? This is where we'd have to pump?" There was a chair, and that's it. But I'm sure by now it's much nicer.

Sharon Varner, CNM: Yeah.

Host: But twenty-three years ago...

Sharon Varner, CNM: We have two comfortable rooms that our colleagues use for pumping. And it's private. No windows, but a comfortable chair. And some have their desk right there if they want to pump and still continue to work.

Host: That's great. Yeah, options, options. I mean, I think new mothers—

Sharon Varner, CNM: There are lots of options.

Host: New mothers need all the help they can get. In closing, is there anything else you'd like to add that you think that women need to know that maybe they don't?

Sharon Varner, CNM: To give yourself grace and mercy. We want to continue to run the household, clean, be able to do everything, and you have to listen to your body. You have to sleep, you have to eat. You need at least 500 more calories a day if you're nursing another person, a baby. You just have to give yourself grace, because there's a lot of changes that your body goes through, and it's a lot to handle.

Host: Very good advice. Thank you so much for sharing your expertise today. This has been so educational. We appreciate your time.

Sharon Varner, CNM: Thank you so much for inviting me.

Host: Of course. Again, that's Sharon Varner. To find a physician, advanced provider, or a certified nurse midwife, visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org.