Mother and Baby

Postpartum care information booklet

All images authorized for reuse or reprinted with permission.

Table of contents Important information ...... 3 Caring for your baby ...... 8

How do I change baby’s diaper? ...... 8 Where should baby sleep? ...... 10 Why is baby crying? ...... 13 Keeping baby clean ...... 17

What is normal? ...... 24 How should baby move? ...... 24 My baby’s head is not round ...... 24 Are hiccups normal? ...... 24 Baby has skin rashes ...... 25 What is normal breathing? ...... 25 Why do my baby’s skin or eyes look yellow ...... 26 What can I do if my baby has jaundice? ...... 27 How do I take baby’s temperature? ...... 28 Can I take baby outside? ...... 29 Feeding your baby ...... 31

Breastfeeding ...... 31 Bottle-feeding ...... 41 Baby feeding record ...... 46 Burping and spitting up ...... 47 Is baby getting enough Vitamin D? ...... 48 Keeping your baby safe ...... 52

Safety at home ...... 52 Safety in the car ...... 55

Taking care of yourself ...... 60

Caring for your body ...... 60 Caring for your breasts ...... 63 Healing after childbirth ...... 66

Where to get more information ...... 81

Supports for new parents

Do you want to speak to a nurse? • Call Tele-Health Ontario 1-866-797-0000 They are open 24 hours A nurse can answer health questions and give you advice

Do you want to learn more about being a parent?

Toronto Public Health offers information about: • Feeding your baby • Looking after yourself • Supports in the community

To find out more, call 416-338-7600 Toronto Public Health is open from 8:30am to 4:30pm

You can also connect online: www.toronto.ca/health

A note to fathers

Dads, you are very important to your new baby and your partner. Remember to: • Take care of yourself. Eat well and sleep when you can. • Make time to enjoy and care for your new baby.

There is a lot to learn about being a dad.

You can get information online at www.dadcentral.ca

When to call 911

Go to emergency or call 911 if baby:

• Looks blue • Has trouble breathing • Does not have much energy

Follow-up appointments

Use this chart to keep track of your appointments.

What When Date and time

2 to 3 days after you go Baby’s first check-up home

2 to 3 days after you go Phone call from home Healthy Babies, Healthy If you have given us Children permission to call

Your post-delivery check-up 6 weeks after you give birth

Do you need help with breastfeeding? Come to the breastfeeding clinic at St. Michael’s Hospital. Our hours are: • Walk-in on Monday and Wednesday from 9 a.m. to 2 p.m. • By appointment on Tuesday and Friday from 9 a.m. to noon and Thursday from 1 p.m. to 4 p.m.

We are on the 4th floor at 61 Queen Street West.

To book an appointment, please call 416-867-7421. 5

When should I call the doctor?

Babies are generally stronger than you may think, but health problems sometimes do happen.

This chart tells you what to look for. Call your baby’s doctor if you notice any of the problems in this chart.

Problems with baby Call your doctor or nurse if…

Baby’s temperature Is 38° Celsius or higher (100° Fahrenheit)

What is in baby’s Baby has fewer wet diapers every day diapers? Baby’s stool (poo) is watery

Baby’s skin and eyes Look yellow

Baby is crying Baby is crying for a long time It sounds like baby is in pain

Feeding Baby refuses to feed 2 times in a row Baby vomits after 2 feedings in a row

Sleeping Is sleeping much more than usual

Activity Baby has no energy Baby is not moving very much

Umbilical cord Baby’s cord is red The skin around baby’s cord smells bad

Make sure to take care of your own health, too. The chart on the next page tells you what problems need to be treated. Call your doctor if you notice any of the signs listed on the next page.

Problems with you Call your doctor or nurse if…

The discharge from your • Smells bad vagina • Soaks through more than 1 pad per hour

Your temperature is • 38° Celsius (100° Fahrenheit) or higher

• Your pain does not get better when you Your belly hurts and take medicine • You are taking more pain medicine each week

• Feels very tired All over your body • Aches as if you have the flu

• Have trouble breathing • Have a warm spot in your leg that hurts, is tender or looks red You • Have trouble peeing • Feel pain when you pee • Have a fever or chills

• Very sad You feel • Anxious • You don’t want to be with your baby

Problems with you Call your doctor or lactation consultant if…

• Burn

Your breasts • Hurt • Have red streaks • Have hard lumps

• Cracked Your nipples are • Blistered • Bleeding 7

Caring for your baby

How do I change baby’s diaper?

As baby grows, you will need to change more and more diapers. By the time baby is 1 week old, you will need to change 6 to 10 diapers each day.

Baby’s diaper will need to be changed soon after each feeding. Here is when to change baby’s diaper: • When it feels wet or heavy • When you see or smell stool (poo)

Pay attention to what is in baby’s diaper. It can tell you if baby is healthy. Here is what is normal by the time baby is one week old: • You will need to change about 6 to 10 diapers every day • Baby’s urine (pee) should be pale • Baby’s pee should not smell strong

• Baby should poop after every feeding or at least a few times each day • In the first week, the colour of baby’s poo should change. The first poo will be black. In a few days the poo should be yellow or mustard colour. • The texture of baby’s poo will also change. They will start our watery and become more grainy or seedy

How many diapers will I need to change?

How old is How many How many What will I see? baby? wet diapers? poops?

1 day old 1 or 2 wet diapers At least 1 poop Poo will be black and sticky. □ wet diaper 1 □ 1 □ wet diaper 2 □ 2

2 days old At least 1 or 2 At least 1 poop Wet diapers may have pink □ wet diaper 1 □ 1 spots.

□ wet diaper 2 □ 2 Poo will be black or greenish.

3 days old 3 or more At least 3 poops Wet diapers may have pink □ wet diaper 1 □ 1 spots. □ wet diaper 2 □ 2 Poo will be dark green or □ wet diaper 3 □ 3 yellow.

4 to 6 days 6 or more 3 to 4 poops No more pink spots in wet old □ wet diaper 1 each day diapers. □ wet diaper 2 □ 1 Poo may be soft, seedy and □ wet diaper 3 □ 2 yellow. □ wet diaper 4 □ 3 □ wet diaper 5 □ wet diaper 6

6 days to 6 to 8 wet diapers At least 3 poops Poo will be soft and yellow. 1 month old □ wet diaper 1 every day □ wet diaper 2 □ 1 □ wet diaper 3 □ 2 □ wet diaper 4 □ 3 □ wet diaper 5 □ wet diaper 6 □ wet diaper 7 □ wet diaper 8

Where should baby sleep?

Your baby should sleep • On their back • On a flat, firm surface

Baby should sleep in their own crib. Do not put baby in your bed.

You can put baby’s crib next to your bed. Keep baby’s crib near your bed until they are 6 to 12 months old.

Illustration used with permission from Hamilton Health Sciences, Hamilton ON Some things can be very dangerous for babies. Canada

Here is how to keep baby safe: • Never cover your baby with blankets • Never give your baby a pillow • Never lay baby on their stomach • Never put baby to sleep in bed with you • Never put stuffed toys or bumper pads in baby’s crib

How long should baby sleep?

Every baby is different. Some babies need only ten hours of sleep. Others need to sleep twenty hours a day. Some babies nap for only a few minutes and some may sleep for 5 to 6 hours at a time. Once you have settled into life at home you will learn your baby’s sleeping patterns.

Your baby may take naps and wake up every time the doorbell rings. Or your baby may sleep deeply and not be woken up easily. Do not feel that your baby needs total quiet. Babies soon get used to the normal sounds in your house.

It is normal for babies to be fussy for a few days in a new place. There are only 2 reasons you need to worry: • If your baby does not wet 6 to 10 diapers per day. This amount is normal after a baby is 6 days old. • If the doctor says that your baby is not gaining weight.

Never put baby to sleep in your bed. Put baby in a crib.

Illustration used with permission from Hamilton Health Sciences, Hamilton ON Canada

What is SIDS?

SIDS stands for Sudden Infant Death Syndrome. When a baby less than 1 year old dies in their sleep, we call it SIDS. We do not know what causes SIDS.

Here is what you can do to reduce the risk of SIDS: Always put your baby to sleep on their back. Once your baby can turn from their back to their tummy on their own, you do not need to check that they are sleeping on their back. Put baby to sleep on a firm, flat surface. Make sure that the air can flow around baby’s head. Here are some things you should never use in baby’s crib: • a soft mattress • fluffy pillows • a comforter • stuffed toys • bumper pads Do not smoke inside your home or car. Keep your baby warm, not hot. If the room temperature is comfortable for you, it is comfortable for baby. To check if baby is too hot, put your hand on the back of their neck. If baby is sweating, they are too hot. When you dress baby, put on as many layers as you would wear. Breastfeed your baby. It may protect against SIDS.

Never put baby to sleep in your bed. Put baby to sleep in a crib. Keep baby out of your bed. Do not let baby sleep between you and your partner.

Why is baby crying?

Crying is your baby’s way of telling you that they need something. Babies cry for many different reasons. You will soon learn what baby’s cries mean. Trust yourself.

First look for physical reasons why your baby is crying. Your baby might be: • Hungry • Soiled • Tired • Hot or cold • Bored • Uncomfortable • Sick

Your baby might also need love and attention. Remember that baby is getting used to: • Being separate from you • Not hearing your heartbeat

It can never hurt to cuddle your baby. You cannot spoil an infant.

This chart lists how to tell if baby needs something from you.

What is wrong? What happened? What you can do

Did baby feed more than 20 minutes ago? Is baby hungry? Feed baby Is baby making sucking movements?

Baby may need to feed more if they are:

Is baby having a growth • 2 weeks old Feed baby spurt? • 3 weeks old • 6 weeks old • 12 weeks old

Does baby have a tummy Did baby start crying right Burp baby ache? after feeding? Change baby’s diaper Does baby need to burp?

See if baby’s diaper needs Is baby uncomfortable? to be changed

Are baby’s hands or feet cold? Is baby too hot or Change baby’s clothes too cold? Is baby sweaty?

Coping with colic

Does your baby cry non-stop at the same time each day? If they cannot be calmed, they may have colic. Babies with colic cry for a long time, several times a week. Colic can last for 2 to 3 months. After that, it will stop.

When baby has colic, the best thing you can do is to hold them. Being able to feel and smell you will comfort them. Being touched tells baby that they are not alone. Holding baby will not spoil them.

Try these hints when baby is crying: • Listen to music while holding baby. Move to the music. Sing and sway. • Gently stroke your baby’s back or head. • Massage your baby’s arms and legs. • Let your baby hold or suck your finger. • Offer a feeding. It may stop baby’s tears. • Stay calm. The baby can sense your moods.

Baby won’t stop crying! What can I do?

Here are some things you can do to calm baby down: • Put your baby in a sling or in a front pack. Carry them around with you. • Give baby a breath of fresh air. Take them outside. Go for a short walk. If it is cold, make sure you are both bundled up.

• Most babies like motion. Try taking baby for a ride in the car. • Most babies like background noise. Run a vacuum cleaner or clothes dryer so that the baby can hear it. But it is not safe to put baby on top of the dryer. Never put baby on top of the dryer. • Sometimes, babies need time to settle. Put your baby down for a rest. Leave the room but listen outside the door. If they start to cry less, they just needed some time to settle.

How to stay calm

You might feel angry or upset when baby will not stop crying. This is normal. Here are some things you can do to stay calm: • Take a break. Put baby on their back in their crib or playpen. Go to another room. Take a few minutes to breathe. Try to release your frustration before you try to calm baby’s crying.

• Ask your partner, a friend, or a family member to watch the baby. Then take time to calm yourself. • Take care of yourself so you can care for baby. Eat healthy foods and nap when the baby sleeps. • Get support. Talk to your doctor or midwife. Call the hospital, new parent groups, or a lactation consultant. Ask for advice.

Keeping baby clean

Baby needs to be clean. But you do not need to bathe baby every day. Too much washing will dry out their skin. You should: • Clean baby’s bottom every time you change their diaper. • Wash the folds in baby’s neck every day. • Wash baby’s face. • Gently rub or comb your baby’s scalp each day. • Wash baby’s scalp once or twice a week. Use a mild, no-tears shampoo. • Give your newborn a bath every 2 or 3 days. • Trim baby’s nails.

How to handle baby with care • Clean only the parts of your baby that you can see. • Never poke cotton swabs into your baby’s ears or nose. • Always use soaps that have no smell (unscented soap).

How do I wash baby’s face and neck?

• Use warm water. Do not use soap. • Wet a clean, soft cloth or cotton balls. • Gently wipe baby’s forehead, cheeks and chin. • Wash behind baby’s ears and under their chin. • To wash baby’s eyes, use a clean cloth or a fresh cotton ball for each eye. Gently wipe each eyelid. Start at the inner corner of the eye and wipe outward.

How do I clean baby when I change the diaper?

Clean baby’s bottom every time you change a diaper. Urine (pee) and stool (poo) will bother baby’s skin. Make sure you wipe it all off. • Use a baby wipe or soft tissue to wipe away pee and poo. • Clean baby’s skin with a warm, wet cloth. Or you can use commercial baby wipes.

• Always remember to clean between the folds of baby’s skin. • Wipe girls from the front to the back. This will help prevent infections. • If your baby boy was circumcised, follow the instructions you were given by the doctor.

• Before you put on a clean diaper, dry baby’s bottom. Make sure it is completely dry. Then put on diaper cream.

How will I know if baby has diaper rash?

If baby has a red spotty rash in the folds of their skin, they probably have a yeast infection. Diaper rash can be treated. Here is what to do: • See your doctor or nurse. They will prescribe a cream. • Put the cream on every time you change a diaper. • Leave baby’s diaper off whenever you can. The air can help baby heal.

How do I get ready to give baby a bath?

Always bathe baby in a small tub. This lets you control the water temperature for the bath.

Before you start, decide where you will bathe baby. Choose a place where: • You can safely use a small tub • The temperature is about 23° Celsius (74° Fahrenheit) • Your baby will not be in any drafts

Then gather all the supplies you need. You will need: • diapers • mild, unscented soap • washcloth • a towel to dry baby’s body • a towel to cover baby’s head, if you are washing their scalp • clothes • small bath

Next, fill the small tub. Leave baby in their crib or playpen while you do this. When you fill the tub: • Start with cool water. Add hot water. • Mix the water until it feels warm. Make sure it is not hot.

• Test the water temperature with your elbow, or drop water onto inside of your arm. You can also use a thermometer made for testing bath water. • When the water is the right temperature, get your baby.

Gently put baby into the bath.

How to keep baby warm while giving them a bath • Make sure baby is out of any drafts. • After washing baby’s head, pat it dry right away. • As soon as you are finished with the bath, pat baby dry. • Cover baby’s head with a fresh dry towel.

How to keep baby safe at bath time • Never leave baby alone in the bath. Babies can drown in 1 inch of water. • Never put your baby near the faucet when the water is running. • Always check the temperature of the water before you put baby in the bath. • To make sure nobody gets burned, turn your water heater down. It should be set at 48° Celsius (118° Fahrenheit) or less.

Do not leave baby alone in the bath! Babies can drown in 1 inch of water.

If you must leave the room, take baby with you.

How do I bathe baby?

Hold baby with one hand while you wash them.

Bathe baby in the same order every time, working from the cleanest area to the dirtiest area: • Wash their head • Next wash their body, arms and legs, • Wash their bottom and genitals last

Here is how to wash baby’s body, arms and legs: • Place a small amount of mild, unscented soap on a clean, wet cloth. • Gently clean between any folds of skin. • Uncurl baby’s fingers to wipe their palms. • Wash under baby’s arms and behind both knees.

After you wash the rest of the body, wash baby’s bottom and genitals. Here is how: • Soap your baby’s bottom. Rinse well. • For girls: Always wash from front to back. • For boys: Never push back the foreskin on an uncircumcised penis.

How to dry baby • Lift baby out of the tub and wrap them in a towel • Gently pat them dry • Carefully dry all of the folds in baby’s body, arms and legs. If you do not, baby’s skin may break down.

How do I trim baby’s nails?

It is easiest to do this when baby is sleeping.

For the first few weeks, use an emery board to file baby’s nails.

After a few weeks, baby’s nails grow past the nail bed. To cut them, use nail clippers with a rounded edge or blunt nail scissors.

Here is how to cut baby’s nails: • Hold the skin away from the nail. This way you will not damage the nail beds. • Cut near the end of the nail

• Cut the nails straight across

Do not bite or chew off baby’s nails. There are lots of germs and bacteria in your mouth. They could infect baby’s fingers.

How do I take care of the cord?

Never pull off baby’s cord.

If your baby still has the clamp on the cord when you go home, the baby’s doctor or midwife will remove the clamp. It could also fall off when the cord falls off. Your baby’s cord will probably fall off in 7 to 10 days. After that, the spot under the cord may take four to five days to heal completely. You may see a few drops of blood. They will quickly go away.

Here is how to care for the cord: • Keep the area clean and dry. • Fold down the top edge of the diaper so the stump is not covered. • Never put any soap or lotion on the cord.

If you need to clean the area, use water.

Call your doctor or nurse if: • The cord smells bad

• There is yellow discharge • The area around the cord is red • Your baby has a fever. This means that their temperature is higher than 38° Celsius (100° Fahrenheit) • Your baby is 3 weeks old and the cord has not fallen off

What is normal?

How should baby move?

When newborns move their arms and legs, they can be a bit jerky. Most babies move both arms and both legs at the same time. It is normal for babies to be surprised easily.

Baby’s movements are not normal if: • Any part of their body does not move at all • Their arms and legs keep twitching or are jittery

Call the doctor or nurse if • The way baby moves is not normal

My baby’s head is not round

This is normal. Baby’s head will become more round during the first few months.

Are hiccups normal?

Hiccups are very common. Babies can get hiccups when they are feeding or after a feeding.

Hiccups will not harm baby. Hiccups will not bother baby. There is no need to treat hiccups.

Baby has skin rashes

Most newborns have a rash on their head and chest. It does not need to be treated. Normally the rash will disappear in 1 or 2 weeks.

If your baby has tiny white, bumps on their face and nose, this is called milia. They are blocked oil glands. Milia do not need to be treated. They will go away within a few weeks.

If baby’s head has scaly patches that are yellowish and oily, they have cradle cap. Cradle cap is not serious. Here is how to treat cradle cap: • Rub warm oil onto baby’s scalp. Use corn oil, olive oil or mineral oil. • Leave the oil on for a few hours. • Then run a soft comb over the scaly patches. • Shampoo baby’s head and rinse it well.

If this does not help, talk to your doctor.

What is normal breathing?

Babies make many kinds of sounds when they are breathing normally. They also breathe at different speeds. Sometimes their breaths are slow and sometimes fast.

You may notice lots of hiccups. You may also notice that baby will take deep breaths and have a red face when they are really upset and crying very hard. All of this is normal. Sometimes, baby’s breathing is not normal. Here is when you need to get help.

Call the doctor or nurse if: • Baby makes grunting noises when they breathe • Baby is wheezing • Baby’s skin is blue or pale • Baby takes fast breaths and is tired • Baby breathes very hard when feeding

Why do my baby’s skin or eyes look yellow?

This is very common. It is called jaundice. It usually happens 3 or 4 days after birth. Jaundice will not last long. But it can be serious. Check your baby every day for signs of jaundice.

Babies get jaundice because their liver is not fully developed. When the liver is growing it may not be able to remove something called bilirubin from baby’s blood. Bilirubin is what makes baby’s skin and eyes look yellow. It can take a few days for the liver to get bilirubin out of baby’s body.

All babies are checked for jaundice before they go home from hospital. Almost half of all newborns show some signs of jaundice. Premature babies are more likely to have it. Most babies have mild jaundice. It is not harmful. Babies with jaundice need to feed more. This helps baby’s body get rid of the bilirubin. The more baby drinks, the more bilirubin leaves their body in urine (pee) and stool (poo).

But some babies have too much bilirubin in their blood. They need regular check- ups with a doctor or midwife. They will need to be treated. They may have to go to hospital to be treated with special lights.

When should I call the doctor or nurse?

Call if: • Baby has a fever. This means a temperature of 38° Celsius (100° Fahrenheit) or higher • Baby’s skin or eyes look yellow

• Baby is not feeding well • You have trouble waking baby up • Baby’s jaundice is getting worse • Baby is 3 days old and has not had at least

3 wet diapers or stools (poo)

What can I do if my baby has jaundice? • Call your baby’s doctor, nurse or midwife.

• Feed your baby often. This helps to remove the bilirubin through pee or poo. • If you are breastfeeding, feed your baby every 2 to 3 hours. Feed your baby during the day and the night. Let baby feed as long as they want. • Check baby’s diapers every day. Make sure baby is passing enough pee and poo.

The chart on the next page shows how many wet diapers and poops are normal as baby grows. It also shows what poo should look like.

Use the chart on page 9 to check that baby’s body is getting rid of bilirubin.

Does baby have a fever?

It is normal for baby’s hands and feet to feel cooler than their tummy. Here are some signs that baby may have a fever: • Baby feels unusually warm • Baby’s cheeks are flushed • Baby is irritable or drowsy

If you think baby may have a fever, take their temperature. The best way to do this is in their armpit. Do not put a thermometer in baby’s bum.

To get a good reading, you must do this carefully. Here is how to take baby’s temperature.

How do I take baby’s temperature?

To take baby’s temperature, use a thermometer that takes temperatures under baby’s arm. Here are the steps to follow: Get the thermometer ready Get baby ready Take baby’s temperature

To get the thermometer ready: • Read the instructions for using your thermometer. • Take the cover off of the thermometer. • Clean the thermometer with soap and water. • Be sure the thermometer is at room temperature.

To get baby ready • Hold your baby on your lap or lay them on their back on a firm surface. • Grasp your baby’s elbow. • Gently but firmly lift baby’s arm away from their side.

To take baby’s temperature: • Place the tip of the thermometer in the fold of baby’s armpit. • Make sure the thermometer will be touching baby’s skin on all sides. • Bring the arm down so it is next to baby’s side. This will hold the thermometer in place. • Keep baby’s arm in place until the thermometer beeps. • Let go and gently lift baby’s arm. Remove the thermometer. • Read the temperature on the digital display. • If baby’s temperature is between 36.5 and 37.5° Celsius (97.7 and 99.5° Fahrenheit) baby does not have a fever. • If baby’s temperature is 38° Celsius (100° Fahrenheit) or higher, call the doctor.

Remember to clean the thermometer with soap and warm water before you put it away.

Call your doctor or nurse if baby’s temperature is:

 38° Celsius (100° Fahrenheit)  Higher than 38° Celsius (100° Fahrenheit)

Can I take baby outside?

Your baby will enjoy getting some fresh air. At first, try to stay away from crowded places.

Keep baby away from any person with a cold or infectious disease.

Feeding your baby

Breastfeeding

Here is what you need to know if you decide to breastfeed your baby: • When to feed baby • How to make sure baby is latched on the breast • What position is best • How much baby will feed • How to take care of your breasts • Who to call for help

When should I feed baby? Cradle position Reproduced with permission from Toronto Public Health Most breastfeeding mothers are surprised by how hungry baby can be. They are also surprised that baby feeds at different times each day.

Do not try to stick to a feeding schedule or routine. This will be frustrating for both you and your baby. You and your baby will establish a pattern that will change as their needs change.

Before breastfeeding: • Wash your hands. • Try to rest as much as possible.

Cross cradle position

How much will baby feed?

In the first month, your baby can feed 8 or more times every day. In the first week or so, your baby may feed many times during the night.

The number of feedings will vary from one day to the next. You will notice that your baby feeds more at certain times of the day.

If you give your baby formula, your body will produce less milk. To keep up your milk supply, breastfeed your baby when they are hungry.

Do you have questions about breastfeeding?

Come to the Breastfeeding Clinic at St. Michael’s Hospital. We are on the 4th floor at 61 Queen Street West. Our hours: • Walk-in on Monday and Wednesday from 9 a.m. to 2 p.m. • By appointment on Tuesday and Friday from 9 a.m. to noon and Thursday from 1 p.m. to 4 p.m. To book an appointment, call 416-867-7421.

To talk to a lactation consultant, call:

• Toronto Public Health 416-338-7600 • La Leche League (Mom to Mom Support) 416-483-3368

Why does baby feed more every few weeks?

Every 2 to 3 weeks, babies have growth spurts. Your baby will need to be fed more often because they are growing a lot. You may worry that you do not have enough milk.

Do not panic! You have not lost your milk. You need to feed baby more often for a few days. Your breasts will produce more milk to meet baby’s changing needs.

To increase your milk supply you also need to rest, drink lots of liquids and eat well.

How do I latch baby on my breast?

You can help your baby suck correctly if you use a good position and make sure baby is latched on your breast.

Try different positions. You can: • Lie down • Sit in an arm chair • Sit in bed with the head elevated

Here is how to put baby to your breast: • Hold your breast with your thumb and fingers. Put your thumb above your nipple (areola) and your fingers under it.

• Hold your baby with their nose facing your nipple. Tilt baby’s head back a little bit. Stroke baby’s upper lip with the nipple until baby opens their mouth wide. Their mouth should look like they are yawning.

• To bring your baby onto the breast, quickly pull them close to your body.

• Make sure most of your nipple is in baby’s mouth. If baby is only chewing on the nipple, they will not get much milk. And you will get sore nipples.

Reproduced with permission from Toronto Public Health Switching Sides

Feed on one breast until your milk slows down or your baby comes off. If your baby still seems to be hungry, offer the other breast.

Breastfeeding after a Caesarean birth

The most comfortable positions for breastfeeding in the first few weeks after a Caesarean birth are the side-lying position and the football position. Here is how

Side-lying position • Lie on your side with your knees slightly bent. Put a pillow under your head and one behind your back. • Lay your baby on his side facing you. Baby’s feet should be close to your front. • To support your baby’s head and back, use a rolled blanket or pillow and the arm on the same side to be nursed. • Position your nipple facing your baby’s nose. • When your baby’s mouth opens wide, bring baby to you. Try not to push your nipple into your baby’s mouth.

Football position • Sit on a sofa or chair. • Put pillows beside you, on the side that you will feed. • Put your baby onto the pillows. Use your arm to hold their body. Hold their head and shoulders in your hand. Let baby’s bum and legs rest on the back of the chair or sofa. • Hold your breast in your other hand, with your fingers in the shape of the letter “C.” Reproduced with permission from • Position your nipple facing the Toronto Public Health baby’s nose. • When your baby’s mouth opens wide, bring baby to you. Try not to push your nipple into your baby’s mouth.

When to stop

Do not limit the length of your feedings. Your baby will stop breastfeeding when finished. Your baby may fall asleep and let go of the nipple. If not, try watching baby’s throat for swallowing. If baby is asleep and no longer swallowing, remove your baby from your breast. To remove baby, first insert your little finger into the corner of baby’s mouth to break the suction.

Is baby getting enough breast milk?

Many new mothers worry that baby is not getting enough breast milk. Here are some common worries: • My breasts do not feel full. This is normal after the first few days or weeks. It does not mean that baby is not getting enough breast milk. • My baby cries after feeding. Your baby may need to be burped or changed. If they are making sucking movements, they may be hungry. There are many reasons babies cry. To find out more, read the section on Crying on page 15.

• My baby feeds often or feeds for a long time. There are no rules about how long or how often a baby should nurse. If you are worried, please go to a breastfeeding clinic. The lactation consultants will be happy to help you.

Here are some good signs that baby is not getting enough breast milk: • Your newborn baby sleeps through the night.

• You have to wake your newborn baby for feeding • Your newborn baby is too sleepy • You only change a few diapers each day. Look at the chart on page 11 to find out how many diapers are normal.

If your baby is too sleepy to feed, call your doctor or a breastfeeding clinic.

Expressing your milk

Sometimes you may need to leave your baby with someone else. To feed your baby when this happens, you can express your breast milk. The caregiver can feed your baby using a bottle.

Expressing your milk once or twice a week will not affect your milk supply, as long as you have been breastfeeding for 4 to 6 weeks.

To express your milk you will have to choose a breast pump. There are manual and electric pumps, and some cost more than others. To get help choosing a breast pump, talk to a lactation consultant.

Breastfeeding after you go back to work

Many women pump when they go back to work. They choose a pump that is portable and easy to use, both at home and at work. An electric pump works best for expressing milk and keeping your milk supply. 36

Once you have a pump you need to practice using it. Plan ahead to get yourself and baby ready for when you go back to work. Have a practice day that follows your workday routine.

Make sure you collect and store your milk so that it is safe for baby. Read the next section to learn how.

To keep up your milk supply, breastfeed when you are at home and pump when you are at work. Feed baby your expressed milk when you are away from home.

Collecting and storing breast milk

These guidelines are for healthy full-term babies. If your baby is sick or was premature, follow the guidelines you were given by the NICU.

How to collect and store breast milk

Always wash your hands before you express or handle breast milk

1. Pump your breasts and collect your milk in: • Clean glass bottles • BPA-free hard plastic containers with an air tight lid, or • Specially manufactured breast milk freezer bags

Do not use disposable bottle liners. They are made of thin plastic that may break when it freezes.

2. In each bottle or bag, only put the amount of milk baby needs for one feeding. At first this will be only 60 to 90 milliliters (2 to 3 ounces).

3. Write the date and time on all of the bottles and bags.

4. Put the milk in the fridge. Put it at the back of one of the shelves. Do not put the bottles and bags on the door of the fridge. The door is not as cold as the back of the shelves.

5. If you pump milk at work, store it in your own cooler with ice or a gel pack. Or store it in the company fridge.

6. If you are going to freeze some of the bottles or bags, let them cool in the fridge for at least 1 hour before you put them in the freezer. After the milk is cold, put the bottles and bags in the back of the freezer. Do not store breast milk on the door of the freezer.

7. Every time you use the breast pump, clean it.

How to warm breast milk

When you are ready to feed the baby, here is how to warm the milk safely.

Take the milk out of the fridge. Only take out enough for one feeding. Check the date on the container. Make sure that the milk has not been stored too long. Use the chart on this page to check how long you can store milk. Throw away any breast milk that is too old. Use the milk with earliest date first.

Put the milk in a bowl of warm water. Or hold the bottle of milk under running water. Do not let the water touch the opening of the bottle or bag. Never warm breast milk in the microwave. Never boil breast milk.

How to thaw breast milk When you do not have much breast milk left in the fridge, take a few bottles or bags out of the freezer. Use the oldest milk first. Check that the milk has not been in the freezer too long. To check if it is still good, use the chart on the next page. Throw away any milk that has been stored too long. Put the frozen milk in the fridge. Leave it in the fridge for at least 4 hours. Never let breast milk thaw at room temperature.

If you need to use the frozen milk right away, here is how to thaw it safely: • Put the frozen milk in a bowl of warm water, or hold it under running water. Make sure the water does not touch the opening of the bottle or bag When the milk has thawed, gently mix it. Check that it is warm enough before you feed baby. Never put breast milk in the microwave. Use the frozen milk within 24 hours if it has been in the fridge, or 1 hour if it has been left out of the fridge.

Throw away any milk that is left over when baby finishes feeding. 39

How long does breast milk keep?

How long will Where What temperature milk keep?

On the counter under 25º Celsius 6 hours (77º Fahrenheit)

In the fridge under 4º Celsius 5 days (40º Fahrenheit)

In the freezer of a fridge under -18º Celsius Up to 6 months (0º Fahrenheit) In a deep-freeze under -20º Celsius 6 to 12 months (-4º Fahrenheit)

If the milk is older than this, throw it away.

Where to get more information about breastfeeding • Best Start www.beststart.org • Toronto Public Health www.toronto.ca/health/breastfeeding

• La Leche League 416-483-3368 (breastfeeding information and support by telephone and/or group) www.lllc.ca • Breastfeeding Website www.drjacknewman.com

Bottle-feeding

Here is what you need to know if you decide to feed your baby infant formula: • How to choose the formula to use • How much to feed baby • How to prepare and store formula

Types of infant formula

Infant formula comes in three forms: Ready-to-feed liquid formula. You do not need to add water or mix this kind of formula.

Liquid concentrate formula. You need to mix this kind of formula with water. Powdered infant formula. This kind must be mixed with water. When you mix this kind of formula, you must be very careful. If you do not prepare it properly, baby could get sick.

Powdered formula can be used for infants who are healthy and full term. Do not use this kind of formula if your baby: • Was premature • Has a low birth weight • Has a weakened immune system

Whatever kind of formula you choose, make sure you follow the directions exactly when you prepare it!

How much should I feed baby?

Pay attention to what your baby does. That is the best way to know how much to feed your baby. Just like you, baby may want to feed more at some times of the day than at other times. When you learn your baby’s feeding patterns, you can adjust the amounts of formula and bottles to feed them.

In the first month, your baby will probably want a bottle every 3 or 4 hours. That is about 6 to 8 feedings every 24 hours. Little babies need smaller amounts and need to be fed more often than older babies. As your baby grows their stomach will grow. They will need more at each feeding.

Do not force your baby to finish the bottle. If you feed your baby too much, they can gain more weight than they should. They may also spit up. If your baby finishes the bottle and still seems hungry, you may offer a little more formula.

Newborn babies often fall asleep while feeding. When they do, you can burp your baby or change their diaper.

How old is How much will they need How often will baby they feed

Newborn 1 to 2 ounces (30 to 60 milliliters) Every 2 to 3 hours

2 months old 4 to 5 ounces (120 to 150 milliliters) Every 3 to 4 hours

4 months old 4 to 6 ounces (120 to 180 milliliters)

They may need more if they are a big baby

6 months old More than 6 ounces (180 milliliters) Every 4 to 5 hours

They may need less if they have started to eat baby food

How do I prepare formula?

Always read the packaging. Follow the directions exactly. You could harm your baby if you add too much water or not enough water.

When you prepare formula, you must make sure that everything is clean. If it is not, your baby could get sick. Here is what you need to do to make sure everything is clean: Gather all of the equipment you need: • Bottles, nipples, rings and caps • A pot of water to sterilize the bottles, spoons and nipples • A bottle brush and a nipple brush • Tongs Clean and sanitize your counters. Wash your hands well. Use soap and lukewarm water. Wash all of the equipment in hot soapy water. Scrub the equipment using your bottle and nipple brushes. Use hot water to rinse the equipment well.

Use boiling water to sterilize the bottles, spoons and nipples. Leave them in the boiling water for 5 minutes. Use tongs to lift them out of the water. Put the bottles, spoons and nipples on a rack to dry in the air. Cover the bottles and equipment with a clean tea towel until you are ready to use them.

When you mix formula, make no more than you will use in 24 hours. Feed your baby with one bottle. Put the rest in the fridge and use it within 24 hours.

How do I bottle-feed my baby? • To warm the formula, put the bottle in a bowl of warm water for a few minutes just before feeding. • Do not use a microwave oven. It can heat the formula unevenly. These “hot spots” can scald baby’s mouth.

• Get comfortable and relax. Hold the baby close to you. • Tighten the cap. Make sure the milk fills the nipple so that your baby is not swallowing air. • Hold the bottle to baby’s lips.

• Do not prop the bottle. If you do not hold the bottle your baby could choke. They could inhale formula into their lungs. • During the feeding, burp your baby several times. Burp them again at the end of the feeding. • Wash the bottle and nipple right after the feeding. This will keep formula from sticking to the bottle and plugging the nipple.

Baby feeding record

Pumped Breastfeeding milk or Pee Poo Time formula Comments Total feeding Amount Yes/No Colour Consistency Amount time

Total in 24 hours

Burping

Your baby can swallow air while crying or feeding. To get rid of the air, gently rub or pat your baby’s back during and after a feeding. Some babies need burping between breasts or after each ounce or two of formula, while others rarely burp. As your baby grows older, you will find that burping is unnecessary.

Spitting up

Many babies spit up a mouthful or so after feeding. Here are some things that can help: • Burp baby often • Feed baby less at a time • Handle baby gently

Spitting up is not the same as vomiting.

Call your doctor or nurse right away if:

• Baby throws up a lot at once • Baby throws up forcefully

Does my baby need water?

No. Baby needs breast milk or formula. Since both are 90% water, you do not need to give your baby more water.

Is my baby getting enough vitamin D?

Babies need vitamin D to help them build strong, healthy bones and teeth. If they do not get enough vitamin D they could get a disease called rickets. Rickets affects how bones grow and develop.

Babies that are fed formula do not need vitamin D. Formula has vitamin D added to it.

If you are breastfeeding, give your baby 400 IU of Vitamin D every day. If you are breastfeeding and bottle-feeding, please ask your doctor how much vitamin D to give your baby.

There are two kinds of vitamin D for babies. Here is how to use them:

Amount of How to give it to baby More vitamin D information

Baby D drops 400 IU Put one drop on a clean Has no taste in each drop or smell. • Nipple • Soother • Fingertip

Let baby suck it off.

D vitamin 400 IU Drop inside baby’s cheek. Comes with in 1 ml a dropper.

Read the directions carefully.

How will I know if baby is getting enough milk?

There are three ways to tell if baby is drinking enough milk: • Baby is gaining weight • Baby pees 6 to 8 times each day • After 4 or 5 days, baby poops 2 or 3 times each day

You will also know that your baby is well-fed if they: • Are alert • Have a good skin tone • Have bright eyes

Baby is gaining weight

The best sign that baby is getting enough breast milk is that they are gaining weight.

In the first few days of their life, babies can lose up to 8% of their birth weight. They will gain the weight back in two weeks.

After they are back to their birth weight, babies will gain from 20 to 30 grams every day. After that they will gain 140 to 225 grams every week for the first 2 or 3 months. You do not need to weigh your baby at home. Your doctor will weigh your baby at their regular check-ups.

Baby pees 6 to 8 times each day

By the end of the first week, baby should pee 6 to 8 times each day. If they do, they are getting enough milk. If baby pees 6 to 8 times a day, this means that you will have at least 6 wet diapers every 24 hours.

Sometimes, disposable diapers feel dry when they are full. Wet diapers are heavy. If you are not sure if it is wet or dry, put a tissue in the diaper. If it gets wet, you will know that baby has peed. 49

Baby has good bowel movements One of the best ways to know if your baby is getting enough milk is to look in their diaper. After the first 4 or 5 days, baby should have more bowel movements. By the end of the first week, baby should be passing at least 2 to 3 good-sized stools (poos) each day. The poo should be yellow. They are usually quite loose. Many babies also stain their diapers almost every time they feed.

All babies have a dark, sticky poo for the first few days. After this, the poo changes to brown, then yellow or tan. Each baby is different, but the colour, consistency and how often they poop depends on whether your baby is fed breast milk or formula.

Normal bowel movements if you are breast-feeding:

Your baby should have at least 1 poo every day in the first few weeks. They could have 2 to 5 poos every day.

Your baby’s poo should be yellow, soft and not formed by day 4 or 5. If this has not happened, call your doctor, midwife, or breastfeeding clinic.

By the time baby is 2 months old, your baby may poop less often. They may only have bowel movements every three to seven days. Or they could have small, frequent bowel movements.

Your baby will probably not get constipated.

Normal bowel movements if you are using formula:

At first, your baby may poop several times a day. This will slowly change to one or two poos a day.

Your baby might get constipated. They are constipated if: • Their poo is hard • Their poo is formed • They cry and strain when passing poo

Your baby could also get diarrhea. They have diarrhea if their poo: • Is watery • Has a strong smell

If your baby has diarrhea, call your doctor right away. Babies can get very sick and dehydrated very quickly.

Call your doctor or nurse if your baby:

• Is constipated • Has diarrhea

Keeping your baby safe

Safety at home

New cribs, playpens, and pacifiers must meet federal government safety regulations.

You may have a used crib, playpen or stroller. If you do, call Toronto Public Health to find out if they are safe for your baby.

Playpens

Playpens can be dangerous. If the walls are made of open mesh, children can fall through it. Their buttons can get caught in the mesh. If this happens they will be strangled. Follow product instructions to ensure the safety of your children.

Always make sure the playpens are far away from windows with blinds. Babies can strangle if they get twisted in the cord.

To find out more about using playpens safely, go to the Government of Canada website: www.canada.ca/en/health-canada/services/infant-care/playpens.html

Cribs

Canada has strong guidelines about crib safety. Follow these rules to keep baby safe:

Bars around the crib must be close together. The space between bars must 3 be less than 6 cm (2 /8 inches). If they are farther apart, baby could choke. The mattress should be firm. If it is soft, get a new one. Baby could get smothered on a soft mattress. The space between the mattress and the sides of the crib should be less than 3 3 cm (1 /16 inches). If the space is bigger your baby could get trapped. Do not use bumpers. Do not put pillows or soft toys in the crib. Always put the sides up. In a few weeks, baby will be able to roll over. They could fall out if the sides are not up. Make sure the crib is not near any window blinds. Babies can strangle if they get twisted in the cord.

Do you have questions about crib safety? Visit these websites:

• Government of Canada www.canada.ca/en/health-canada/services/safe-sleep/ cribs -cradles-bassinets.html

• Parachute Canada, a charity that cares about safety www.parachutecanada.org/injury-topics/item/ home-safety-bed-time

Pacifiers

Pacifiers can be dangerous because they wear out. If you choose to use a pacifier it should be replaced regularly. If they become weak or crumbly, baby could choke on a piece of rubber.

Pacifiers are also dangerous if they are on a cord. Never put the pacifier on a cord. The cord could strangle the baby.

Never dip the pacifier in sweet things such as jam, sugar or honey. These will cause cavities.

Babies who are breast fed should not use pacifiers for at least 6 weeks.

Here is where to find Government of Canada safety information about pacifiers: www.canada.ca/en/health-canada/services/infant-care/bottles-pacifiers-teething- necklaces.html

Pets

Pets can be dangerous to your baby. They can get jealous and attack the baby. They also carry germs. Here is how you can keep baby safe: • Keep pets out of the baby’s room. Never leave the baby alone with your pet. • Never put your pet into the baby’s bed or playpen. • Do not allow your child to tease your pet. • Do not let your child play with pet toys. • Make sure your pet’s needles are up-to-date. • After you touch your pet, their toys or their litter, always wash your hands. • After your child touches the pet, their toys or their litter, make sure they wash their hands. • You can prevent allergies if you vacuum often to clean up the pet hair.

Safety in the car

Each year thousands of children are injured or killed in car crashes. The best way to keep children safe is to make sure they are in a car seat that faces the back of the car.

In Ontario, children must ride in rear-facing car seats until they weigh at least 9 kilograms (20 pounds). Babies should be in a reclining car seat. This will keep baby’s head from flopping forward.

Car safety seats can help keep your child safe. But they need to be used correctly. This means you must: • Use a car seat every time your child rides in a car. • Use car seats in the back seat of your vehicle. This is especially important if your car has air bags in the front seat. • Follow the manufacturer’s instructions about how to use the car seat. Also check the owner’s manual for your car. Keep both manuals handy so you can check them if you have questions. • Use a rear-facing car seat until your child is too big for the seat.

To make sure baby is safe, you need to: • Buy a good car seat • Install the car seat correctly • Use the car seat safely

Buying a good car seat

To make sure your car seat is safe, look for the National Safety Mark label. This is proof that the car seat meets safety rules made by the federal government.

How do I choose a car seat?

There are two kinds of car seats. Some face backwards, and are called rear-facing. Car seats that face the front of the car are called forward-facing.

In Ontario, children must ride in rear-facing car seats until they weigh at least 9 kilograms (20 pounds). They can stay in a rear-facing seat until they reach the height and weight limits for that seat.

Some rear-facing seats are only good for babies. Other rear-facing seats are convertible. This means they can turn into a forward-facing seat when the child is big enough.

Here is how to choose a car seat that is best for you and your baby: • Choose a seat that fits properly in your car. Do not just choose the cheapest car seat. • Make sure the car seat fits your child and your car. • Try the seat before you buy it. Put your child in it and try adjusting the harnesses and buckles. • Make sure you choose a car seat that you can use correctly every time.

To learn more about car seat safety in Canada call

• Transport Canada 1-800-333-0371

They are open Monday to Friday from 8:30 a.m. to 4:30 p.m.

How can I be sure the car seat is safe? • Never use a car seat that has been in a serious crash.

• Do not use a used car seat if you do not know its history. • Never use a car seat that has been recalled. If a car seat has been recalled by the manufacturer, it is not safe. • When you buy a new car seat, fill out the registration form. If you do, you will be told if the seat has been recalled. • Don’t use a car seat after it has expired. Car seats expire after about 6 years. To find out when the seat expires, check the car seat manual.

When should I get a new car seat?

As baby grows, you will need to get a different seat. The seat you must get depends on your child’s weight and height.

Choose a seat that fits your child’s weight and height. In Ontario, you must use a forward-facing car seat when your child weighs between 9 and 18 kilograms (20 and 40 pounds). To find out if your child needs a new car seat, keep track of their height and weight.

When your child has outgrown a car seat, switch to a booster seat. Children in Ontario must use a booster seat if they: • Are less than 8 years old • Weigh between 18 and 36 kilograms (40 to 80 pounds) • Are less than 4 feet 8 inches tall

For information about child passenger safety laws in Ontario, visit:

• www.mto.gov.on.ca/english/safety/choose-car-seat.shtml • www.parachutecanada.org/injury-topics/topic/C2

Installing and using the car seat

Always install car seats in the back seat of your car. Here is how to install car seats correctly. • Make sure the seat doesn’t move more than 1 inch from side to side where the seat belt goes through the car seat (the belt path). • Read the manual for your car seat. Follow all of the recommendations in the manual. Keep the manual handy at all times.

• Check the owner’s manual for your car. Find out how to install car seats properly. • To make sure your car seat has been installed correctly, find a car seat clinic close to you. For more information visit: www.parachutecanada.org • If you want someone to check that you installed your car seat correctly, call the police or fire department. Find out when they are holding a car seat clinic. To find a car seat clinic visit: www.canada.ca/en/services/transport/road/child-car-seat-safety/child- car-seat-clinics-other-resources.html#_ontario

Make sure the child is secured in the car seat safely. Here is how: • Check the car seat instructions to make sure you’re using the equipment correctly. • When you put baby into the car seat, make sure the harness holds baby in place. • Make sure harnesses are snug and lie flat against the child’s chest. • Keep the retainer clip at armpit level. • For a rear-facing car seat, the harness should come through the car seat slots located at or below the child’s shoulders. Always follow the car seat’s manufacturer’s instructions for correct harness placement. • For front-facing car seats, the harness should come through the car seat slots located at or above the child’s shoulders. Always follow the car seat manufacturer’s instructions for correct harness placement. 58

Taking care of yourself

Caring for your body

For the first few weeks, try to focus only on caring for yourself and your baby. To take care of your body you need to: • Get enough rest and sleep • Eat well • Take care of your breasts • Recover from giving birth

How can I get enough rest and sleep?

You will be very tired for 6 to 8 weeks after you give birth. Your body is going through many changes. At night, your baby may wake you up every few hours. You will not have a lot of sleep and you will get tired easily.

Here is what you can do: • Rest whenever you can • When baby is napping, relax and try to sleep • In the first 2 weeks, try not to have many visitors • Ask others for help. They can do chores like cooking, cleaning and shopping. • Each day, slowly do more things yourself

What can I do to eat well?

To take care of yourself and baby you need to eat well. Continue with the healthy eating habits you had when you were pregnant. Ask your doctor if you need to take vitamins. It may be a good idea to keep taking your prenatal vitamin-mineral supplements.

You will probably lose up to 15 pounds (6.8 kilograms) soon after your baby is born. After that you could lose about 1 to 2 pounds (½ to 1 kilogram) every week. This is normal.

Here is what you can do to eat well:

• Choose foods that are full of nutrients and low in fat and sugar. These foods are: o Low-fat dairy foods such as milk, cheese and yogurt o Meat or meat alternatives o Fresh fruits and vegetables

o Whole grains • To find out how much to eat, follow Canada’s Food Guide. • If you don’t have enough calcium in your meals, you may need to take a calcium supplement.

• You may find that you are more thirsty than usual. Make sure you drink extra liquids. If you are breastfeeding, you may need to drink as much as 1 cup every time you breastfeed the baby.

Can my diet affect baby?

Sometimes the foods you eat can make your baby fussy. Here are some foods that can affect baby: • Milk products such as milk, cheese and yogurt • Foods that have caffeine such as coffee, tea, chocolate and cola

To find out if a food is bothering your baby, here is what to do: • Do not eat that food for 72 hours (3 days) • Try eating it again • Watch your baby over the next 24 hours (1 day)

If your baby is crying more than usual in that time, they are probably reacting to that food.

Who can answer questions about my diet?

If you want some advice about your diet, OHIP will pay for it.

Here is where you can get help: • Ask your doctor to refer you to a hospital dietitian. You will have an appointment in the Women’s Health Care Centre or the Family Practice Unit.

• Ask for help from a Public Health Nurse. To speak to a Public Health Nurse, call Toronto Health Connection at 416-338-7600. They are open Monday to Friday from 8:30 a.m. to 4:30 p.m.

Caring for your breasts

A few days after your baby’s birth, your breasts will swell with milk. They are likely to feel tender and heavy. This is normal. To help prevent breast soreness and control irritation, take care of your swollen breasts and your nipples and wear a good bra.

If you are not breastfeeding, your breasts could still get very sore. Here is what you can do: • Try not to stimulate your nipples • Wear a bra that is tight • When your breasts are uncomfortable, apply ice packs

What to do about swelling (engorgement)

If your breasts are very full they can be very tender. You can: • Take mild pain relief medicine such as acetaminophen (Tylenol®) • Use moist heat to help reduce the ache. • Put cold packs or cold cabbage leaves on your breasts after breastfeeding. These can give you some relief.

• Breastfeed more often. This will keep milk from clogging your breast ducts. • If your breasts are so full that your nipples are flat, squeeze out a few drops of milk. This will make sure that baby can get a good latch. • If your breasts stay swollen you could get an infection, called mastitis. Women mostly get mastitis when milk collects in the breast and the fatty tissue becomes inflamed. The best way to prevent mastitis is to keep your milk flowing. Breastfeeding often will help to keep your milk flowing.

Even if you do get an infection, your milk should still be fine for baby.

How to prevent sore nipples

Your nipples can get very sore if baby does not latch correctly or if you don’t take good care of them. Here is what you should do: • Make sure baby latches on to your breast correctly. Your nipple should be between the baby’s tongue and the top of the baby’s mouth.

• Do not clean your breasts using alcohol, soap, or scented cleansers. These can dry and crack your nipples. Do not wear nursing pads that are lined with plastic. They hold in moisture. This will make your nipples chapped.

If your nipples do get dry and cracked, use pure lanolin lotion or cream. Lanolin will soothe your chapped nipples.

How to choose a good bra

Wearing a bra that is the right size is very important. A bra that is too tight could cause one of your ducts to clog and become irritated.

When you are shopping, try to have a salesperson help fit you for a new bra. Look for a bra that is 100% cotton and has no underwire. Also, choose a bra with wide straps that won’t dig into your back and shoulders. If you are breastfeeding, find a nursing bra that lets you to uncover one breast at a time.

Call the doctor or nurse if you have:

• A fever or chills • Burning or pains in one or both breasts • Streaks on your breast

• Breasts so swollen your baby cannot latch on to the nipples • Nipples that start bleeding • Low milk supply

• Milk that does not flow freely

Call if you feel: • Aches all over and very tired, as if you have the flu

• Hard or lumpy spots in one or both breasts • One or both breasts are warm or hot

Healing after childbirth

After the birth, your body will need to heal. Your uterus will slowly go back to the size it was before you were pregnant. It will bleed as it shrinks. You may have hemorrhoids, and it may be painful to urinate (pee). As your body makes milk for the baby, you may have a temperature. All of these things are normal.

Your body will change as it recovers from giving birth. Here is what you will notice: • Your uterus will get smaller • You may feel warmer than usual • Your uterus will bleed • Your stitches need to heal • You may have hemorrhoids • You may have trouble urinating (peeing)

Why do I have pains that feel like labour?

After you give birth, your uterus should feel round and firm, like a large grapefruit. It should be around or below your navel. Over the next 6 weeks it will get smaller each day. Then it will be about the same size as it was before you were pregnant.

As your uterus is getting smaller you may have pains that feel like contractions. These are called after pains. They may be stronger when you are breastfeeding. These contractions help your uterus get back to its usual size.

Here is what you can do when you have after pains: • Take a warm shower • Use relaxation techniques • Before you breastfeed, take a pain medicine such as Tylenol. Take the pills at least half an hour before breastfeeding.

Why do I feel so warm?

You may feel warmer than usual. This is normal when your body is making breast milk. If you are worried, take your temperature.

• A normal temperature is between 36° and 37.5° Celsius (96° to 99° Fahrenheit) • If your temperature is higher than 38° Celsius (100° Fahrenheit), you have a fever. Call your doctor, nurse or clinic.

How much bleeding is normal?

After you give birth, you will be bleeding from your vagina for 2 to 6 weeks. For the first few days this flow will be dark. It will have blood clots and will not smell bad. After 2 to 3 days you should bleed less. The flow will look more brown. It will be like the flow in the last days of your menstrual periods. After about 10 days, you should not be bleeding. The flow should be yellowish white.

If you are more active, you may notice that you are bleeding a little more. Try to rest a little more if this happens.

If you soak through more than one pad in an hour, or if the clots are larger than a loonie, call your doctor.

Call your doctor or nurse if:

• The bleeding gets heavier. This means you soak through a pad in less than 1 hour

• You notice a strong smell

How to take care of your perineum and stitches

After your baby was born your perineum and vaginal area may be sore for a few days or weeks. There are things you can do to be more comfortable and to help your body heal.

Keep your stitches clean

You may have gotten stitches in the skin near your vagina. The stitches were to repair torn skin, or to close a cut to make the opening of the vagina bigger. This cut is called an episiotomy. Your stitches should dissolve within ten days.

You can reduce your risk of infection by keeping the stitches clean. Here is how: • When you go to the bathroom, gently wipe from front to back after you urinate or have a bowel movement. After wiping, spray warm water on the stitches. Pat dry. • When you bathe, do not use soap or any solution. Only use water to clean your perineum and stitches. • Change sanitary pads every 2 to 4 hours. You can change more often, but never wear the same pad for more than 4 hours. Keep your bowels moving

You may be worried that it will hurt to have a bowel movement. There are things you can do to keep from getting constipated. Follow these tips: • Eat fresh fruit and vegetables, whole grains, and bran cereals. • Drink plenty of water.

If you are getting constipated: • Do not strain to have a bowel movement. • Ask your healthcare provider about using a stool softener. If you are breastfeeding, always ask before you take any medicine. • Remember that your stitches will not ‘pop’ with a bowel movement.

How to ease the pain • Sit in a shallow warm bath (sitz bath).

• Put a cold pack or a heat pack on your stitches. Make sure to put a thin towel between the pack and your skin. • When you sit down, choose a firm seat. The stitches will pull less if you sit in chairs that are firm. • If your doctor prescribed a medicine spray, use it.

Call your doctor or nurse if:

• Blood clots the size of a quarter, or bigger, come out of your vagina • Your bleeding soaks two pads within 15 minutes • Blood is gushing from your vagina • Your discharge has a strong smell • You have severe pain in your belly • The pain near your stitches is getting worse • You have a fever or chills. • You have not had a bowel movement within 1 week after giving birth • Feeling like you have to pee even though nothing comes out • Burning or pain when you pee • Having to pee many times a day • Not being able to pee

Hemorrhoids

Many women get hemorrhoids when they are pregnant. Follow your doctor’s advice about how to care for your hemorrhoids.

Some treatments help relieve symptoms right away. For example, your doctor may prescribe anti-inflammatory medicine.

Other treatments are long-term. Changing your diet and exercising more can help ease constipation and can keep symptoms from coming back. Keep using the medication you received in the hospital.

Here is what you can do to relieve the pain and swelling: • Take sitz baths twice a day. This means sitting in a few inches of warm bath water. Soak for 15 to 20 minutes two times a day. A sitz bath can relieve the pain of hemorrhoids. It can also help keep the area clean. • Put an ice pack on the hemorrhoid. Placing an ice pack wrapped in a cloth or towel on an external hemorrhoid can help relieve pain right away. It will also help reduce the blood clot. Use the ice for 15 to 20 minutes at a time. Keep the cloth between the ice and your skin to prevent skin damage.

• Use over-the-counter treatments. Try using cotton pads soaked in witch hazel (Tucks® pads). You can get them at most drugstores. You could also user hemorrhoid ointments and petroleum jelly.

Constipation

If you had a C-section you are likely to be constipated. Only use laxatives or enemas if your doctor gave them to you. Here is what you can do to prevent or ease constipation.

Develop good bowel movement habits. This means:

• Use the bathroom when you need to. • Don’t ignore the urge to go. This can make you constipated, turn your stools hard, and can make you strain to go. • Do not read while on the toilet. Sit only as long as you need to. • Wipe gently with soft, unscented toilet tissue or baby wipes.

Add fiber to your diet. This can help relieve constipation. It will make stools softer and easier to pass. To increase your fiber intake, your doctor may recommend a bulking agent such as psyllium. Psyllium is a high-fiber supplement. You can get it at most grocery and drugstores.

Eating more fiber-rich foods will also help. For example, eat more whole-grain breads, fresh fruits, and vegetables.

Drink more water . Drinking more water can also help ease constipation. Water helps make stools soft and bulky. Be sure to drink plenty of water throughout the day. Drinking fruit juices, such as prune juice or apple juice, can also help prevent constipation.

Urination (Peeing)

Some women have trouble peeing after giving birth. This could happen if you had pain medicine (anesthesia) for the delivery. This is normal.

After the first 2 days, you may notice that you are urinating (peeing) more than usual. This happens because your body is getting rid of the extra fluid that you retained when you were pregnant and in labour.

What to do if you are having trouble peeing: • Pour warm water over your perineum as you sit on the toilet. This will reduce stinging. • Drink lots of liquids. This will help prevent bladder infections. Try to drink at least eight glasses of liquid every day.

Call your doctor or nurse if:

• The trouble you have peeing does not get better • The stinging when you pee does not get better

Post-natal exercises

Talk to your doctor about post-natal exercise. If you do exercises every day, your belly will flatten and stay firm and your back will get stronger.

Keep doing pelvic floor exercises (Kegels) every time you use the toilet.

If you have young children at home, they will probably enjoy doing the other exercises with you.

Kegels

These exercises • Strengthen the muscles in your pelvic floor that were stretched during pregnancy and delivery • Help improve your bladder control • Help improve your pelvic support

What to do: • Do these exercises when you are sitting down. • Tighten the muscles that block the flow of urine. Keep tightening and slowly count to five, then relax. If this is too hard, put your legs up on a chair. Once you have learned how to do this, it can be done in any position at any time. • Repeat the above exercise. This time, quickly tighten and relax the muscles in a “pulsing” manner, as many times as you can.

Pelvic tilt

This exercise: • Strengthens the muscles in your belly • Flattens your stomach • Improves your posture

What to do • Lie on your back with your knees bent and your feet flat on the floor. • Push the small of your back into the floor. Do this by pulling in the muscles in your belly and your buttocks.

• Hold for five seconds. • Relax. • Repeat the pelvic tile. Do it a few more times each day. Work up to 8 to 10 repetitions.

• Practice this exercise when you are sitting or standing.

Abdominal exercise

This exercise will: • Strengthen the muscles in your belly • Flatten your stomach • Improve your posture

What to do • Lie on your back with your knees bent, your feet flat on the floor and your arms by your sides. Tuck in your chin. • Stretch your arms towards your knees. Push the small of your back into the floor. As you breathe out, raise your head and shoulders off the floor, as far as you can.

• Hold this position for 5 seconds. • Relax. • Repeat this stretch 6 to 10 times or however many times is comfortable for you.

Recovering from a Caesarean

If you had a Caesarean, recovering can take time. Your belly will be sore and you will have to move carefully. Here are some tips:

• Be careful how you move. Hold a pillow against the incision when you get up from sitting or lying down. Hold a pillow against your incision when you laugh or cough. • Avoid heavy lifting. Do not lift anything heavier than your baby until your doctor or nurse says you can. • Take the pain medications your doctor prescribed. Do not take codeine or any pain medicine containing codeine.

You must make sure that your incision does not get infected. Here is what you can do: • After you shower, pat the incision dry. Do not rub the incision.

• Watch for signs of infection. If the cut looks more redness or is leaking pus, call your doctor.

Call your doctor or nurse after a Caesarean if:

• You have a fever that is 38° Celsius (100° Fahrenheit) or higher

• The cut from your surgery is red or painful • Discharge is coming out of the surgery scar • Blood clots that are the size of a quarter, or bigger,

come out of your vagina • Your bleeding soaks a pad every hour • You have severe pain • You have not had a bowel movement within 1 week after giving birth

Baby blues and postpartum depression

After baby is born you may feel sad. You could have something called the baby blues or you might have a more serious depression. Both moms and dads can get postpartum depression. Call your doctor or nurse for help.

What are the baby blues?

Most mothers have the “baby blues” in the first 3 to 5 days after baby is born. The “baby blues” will last less than two weeks. You may cry easily and you may feel: • Restless • Irritable • Discouraged • Depressed • Helpless

Remember that these feelings will go away.

What is postpartum depression?

Postpartum depression is more serious than the “baby blues.” It can happen right after birth or any time in the next eighteen months. Dads can also get postpartum depression.

If you have postpartum depression you may cry easily and you: • Feel exhausted • Have no appetite • Feel isolated and worthless • Have trouble sleeping • Feel inadequate and not able to cope • Are not interested in things you normally enjoy

If these feelings last more than 2 weeks, you have postpartum depression. Call your doctor right away.

78 Adapted and reproduced with permission from the Best Start Resource Centre

Caring for baby’s brothers and sisters

Having a baby is a big change for the whole family.

If you have other children, make sure you plan a special time every day to be alone with them. This will help them accept the new baby.

When can I have sex again?

You can have sex when: • Your perineum does not hurt • Your flow is no longer red and • You feel like it

Use a condom. You can get pregnant a few weeks after your baby is born, even if you have not had a period.

Here are some things you can do if your perineum is still tender: • Take a warm bath. • Allow extra time for cuddling and relaxing. • Try a water-soluble lubricant such as K-Y® jelly. Do not use oil or Vaseline®. • Try different positions.

Will sex be different?

Your body is going through lots of changes, so sex may feel different. It will take time for your body and your emotions to be ready for sex again.

• If you are breastfeeding, some milk may be released with sexual play. • Your body has less estrogen than before baby was born. This means that your vagina may not lubricate as it did before. Try using a water-based lubricant (such as K-Y® jelly) or a contraceptive foam. • Partners, please be patient! Things will get back to normal soon.

Talk to your doctor or nurse if you have any questions or concerns.

How soon could I get pregnant again?

If you are breastfeeding, your first period could be as soon as 3 weeks after birth, or it might not come until a few months after you stop breastfeeding the baby. Breastfeeding will not keep you from getting pregnant. Most women ovulate before they start to menstruate again. You could get pregnant very soon after you give birth.

If you are formula feeding, you will probably have your period 3 to 7 weeks after giving birth. Or you may not menstruate again until 12 weeks after baby is born. Remember that you will probably ovulate before your first period, so you could get pregnant very soon after you give birth.

If you are not ready to have another baby, use condoms until you decide what kind of birth control you want to use on a long term basis. Your doctor or nurse will discuss family planning at your post-natal check-up. They can help you decide what type of birth control is best for you.

Where to get more information

If you do not know where to find the information you need, call:

Community Information Toronto 211

St. Joseph’s Hospital Women’s Health Centre 416-530-6850

Women’s College Hospital Reproductive Life Stages Program 416-323-6230

Toronto Public Health www.toronto.ca/health 416-338-7600

Toronto Public Health offers many free and confidential supports, including: • Breastfeeding support • Cancer prevention • Dental care • Environmental protection • Food safety • Immunizations • Injuries and falls prevention • Newborn hearing screening • Nutrition programs • Parenting support • Physical activity promotion • Postpartum depression • Preschool speech and language • Prenatal and postnatal care • Sexual health clinics

Supports for teen mothers

Humewood House 416-651-5657 www.humewoodhouse.com

Jessie’s Centre 416-365-1888 http://jessiescentre.org/

Massey Centre 416-425-6348 www.massey.ca

Rosalie Hall 416-438-6880 www.rosaliehall.com

Crisis lines (open 24 hours)

Assaulted Women’s Helpline 416-863-0511

Distress Line 416-408-4357

Toronto Distress Centres 416-408-4357

St. Elizabeth Health Care 416-498-0043 (Mobile Crisis) extension 310

Support Groups

Bereaved Families of Ontario 416-440-0290 Supports grieving families

Smokers’ Helpline 1-877-513-5333 Call to get help quitting smoking

www.smokershelpline.ca

Family planning and sexual health clinics

AIDS & Sexual Health Info Line 416-392-2437 www.toronto.ca/health/ai_index.htm

Bay Centre for Birth Control 416-351-3700 www.womenscollegehospital.ca/ programs-and-services/bcbc/

Hassle Free Clinic 416-922-0566 www.hasslefreeclinic.org

Immigrant Women’s Health Centre 416-323-9986 www.immigranthealth.info/home.html

Planned Parenthood 416-961-0113 www.ppt.on.ca extension 121

Women’s Health in Women’s Hands 416-593-7655 www.whiwh.com

Children’s Aid Societies

Catholic Children’s Aid Society 416-395-1500

Children’s Aid Society 416-924-4646

Jewish Family and Child Services 416-638-7800

Native Child and Family Services 416-969-8510

Housing and shelters

Housing connections 416-981-6111 Call to get into subsidized housing

City of Toronto Shelters – Central Family Intake 416-397-5637 Call 24 hours for help finding emergency shelter

Toronto Community Housing 416-981-5500 Offers housing to people with low incomes [email protected]

Food

Daily Bread Food Bank 416-203-0050 Call to find food banks in your neighbourhood

FoodLink hotline Call to find food programs in your neighbourhood 416-392-6655 www.foodshare.net

Dial-a-Story 416-395-5400 Children can hear a story in several languages. Offered by the Toronto Public Library.

Financial support

Ontario Works Income support to help with the costs 416-397-0330 of basic needs such as food, clothing and shelter

Toronto Children Services 311 Call to apply for a childcare subsidy

www.toronto.ca/children/subsidy

Government offices

Government of Canada 1-800-0-CANADA Child Tax Benefits

City of Toronto Call for services and information, 311 not for emergencies

Government of Ontario 1-866-532-3161 Call to get a birth certificate for your baby www.gov.on.ca

Service Ontario Register your newborn Get a Birth Certificate Apply for Social Insurance Number 1-800-267-8097 Sign up for Ontario Child Benefits www.serviceontario.ca/newborn

NOTES:

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NOTES:

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Unity Health Toronto cares about your health. For health information you can trust, visit us online at unityhealth.to/learn.

This information does not replace the advice you receive from your health care provider. If you have questions, ask your health care team.

30 Bond Street, Toronto, ON M5B 1W8 Canada 416.864.6060 stmichaelshospital.com

Adapted and reproduced with permission from the Best Start Resource Centre

69347 Rev. Aug 5 2020 V3