Dr Sam Manger 0:00   

Health and Wellbeing Queensland acknowledges the Jagera and Turrbal people, the Traditional Custodians on the lands on which this podcast was recorded, and the Traditional Custodians on the lands and waters on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander Elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia’s First Nations people. 

[Intro] Emma Shipton 0:20 

I think it would be great if women and their families really knew that birth is important, but the postpartum period is more critical. I think there’s such a focus on birth, but really it is sort of one day and then beyond that, your life changes. 

Dr Sam Manger  0:38   

Hi, I’m Dr Sam Manger, a GP, and your host of this series, the Clinician’s Guide to the First 2000 Days, brought to you by the Queensland Government through Health and Wellbeing Queensland.  

Prevention across the first 2000 days offers an opportunity for healthcare professionals to support generational health improvements, but preventative health will only be successful if it is done with confidence and empathy and an evidence base.  

Over the course of this series, I will be talking to some of Queensland’s leading experts to explore how they discuss preventative health and how to create meaningful change for the next generation. Let’s get started. 

Once a baby is born, a mum goes home from hospital, the shared care that happens from the tertiary and primary care is integral for both mum and baby. To share their insights on how we can help mum transition to life with a newborn, I’m talking today to Emma Shipton and Dr Dale Garred.  

Emma is a registered midwife, lactation consultant and PhD candidate, currently working at the Royal Women’s Hospital in Brisbane. Dr Dale is a GP at Manly Village Medical with a special interest in women and children’s health and works with Mater mothers as part of their GP shared care program.  

Thank you so much for joining me, Dale and Emma. 

Emma Shipton  1:52   

Thanks for having us.  

Dr Dale Garred  1:54   

Thanks, Sam.  

Dr Sam Manger  1:54   

So, let’s start at the beginning. Considering current Queensland Health Services, can you briefly describe Dale, what you would expect a new mum’s journey to be after a mum and baby get home from hospital? 

Dr Dale Garred  2:06   

Well, look, currently in Queensland, new mothers and their babies upon returning home typically receive a midwife visit from the hospital’s community midwifery service, and this usually happens within the first seven days. Sometimes this visit might be conducted via telehealth and then a decision as to whether a home visit is required would be based on the content of that telehealth appointment. And then, really, from here Sam, postnatal care really is tailored to the individual, and any subsequent midwifery visits that occur would be determined based on need.  

So, some women might be discharged after this initial visit, and then other women might receive a few more scheduled visits, and then, in addition to these home midwifery visits, hospital staff really do encourage patients to book an appointment with their GP for a baby check within the first 5 to 10 days after discharge. And this is often the first outing for mums and dads. So, it’s a pretty mammoth effort.  

So, in our clinic, we really encourage mothers to capitalise on this outing and to book an appointment for both themselves and their baby. And I would really love to see this recommendation get more widely adopted by GPs. Then we might see the baby for a few weight checks between that five-to-ten-day visit and the 6-week mark, at which point, women are encouraged to book a postnatal check for themselves at the same time as the 6-week checkup and immunisations.  

So, you can see that these first few weeks after leaving the hospital, unfortunately, are really busy and chaotic time for a family. In addition to doctor’s visits, there might be other appointments to fit in, such as community-based hearing tests if there wasn’t enough time to perform these in the hospital. And then on top of all this, there’s an influx of visitors, a change in the home dynamics with both parents often being at home initially, and so this postpartum journey can really be quite overwhelming for new parents.  

Dr Sam Manger  3:48   

And Emma, we identified the key roles the midwife immediately, during and immediately after, and it sounds like there’s lots of nuance to that that review, because, as we just said, there’s sort of biological matters, there’s psychological matters, there’s social and cultural matters that have got to be, have got to be reviewed and considered in sort of ongoing planning.  

Emma Shipton  4:06   

Yeah, and triaged really quickly, right? You’re seeing a woman in a very short time frame and really trying to get a good assessment done to triage. Does she need some further follow up? Who can we refer on to link into child health, or again, just refer back to the… to their own medical team or their private doctor or their general practitioner.  

Dr Sam Manger  4:27   

So, Dale, how can primary care support this transition? And you’ve listed a number of things there to ensure that continuity of care during this the fourth trimester, that sort of 3 months immediately post birth. 

Dr Dale Garred  4:38   

Yes. Sam, look, I really think primary care plays a vital role in optimising postpartum care, and it really starts by having the conversation during pregnancy. So, in the later stages of pregnancy, I would encourage GPs to start a conversation about postpartum care and what this might look like for that patient. So, this conversation would include making it clear who the primary care provider will be for the patient and their newborn. When to book an appointment, with who and for how long, and I think that anything short of a long appointment for this consultation really just doesn’t provide enough time to properly ensure continuity of care postpartum. And then in late pregnancy, we can also start to talk about making plans for long term management of underlying chronic conditions. So, these are conditions that might have improved through pregnancy, like endometriosis or some autoimmune conditions, or they might be new conditions that have popped up during pregnancy, such as hypertensive disease of pregnancy and gestational diabetes.  

I really like to emphasise the value of postpartum care, not just for baby, but for mum as well. You’ll regularly hear me say in my appointments that a happy mummy equals a happy baby. But I also really appreciate that it’s a busy time for new parents, and so remembering to book an appointment with the GP can be difficult. So, in our practice, if we see a hospital discharge come through with a birth notification, we’ll ask our reception team to phone the family and congratulate them and then use this opportunity to book those initial appointments. And so really, receiving this hospital discharge summary in a timely manner can also really help to support continuity of care postpartum. 

Dr Sam Manger  6:11   

I like that response of the whole Primary Care Center to sort of congratulate the mum, and then, you know, organise the plan from there. But it’s not just a simple doctor-led process. It’s a whole primary care-led. So, the practice manager, the receptionist, the nurse, everyone’s involved in that, supporting that woman in this period, which is lovely. 

Emma, there’s this recognition that within antenatal and postnatal support, we need to move away from a sort of one size fits all approach, and we’re, and that’s lovely to see a more personalised, individualised approach coming forwards. How can healthcare providers support that individualised care plan approach and address the unique needs of the mother in this period? 

Emma Shipton  6:45   

Yeah, and I think that Dale’s really just given us some perfect examples of that, of treating the woman and her family like an actual person. It can be easy just to fall back onto checklists and just doing physical assessment, but it’s really critical we step away from the computer, take the paperwork away and actually just sit down and look the woman in the eye and ask her how she’s going. And I think just from asking that one question, you’ll actually be able to unpack a lot more in a lot shorter time frame. So, it will actually be better for the woman and also better for yourself as well. But I think working with the woman finding out what’s really important to her so we can prioritise her needs and really meet her expectations of what she wants as well. There’s no point us going into a consultation with our own expectations and our own plans for what we’re going to talk about if it really doesn’t suit the woman and her family and their own needs. So, I think it’s really critical. We need to ask her what’s really, really important to you and your family during this time. 

Dr Sam Manger  7:42   

Stay with us, we’ll be right back to continue our conversation. 

Advertisement  7:45   

Health and Wellbeing Queensland is working with our hospital and health services to meet targets for healthy food and drink supply in retail outlets, vending machines and staff catering. Providing a healthier range of food and drinks is just another way Queensland Health is enabling hospital staff and visitors to live healthier lives. Find out more by searching ‘A Better Choice’ at hw.qld.gov.au. 

Dr Sam Manger  8:09   

And now back to the conversation. 

We talked about in past episodes, the use of the acronym, which we use in GP a lot, called ICE, which is ideas, concerns and expectations, and so making that a sort of open ended question around the ideas concerns expectations that women may have both what’s happened, what’s happening now and then, what are the future, sort of expectations, and how we can best work around that is a good little acronym to use. So, Dale at around six weeks, we’ve talked about the importance of a comprehensive postpartum checkup with a GP or a midwife, but the research literature does not identify a benefit to this so what’s included in this check, and what would you say are the reasons that we actually should be doing this postpartum check?  

Dr Dale Garred  8:48   

So, look, I personally think that the six-week postpartum visit for mum is absolutely vital to identify and address any physical, emotional or social needs that might have popped up post pregnancy. So, this time is a time of really increased need and a major life transition for families. So, in addition to it being a time of joy and excitement, that fourth trimester really can present some considerable challenges for women, we find that mothers often neglect themselves for the sake of their new babies. So, this six-week postpartum check wonderfully provides an opportunity for early intervention and safety netting to prevent more serious conditions. And I think that it’s this that underscores its importance. I wonder if mitigation of problems before they even begin may be the reason that the literature might struggle to quantify benefits. 

Dr Sam Manger  9:36   

Yes, that’s right. And so, what would you include within this checkup, what’s your, I suppose, internal or set checklist, as it were. 

Dr Dale Garred  9:44   

Well Sam, as is always the case in general practice, I would start by taking a clear history and then perform an examination. And the key areas that I would focus on on history would be firstly, taking a birth history. So even if I’d been given the details of in a hospital discharge summary or discharge letter. I often find that these can be inconsistent with what actually happened, or, at times, can miss important details. So, I would simply start by asking an open-ended question, like the hospital gave me a summary, but you tell me how it all went. And by doing this, in addition to getting those vital pieces of information, it just gives the opportunity for the mother to have a bit of a debrief about her birth experience and any unexpected outcomes. So right from the outset, we as GPs can be starting to gauge if there are any mental health risks.  

Next, I would ask about birth recovery. So, this is a really practical feature of history, checking for problems right now, early on in the consult, in case there are any medical red flags. So, you want to ask about ongoing pain and bleeding, wound healing, and check for signs of infection, like fevers, discharge, swelling or redness. I would also check on bowel and bladder function. So, something as simple as constipation can really affect a new mother’s mental health, and it’s something that can so easily be fixed.  

And then finally, breast concerns for both both breast and bottle-feeding mothers. And I’d be really careful here not to assume that every mother is breast feeding. And so again, I would ask an open-ended question as to whether they are breast or bottle feeding or both, because even if the baby is bottle fed, mothers may still be struggling with engorgement and pain. Then after asking about the birth history and birth recovery, I’d then shift my focus to maternal mental health. So, I’d ask specifically about mother-infant emotional attachment, how partners at home are adjusting the level of social support from family and friends. And I’d conduct a postnatal depression screen using the Edinburgh Postnatal Depression Scale. So, in our practice, we hand mothers a laminated sheet to fill in, and then we’d start having a look at the baby while they’re filling that out, so that they don’t feel time pressured to just get it done, but rather, they can take their time and give us a really honest view of their emotional health.  

And then finally, I’d conclude my history by asking and talking about contraception, recommencement of intercourse and other aspects of sexual health. So, this would include checking if their cervical screening is up to date, and if not, making arrangements for this to be done, making plans for them to return if they experience any dyspareunia, vaginal dryness or loss of libido, which are really common in the first three months postpartum. And then, of course, discussing the various options available for contraception, we know that the timing of ovulation postnatally varies significantly and may often occur before the first menstruation after pregnancy. And so unplanned pregnancy in the postpartum period is certainly possible and important to prevent.  

And then at that point, I would perform my physical examination, so looking for any obvious signs of anemia, checking for shortness of breath, checking blood pressure. And then I would do an abdominal examination to check fundal height and abdominal separation. And finally, I would also offer the woman a breast and pelvic examination to check for any breast trauma or risks of infection as well as any perineal wounds.  

Dr Sam Manger  13:03   

Excellent, thank you. Just to note that we are going to be covering breastfeeding and baby check milestones in future, in depth, in another episode.  

Now, there’s a number of points you mentioned there Dale around birth experience, their perception of that as well, which may be different from as you say, what the discharge summary, says the complications and their recovery, general wound care, which may be perineal or C-section or other aspects, breast health and breastfeeding, raising that question, bowels – very important, mental health, general movement, pain and lifestyle factors, as well as vital signs, blood pressure and so on, so forth. And following up on any chronic diseases that may have been present as you said, earlier, before pregnancy, that may have come up during pregnancy. So, following up on those other aspects there.  

Emma, this is something you do a lot as well. So, adding any other sort of pearls or tips to add to this. And then on top of that, what was mentioned around fatigue and sleep deprivation is very common concern and how you might approach that.  

Emma Shipton  14:02   

Yeah, so I think Dale’s provided a really excellent list, a really thorough list of things. And I think definitely talking to the woman as well about her experience during birth is really critical, as we know a lot of women do experience birth trauma, and at this six-week check, you know, this might be the first time that someone’s really asked them, and they’ve had enough time to really think about things.  

So, it’s great to be able to talk about that and see if there are maybe some concerns there that warrant some further investigation. In terms of sleep deprivation, it’s absolutely normal, but it can be a really difficult transition in becoming a new parent, it is a really difficult time anyway. And then you throw in if you’re not sleeping well, which most parents aren’t, right? So, I think talking about that, making sure that women and their families are able to get some rest, and that doesn’t have to be sleeping, but rest. Rest. It can be really tempting to when the baby sleeps, think now I’ll race around and get all the laundry done and everything, but just to rest during that time is really critical, going outside, getting fresh air, just trying to, I guess, continue in your life without letting that tiredness take over whilst maintaining your own safety is really critical, I think. 

Dr Sam Manger  15:24   

There’s an aspect of pacing here, which we often talk about in certain conditions around just pace yourself if the temptation, as you say is… as you say, is to sort of boom and bust, you know. So, push yourself when you’ve got the opportunity to push yourself, and then you’ll bust, because you’ll exhaust yourself, and that is a much less sustainable approach. So, it’s very, and we’ll come back to this around the transition of becoming a parent, but that some degree of acceptance of chaos within this and just taking the opportunistic moments of rest, as you say, is part of that growth curve.  

Emma Shipton  15:55   

Yeah, and I think when you accept something, it becomes inherently easier than trying to fight against it and think, no, I’m going to control this and I’m going to maintain things how it used to be when it’s not how it used to be anymore. 

Dr Sam Manger  16:09   

Absolutely. Now Dale, some women experience other symptoms like heavy bleeding or excessive fatigue, and that could be a sign of something particularly serious. What sorts of complications should health professionals be aware of that could indicate something like that? 

Dr Dale Garred  16:24   

Great question Sam. Look, we know that timely recognition and intervention can significantly improve outcomes for postpartum complications, so women should be encouraged to seek care promptly if they or another care provider notice anything concerning. So, things that we’d be on the lookout for in that first six weeks would be less common but really serious conditions like postpartum preeclampsia or hypertension and also deep vein thrombosis or pulmonary embolus.  

So, these can often both present in subtle ways, such as mild shortness of breath or fatigue, and the woman might just put this down to being sleep deprived. And then there are other more common things to be on the lookout for, so things like infections. These could be wound infections, could be breast infections in the form of mastitis or even endometritis, which may or may not be due to retained products of conception, and it will often accompany prolonged and ongoing heavy bleeding as well as pain and other features of infection.  

And then there are some other common non infective conditions that it’s important to be aware of. So postpartum thyroiditis is actually quite common. It affects about one in 20 women, and it’s a common source of fatigue and tiredness, but also other symptoms like palpitations, which, again, women might just ignore or put down to them neglecting themselves or feeling just a bit more anxious about baby. Another complication to be on the lookout for would be iron deficiency anemia, which can also present in similar subtle ways, as well as things like persistent pain from nerve injury, hematomas or musculoskeletal strain during delivery, which can all have a really significant long term negative impact on a mother’s wellbeing if they’re not picked up and addressed early.  

And then, of course, as we’ve already spoken about, it’s imperative to have a really sensitive radar out for identifying postpartum depression and psychosis, because, as we’ve said, this can be really serious and might often be masquerading simply as tiredness or fatigue. 

Dr Sam Manger  18:18   

So, a number of really important considerations there, we mentioned the lifestyle factor, sleep deprivation, but also, as you said, anemia, thyroid problems, gestational diabetes, or persisting diabetes, persisting sort of preeclampsia, or blood pressure problems, infections as well, and mental health. So, a number of aspects there, we should be seeing, generally, a woman and baby get healthier with each passing week, but if that deviates from that trajectory, then we should have our flags raised and some concerns for looking further. 

Dr Dale Garred  18:47   

So there’s a few other things that will often just fall naturally into those history areas, but other things in the back of my mind, if they don’t pop up elsewhere, would be certainly assessing the woman’s awareness of community resources and how to access these. So taking the opportunity also to offer some anticipatory parental guidance of what to expect in the next few months, and where to access specific evidence based parenting resources like the raising children’s network .  

And so, throughout the whole history, I’m really trying to gauge that level of maternal neglect or lack of self care that often occurs in that postpartum period. So, things like, as Emma said, unaddressed sleep deprivation, poor eating habits, social isolation. So, these things can, really can be nipped in the bud early, either through education or arranging access to other support services.  

And then other more practical things I would check in about would be things like the rubella immunity status, so offering immunisation if the patient wasn’t found to be immune in pregnancy, and then finally, considering if any follow up blood tests are required post pregnancy, and arranging for these, such as iron studies and full blood count if blood loss was an issue at delivery. Thyroid levels, if these required addressing in pregnancy or follow up diabetes screening for patient. Patients who had gestational diabetes, because we know that women diagnosed with gestational diabetes are 10 times more likely to develop Type 2 Diabetes in their lifetime.  

Dr Sam Manger  20:08   

Thank you, and when we think about the serious conditions which you just mentioned, and we’ll come back to chronic diseases in a moment, but I just want to pause for a second and also think about the serious mental health conditions that can be present, especially during this period, sort of postpartum. How do we distinguish expected postpartum, natural hormonal changes that might be causing mood swings compared to actual mental health conditions that may require more intensive assessment and support? 

Dr Dale Garred  20:33   

 Yeah, look, obviously there’s some normal postpartum blues and, sort of, we usually expect those to finish at about that two-week post pregnancy mark. So, I really am looking to see if those mental health concerns persist beyond that two-week mark. And then for me, really trying to determine whether this is a problem or not. I really try and ascertain whether it’s affecting the woman or the family’s ability to function.  

So, if they’re not eating, if they’re not managing to shower, if they’re not getting changed, if they’re not managing to tend to their baby’s needs, then when things are really affecting their ability to function, I worry that we’re really dealing with more of an organic problem here. I guess the other thing is, when it’s being noticed by family members. I think Emma, you sort of alluded to that a little bit. So, if we’ve got family members that are saying that they’re worried, it really represents that this is a significant change from the patient’s baseline. And, so again, we may be dealing with more of a pathological problem. 

Emma Shipton  21:30   

I think a really clear gauge for me is, are you still able to have some sort of laughter? It’s a really stressful time, and I anticipate that parents will often have some low mood as they are tired, and their life has been just changed overnight. But also, what I want to know is, with your partner or your support, are you able to laugh? Is there something funny that happens and you’re able to see that that is funny in amongst the chaos, or are are you getting to the point that you’re not able to see anything as funny anymore? You’re too low and not able to come back up again? So, I think that’s sort of how I would start a conversation and start to assess where the woman is at in terms of her mental health, because there certainly can be some really serious effects, right, for having a baby and not treating or not seeking help. 

Dr Sam Manger  22:21   

So, when would you say, Dale, is a good time for GPs or a child health nurse to discuss chronic disease health with a woman who has a new baby?  

Dr Dale Garred  22:28   

Yeah Sam, as I mentioned earlier, I really believe that planning for management of long-term conditions, whether they be new conditions that have arisen in pregnancy or old conditions that might have changed during pregnancy, really should start in the third trimester and then be covered again within the first 10 days post delivery, and then again at the six-week visit.  

So you see, pregnancy is a bit like a natural stress test for the body, and is therefore really useful at identifying women who are at risk of longer chronic conditions, but because many pregnancy related conditions often resolve postpartum such as pregnancy-induced hypertension or gestational diabetes, the increased lifelong risks that these conditions hold for women is often not consistently communicated to them and often forgotten. So, these conversations really do need to happen early to ensure that we keep women safe in the long term.  

Other important considerations would be reviewing medication in the third trimester. So, a conversation really needs to happen about medication adjustments in the immediate postpartum period. In their third trimester, there may be medications that the woman takes that might not be safe in breastfeeding, or there might be some immediate postpartum adjustments that need to be made to medications to things like anti epileptics, thyroxine or psychotropic medications, and if these aren’t considered and adjusted to reflect postpartum physiology until the six-week mark, it could result in considerable harm to both the mother and possibly even the infant. 

Dr Sam Manger  23:56   

So, a number of things there. Do you have any sort of… how do you guide this extensive check? I mean, do you have, do you use the pregnancy books? Do you use certain guidelines or resources?  

Dr Dale Garred  24:08   

Yeah look, I think GPs are really lucky. Within our practice-based software, we can create auto fills. So, I do this for a number of the things I’ve spoken about above. So particularly complications to be aware of, having a list of these that I can just include in my auto fill so that they’re not missed in those pregnancy post-pregnancy conversations. 

Dr Sam Manger  24:27   

And Emma, what resources do midwives often use? I mean, do you use the red book as a sort of go to, or do you have other internal guides? 

Emma Shipton  24:34   

Yeah, I think when working for Queensland Health, using the pregnancy health record, like the hand-held record, or the baby’s red book, it’s a really good place to start. It’s sort of a jumping off pad. It can start a lot of conversations and be a really good prompt to then take things further. So, I think that they’re both really great places to start. 

Dr Sam Manger  24:53   

So now let’s talk about this sort of transition. We know being a new parent can be very life consuming, can be difficult for parents to prioritise their own wellbeing. And so, Emma, I’m curious as to what sort of advice, practical advice, you give to new parents on this transition in life, and then also how that progresses to eating well, getting more movement, getting enough sleep, and those determinants of wellbeing.  

Emma Shipton  25:15   

So, I think we’d already talked about right, sort of going with the chaos. There’s no point fighting against it. Babies are really unpredictable, or can be, and we really can’t control the uncontrollable. But what we can do is take care of ourselves, rest, eat nutritious food where we can and lots of practical tips around that, like meal prepping, even having a menu on rotation, so it takes less thought out of it.  

I think it can be difficult for women to do, or for many parents to do, but accepting help when it’s offered, we sort of want to be seen as a really great parent and we’re able to do it all. And so, it’s easy to say no to help, but I think if help is being offered, it’s really great to accept it. If people are dropping off food, accept it. If people come around and offer to put out a load of washing or stack the dishwasher, we need to be accepting it.  

And by the same token, it’s really important that for people who are coming around to visit that they understand they’re not just there to hold the baby. They’re also there to hold the mother as well, and to prioritise her and do what they can do to help, not just pop by and then leave their plates and go home again.  

Dr Sam Manger  26:35   

Dale, this must, this is something as well that you must have conversations with your patients and new mums about this all the time. Is there any sort of, pearls or tips that you give mums around just, and dads, around the changing in this life transition? 

Dr Dale Garred  26:48   

It’s really important to have a team approach, so it’s not just all on the mother and so really getting dads involved. And sometimes we need to give permission for mothers to go out for a walk and let dad stay with the baby. They’re often a bit nervous to do that, I think again, really planning for this time in the third trimester.  

So having those conversations in the third trimester, and, you know, just having a conversation about those resources available to families. So even things like arrange to get your groceries delivered, what meal services might be out there that could be delivered, delivering nutritious foods that you don’t have to worry about it. Even things like, have you bought a carrier that can be a really useful option to allow you to sort of keep functioning as an adult. So really preparing for that in those sorts of late third trimester conversations. 

Dr Sam Manger  27:35   

Yeah, that’s very helpful. I, as a parent myself of three children, and I’m, you know, a dad, so sort of not, not the mother, obviously, I think there’s a very different experience for, for mothers and dads, sometimes, one of the quotes that stuck out to me only when I was changing my son’s nappy and he was, you know, crying, he’s my firstborn, and it was a big adjustment, was a quote from Socrates, which is, “All suffering comes from wrong expectations”. And, and I was thinking, “Yeah, my expectations are just wrong”. Of course a child is going to cry. I should just know that and assume that that’s going to happen and not be irritated by it, because it’s going to happen.  And there is this shifting where you go, okay, my expectations as to what is now normal needs to change. And sometimes it’s good to have that question around, what are the new norms likely that are going to be in your life? There’s likely going to be some sleep disruption, there’s likely going to be some crying and some dirtiness and some chaos. There’s likely going to be a little bit of sleep deprivation, to the point where there might be pressure on the relationship and the dynamics of the relationship. So, let’s just open up that these are now the new norms, and what are we going to do about it? And that can at least start that conversation going around. As we said, expectations.  

The other point that you both raised there was the importance of community in that regard, and it is worrying to see trends in sort of social isolation and loneliness that we’re seeing in society at the moment, especially considering this is a sacred period of life, and often this is the time in traditional cultures where there would be a much, much thicker presence of aunts and uncles and cousins and other non family members visiting, as you said. 

Emma, how do you approach this in the sense of, do you encourage people to connect with mum’s groups? Or do you just simply assess their sort of social loneliness, or their social determinants to some degree. How do you support mothers to connect with their community, especially in a world where it may not be as traditionally normal look?  

Emma Shipton  29:28   

I think that has to be really personalised. For some women, they’re going to want to seek that kind of community in terms of a mother’s group or something like that. And for some women, that’s going to be their worst nightmare to go and sit in the room and talk to other people that they don’t know. So, I think it really has to be personalised. But I guess irrespective of your personality traits are what suits you personally, it’s important that we continue living and that we don’t stay at home and stress and worry and just get lower and lower. So, whatever that looks like for each woman is going to look a little bit different, but it definitely means going out seeking some sort of social support or connection, whatever that looks like.  

And I think a mother’s group or a parent’s group is a really great place to start. There’s something really lovely about connecting with someone who has a similar experience to what you’re going through. It’s really validating. And I think finding those people, they don’t have to be your best friend forever, but in that time, it can be really helpful just to have that support. And I think a mother’s group is quite helpful for that. 

Dr Sam Manger  30:41   

Don’t go anywhere, our conversation continues after these messages. 

Advertisement  30:46   

A walk a day can keep the doctor away, and if your patients are looking for a free regular activity that can be done anywhere, anytime, they can join the 10,000 steps program today. The program raises awareness about the importance of physical activity and increases participation by encouraging incidental activity as part of everyday living. To find out how the 10,000 steps program can help your patients live a healthier life through physical activity, visit 10000steps.org.au 

Dr Sam Manger  31:14   

And now back to the conversation. 

And what about dads? So, you know dads, as we alluded to, can sometimes be a little bit of a, sort of third wheel, or forgotten person in this dynamic, especially in those first few months where the dad hasn’t had that sort of thick bonding experience of pregnancy and birth. So, they’re still being fairly, let’s just say, “more disconnected from the situation”, not totally, of course. So how can healthcare providers support the needs of new fathers in that first period?  

Emma Shipton  31:44   

Yeah, so I think if they are there, just involving dads in the conversation, almost just inviting them in. Because I think dads can feel like this kind of feels like woman’s work, which isn’t right. It’s absolutely about a caregiver, not a mother or a father, so if they are there, definitely involving them in the conversation, getting their thoughts. There’s an expectation, I think, that women just know what they’re doing, because they are a woman, and they are a mother. But of course, that’s not true either. So, I think allowing men to sort of navigate their way through this as well, and being there to support is really, really important. If they’re not at the visits, or you don’t have that face-to-face contact, definitely including them when you are having a conversation with the woman, I think is really good. Offering supports for fathers in particular, and we talk about mothers groups, but there’s certainly fathers groups as well that can be really good to link in with. There’s plenty of things on Facebook, which is the beauty of the time that we live in now. So, there are plenty of resources just for men as well, or fathers. 

Dr Sam Manger  32:54   

Dale, this is something again, you must go through.  

Dr Dale Garred  32:56   

Yeah, look, I think I really try and take the opportunity to talk to both parents about this being a real team approach, like I said earlier. So just because dad is getting up and going to work every day doesn’t mean that he doesn’t have to get up and help with the baby overnight. I think that a job of a mum staying home with a baby is just as hard, if not harder, than the dad going to work. So, dad gets to go to work and eat lunch and go to the toilet in, you know, in isolation. And so, I really tell parents that it’s a team approach. I think a lot of this is on the mother. So, I think mothers think it’s their responsibility to do everything for the baby, because the dads are going to work. But I really very early on, try and quash that myth and make sure that they’re aware that you take this in turns. You know, if you’re getting up to breastfeed, dad, get up, gets up to make you a cup of tea or get you a blanket, or, you know, get you whatever you need.  

Dr Sam Manger  33:51   

Or just to open up the conversation in some degree, it says, ‘let’s just talk about this and see where it goes and how we’re going to address those needs that we all have in this context, and balance that out proactively’, rather than waiting for conflict to arise and then dealing with it later.  

Dale, we mentioned there around social aspects, in the sense of loneliness and that being a really important component. But there are, of course, other social determinants of health that need to be assessed and individualised to a new mum and dad, such as transportation, social support we mentioned, but finances, accommodation, potentially even so when health professionals are working in this postpartum space. How do we mitigate these disparities when GPs are often stretched for time? But we obviously have to address these really important components?  

Dr Dale Garred  34:35   

These are real challenges we’re facing today as GPs, but I do think that there are some ways we can support postpartum families in overcoming these social barriers to care, even within the constraints of a busy practice. So, we can start by collaborating with community health workers who can assist with just education and connecting new mothers to resources. We should continue to utilise telehealth, offering phone and video consultations to reduce the burden of transportation where appropriate, as well as maintaining up to date with lists of transportation options for patients, including those offered by many local charities.  

So, practices might even consider providing flexible scheduling, such as in our practice, we offer late appointments one day a week and Saturday appointments to accommodate those mothers who face scheduling difficulties, particularly when they have multiple children. We can also establish relationships with local community services for housing, food, mental health, childcare support.  

And I find having a list of trusted services that I can refer to really does save me time during appointments and ensures that the patient actually receives this information, and so then, as GPs, we might even need to consider delegating some parts of the postpartum follow up to other team members, so practice nurses or community allied health, who can address social challenges and also conduct some pre screenings for us.  

Dr Sam Manger  35:55   

And this seems like a crucial area for midwifery as well, because you’re often working with women in the community, direct in their home a lot of the time, you can, you see it’s one of those really important things about home visits, is you suddenly see the context, and you go, actually the advice that I was giving before is not that relevant, because this context is completely different to what I imagined. And so, midwives have that intimate contact with mums and families in that period. So, I imagine screening and assessing social needs is a pretty core part of what midwives do as well.  

Emma Shipton  36:26   

Absolutely, and I think it goes back to what we’re saying with that personalisation of advice, there’s no point providing education and advice if that is not going to work for that woman and her family. And there’s nothing like going into a woman’s home, it’s deeply personal to go into a home and really be able to assess what the dynamics are within that home, and really, I guess, prioritise linking women with good quality support services in the community, to be able to support them during that postpartum journey.  

Dr Sam Manger  36:59   

Yeah, I think almost formalising at some degree around assessing social needs in the sense of, no, this is just something we do as again, as a clinical norm, as it were, can be a helpful way to structure that. And do we see telehealth be used a little? We’re seeing it across health more broadly. 

Emma, have you seen it have a bigger role in postpartum healthcare checks in particular? Should all reviews be face to face? Or is telehealth a viable option in this regard, and especially in rural and remote regions? Are we seeing it used in that context more?  

Emma Shipton  37:30   

I think one of the good points, if there was any good that came from Covid, was it really allowed us to think about how we can be creative about providing help and support to women and their families, and telehealth does provide you with a good avenue to be able to touch base with women that perhaps you may not have been able to previously. So it certainly does provide a good opportunity, I think, as probably as a triaging tool, and maybe to form part of an assessment, I think there’s nothing better than seeing a woman face to face, because, of course, there are things that you can’t pick up on a telehealth call, but it’s certainly good as a first line point of contact to actually provide a good kind of assessment tool as to how things are going, and if you do need to put further supports in place. 

Dr Sam Manger  38:19   

And Dale, how can health care providers incorporate, sort of, culturally sensitive practices and address the cultural needs we talked about addressing, assessing and addressing social needs, but now with cultural needs into this postpartum fourth trimester period so that we can provide the care that’s appropriate for diverse backgrounds? 

Dr Dale Garred  38:37   

Look, this is certainly something I as a GP could be better at. I work in a really urban, metropolitan practice with a large population of Caucasian Australian patients, and so often I might forget, might forget to incorporate questions about cultural beliefs and practices when I’m meeting new families, because I simply just don’t see that level of cultural diversity in my day to day practice. So, for me, again, incorporating these questions into my practice software-based auto fills will really help me to ensure that I practice in a way that’s culturally sensitive. And then I think just also being really mindful to use plain language and visual aids to convey medical advice and instructions is really important to ensure that information is received by everyone. But as GPs, we also need to ensure that we are regularly keeping up to date with the resources available to us to provide culturally competent care so such as interpreters and where to obtain translated education materials. 

Dr Sam Manger  39:32   

Excellent. Thank you. And finally, we’ll start with you, Emma. What are the top one to two things you wish every woman knew in the first few months of having a baby.  

Emma Shipton  39:40   

I think it would be great if women and their families really knew that birth is important, but the postpartum period is more critical. I think there’s such a focus on birth, but really it is sort of one day and then beyond that, your life changes. So I think if women could think about the kind of things which we’ve talked about, really having those open conversations with their partner and their support people, about, how are we going to manage this as a team? Who is going to to be up with the baby? If I’m breastfeeding, who’s going to cook dinner? How are we going to organise that? Who’s taking the toddler to swimming? These kind of conversations just about the practicalities of really how you’re going to get through really difficult times, I think, are often overlooked in favour of planning for a birth, which is an important part of the journey, but not the whole part.  

Dr Sam Manger  40:37   

It is interesting, isn’t it, because we talk about birth plans, but we don’t talk about postpartum plans, so it’s a very valid point you raise. Dale? 

Dr Dale Garred  40:45   

The top one to two things that I wish women would know is that their care doesn’t end at the end of pregnancy. So I think that they’re still a patient, and getting those postnatal checks are really important, because I do see them getting forgotten quite often. Often, I’ll book a 45-minute appointment for a six-week baby check. And in my mind, 15 minutes of that is prioritised to the mother, because they often won’t book an appointment for themselves. But yeah, really trying to encourage women to start booking an appointment for for themselves in those and in those first six weeks. And then, I guess my second point is that this is a team. So, it’s not just the mother, it’s the mother and the father and the baby. And I think really including dads in that process, and tending to the baby as a team, and caring for the baby as a team is really important. 

Dr Sam Manger  41:32   

As you say, it’s the mum or the carers or other partners, the babies, the siblings, the cousins, it’s open, time to open up that conversation.  

Well, thank you both for your time today and your expertise and your experience. It’s been fantastic hearing your responses and hope to meet once again. 

Dr Dale Garred  41:48   

Thanks so much, Sam.  

Emma Shipton  41:49   

Thanks, Sam. 

Dr Sam Manger  41:52   

Today we’ve been talking to Dr Dale Garred and Emma Shipton about women’s health postnatally. For more information on today’s topics, visit the Health and Wellbeing Queensland website @www.hw.qld.gov.au  

If you liked today’s conversation, be sure to subscribe to future episode updates. We’ll see you next time on the Clinician’s Guide to the First 2000 Days.