There may be a sense of inevitability about it: 'I had a Caesarean last time so I'm bound to have another.'

Alternatively, a previous experience may have encouraged you to do it differently this time.You may have attended birthing cla.s.ses again, chosen a home birth this time, decided to have acupuncture if you need to be induced. A distressing experience first time may galvanise you into action to prepare yourself in a different way.

The biggest issue for subsequent pregnancies is usually managing your multiple responsibilities. If you are feeling unprepared or unsupported concerning labour, it is going to be a less positive experience. It is important to recognise that you still need the active support and guidance of a birth partner. Even though there can be other children to think about, it is important that you have the support as well.This may be even more true as you may feel you are more tired, less relaxed and your thoughts are more split than they were first time around.

Complications and loss 103.

Complications and loss Complications and special care Every labour is different and there is not just one type of experience that could be considered a normal labour. Partly too complications are to do with your perception of the events. If you have a planned Caesarean section, perhaps for a breech presentation, then you may not perceive your labour to have been complicated even though you have had full medical intervention. However, there are events in labour such as your baby being 'in distress', or your blood pressure rising too high, that lead to further intervention which can in turn leave you feeling distressed and troubled by your labour. In the next chapter we will be looking at recovery from the birth and considering how these events may affect your recovery.

Even where your labour was uncomplicated, some newborn babies will need 'special care' or in more serious circ.u.mstances 'intensive care'. This may involve just a few hours of closer observation or it may involve many weeks of specialist medical and nursing care.The reasons for this type of care are most often to do with babies being born premature and being of low birth weight. Some babies are 'small-for-dates', that is, less mature than their age would suggest. Some of the other reasons for needing special care, such as breathing or feeding problems, are usually related to the baby being early or small and therefore his organs are less mature.

Jenny's story Jenny gave birth to her daughter Imogen at 32 weeks following an emergency Caesarean section. This was her first baby and she had had a reasonably uneventful pregnancy until her waters broke unexpectedly. She went into hospital where the doctors became concerned about her health and that of the baby and therefore the delivery was carried out. Jenny said that she had been completely unprepared for the birth of the baby. She had left everything until she had planned to start maternity leave at 36 weeks. Her mother, who lived abroad, had planned to come over and support her around the birth but she did not arrive until the baby was a week old. The baby was in Special Care for eight weeks and Jenny and her husband felt their introduction to parenthood was like 'caring for a sick relative'. It was hard to feel connected to this tiny baby that Jenny said seemed so unlike a baby.

She found the hours in the hospital a relentless stress followed by a 104 deep emptiness every night when she returned home without Imogen.

Three weeks after the birth Jenny's mother returned home and Richard had returned to work. It was then that Jenny began to feel depressed: her experience was so unlike her expectations. Instead of walks in the park pushing the pram, she spent endless hours watching her baby sleeping and feeling like 'a fish out of water' in the inst.i.tutional environment of the hospital. Six months after Imogen came home Jenny began to have the experience of parenthood she had hoped for. As Imogen became more active, Jenny began to enjoy her daughter and this helped to lessen her sense of loss.

Stillbirth and neo-natal loss It is almost impossible to imagine the grief of parents who have lost their baby. Around 1 per cent of pregnancies end in the loss of the baby: either the baby dies later in pregnancy, during birth or in the first month of life.

Often the reasons are never clearly known, especially where the baby dies late in the pregnancy. Sometimes there are concerns during the pregnancy about the viability of the baby once he has left the womb but, more often than not, the child dies before, during or shortly after the birth without warning. The most common causes of death are serious con-genital abnormalities or very premature birth. Some women have the trauma of having to give birth to the baby knowing that he has already died. Sometimes the death occurs in labour, for example, because the cord is around the baby's neck when he enters the birth ca.n.a.l. However the baby is lost, the impact can be profound and long-lasting.

The reactions to this type of loss can be very varied and research has shown that parents demonstrate high levels of psychological distress particularly in the first six months after the loss. This may manifest as depression or anger or withdrawal from usual activities and relationships.

Dealing with the loss is very individual but many parents find it helpful to keep a few mementoes such as a lock of hair, a nametag, photos or other personal items that carry special memories.

All new parents seem to need to recount their birth story over and over and this seems to be a helpful way of 'processing' or coming to terms with this very unique experience. For parents who have lost their baby, this is probably more important but often others find this difficult: they are embarra.s.sed, don't know what to say or do, or feel that they 'should have moved on by now'. What grieving parents need Complications and loss 105.

is for those around them to talk to them, to hear their story and to offer whatever practical support might be necessary. Also they need to be given time to recover. It is this factor often that leads people to seek professional help, as they still need to go over what has happened.

Parents usually feel that others don't understand and particularly don't understand how long it can take to grieve the loss of a child. A year or so after such a loss some parents do feel they are recovering but the research suggests that many are still struggling two to three years later. Recovery is also hampered by other problems, for example, if you have difficulties with your relationship, if generally you have a lack of support in your life or if you have had psychological problems in the past. Sometimes parents recognise that they need help because something is getting in the way of them moving on. Recovery can be hampered by feelings of guilt or blame that can be very difficult to discuss with a partner.

Sharon's story Sharon came to see me about two years after the death of her baby Alfie. Her appearance was striking, as she was dressed totally in black.

At a routine visit to the midwife at 39 weeks no heartbeat was found and a scan revealed that her baby had died. Her labour was induced and she said there was no explanation found for his death. Sharon appeared very depressed and found it difficult to talk freely about anything in our first meeting. Sharon had five children from a previous relationship and Alfie was the first child of her current marriage. She said her husband had wanted her to come and see me because he was worried about her. He felt that it was time now for them to put away the clothes that she had prepared for Alfie and to dismantle the crib that was in their bedroom. Sharon said she didn't really want to argue with him but she still felt the need to go and sit next to the crib and look at the clothes and think about Alfie.

Sharon did take a long time to come to terms with her loss. She felt unable to move on and come to terms with what had happened partly because she was troubled by terrible feelings of guilt. These feelings related to having missed some of her ante-natal appointments with the midwife. Also Sharon's family had disapproved of her choice of her husband and had warned her that marrying someone of a different culture wasn't 'right'. Sharon felt that for these reasons the outside 106 world would blame her for the loss of the baby. It was easier to imagine what it would have been like if Alfie had lived rather than face her own anger with herself and others.

Moving on from loss For most parents who have lost a baby, embarking upon another pregnancy will prove an anxious time. There is probably no 'right time' to consider another pregnancy since this very much depends not just on grieving and physical recovery but on all the other factors that go into deciding when is the right time to have a baby. Often in a subsequent pregnancy there is an emotional detachment from the pregnancy: an unwillingness to invest emotionally and risk experiencing the intense feelings of loss again. There is some suggestion too that the children born following a loss can have more physical or emotional difficulties due to over-anxious or over-protective parenting. It is probably important therefore to be prepared for the possibility of problems so that you are more ready to face them should they arise.

Who can help ?

During your labour and birth you will come into contact with a wide range of professionals especially if you have a hospital birth. However, your starting point is your GP and the local midwife who should be able to advise you about local services.Visit your maternity hospital and do the ward 'tour', where you can ask questions, see the labour ward facilities and the post-natal ward set-up. Find out about local ante-natal or parenting cla.s.ses from your midwife as here you will be given in-depth information about questions such as 'what is an epidural' or 'when should I go into hospital?'.

If you are seeking help with questions following your labour or struggling to come to terms with the loss of a baby, then both your GP and midwife should be able to answer questions about what happened and why. Following the loss of a baby, the consultant obstetrician will usually discuss the details of what happened or any information from the post-mortem.

When recovering from loss, the support of family and friends can be very important. At some point in time you may wish to speak to a Discussion points 107.

bereavement counsellor and your GP or midwife may be able to advise.

Not everyone wants or needs this type of help after a loss. For some people it is months or years later that they decide their grieving is 'stuck' or going on for too long. It may be another pregnancy that makes someone feel that they have issues to resolve and that they need to talk to someone.

On p.181there is a list of addresses of organisations that support parents who have lost a baby. This type of support, from others parents who have been through similar experiences, can be very helpful.

Discussion points This chapter raises numerous issues in terms of thinking about where and how you might like to have your baby and how you will manage the experience of labour. It might be useful to discuss some of the following points: 1. Where would you like to have your baby and what types of facilities would you like available? What is available locally? From where/whom can you get more information?

2. What preparations do you need to make? What ante-natal cla.s.ses are available?

3. Who should/will be able to attend?

4. What do you know already about different types of pain relief and what appeals to you? What helps you to relax? Do you have any experience of dealing with pain and, if so, how did you cope?

5. Who is around to help? Who will be your birth partner? Who can help out in those first few days? What specific help will you want: someone to do some shopping? A relative to stay at the house? Or would you prefer not to have visitors?

6.The first few days.

Your baby arrives at last !

It is impossible to describe those first few moments after your baby is born since the experience is so unique and personal. For the majority of women their first meeting with the baby will be as it arrives into their arms as soon as it has been delivered. It can be a moment of elation, of enormous relief and great joy. That is not to say that it is universally a pleasurable experience since many couples may be feeling so overwhelmed or exhausted that they hardly know what to think. Should your baby be unwell or born very early, there may be no relief at all as medical a.s.sessment gets underway and the baby is taken from your arms. These few moments are particularly precious since it is a time to meet this new person before other events take over: the initial a.s.sessment of the baby, the need for special care, the delivery of the placenta, the need for st.i.tches and all the other immediate and more medical concerns.

Going through your labour may have been an intense and exhausting experience both physically and emotionally. Had you just run a marathon, you would now expect to put your feet up and have a well-deserved rest, however, labour is just the first lap of an incredibly long journey.Whatever way the baby arrived, however exhausted and physically ill you might be, the task of parenting begins immediately. You will experience from the start, at its most intense, the dilemma that is central to parenting: the balancing of your own needs versus that of the baby's. This factor seems central to what makes the first few days such an intense and at times difficult experience and why almost all mothers will struggle emotionally at times in the first few days.

110.

In this chapter we will look at what might happen in those first few days.

What are the immediate tasks of parenting: how often should I feed the baby? How long will he sleep for? Should I pick him up when he cries? Is this something that we learn or that comes instinctively? Second, the mother has to recover from the labour. You may have st.i.tches, a catheter, bruising and discomfort and most likely you will feel exhausted. There can be a roller coaster of emotions too. Most women initially are on something of a high: they are immensely relieved the baby has arrived and appears well, the pains and emotions of labour have disappeared and they are sharing those first few moments with their baby. This, however, can very suddenly be replaced by tears, frustration and uncertainty as the reality of caring for the baby dawns and your tiredness and discomfort kick in.We will consider the emotional situation of those first few days looking at the range of reactions such as'baby blues'through to the serious but rare problem of puerperal psychosis. What is the significance of these emotional reactions and will they have long-term effects? How does an attachment develop between parents and their baby?

A time of intense and rapid adjustment Often books on pregnancy seem to trail off after the sections on childbirth and perhaps many parents-to-be are not interested in reading much further during pregnancy. However, it does seem important to emphasise that the emotional experience of those first few days may be very intense.

The labour and the birth of the baby are an important part of the transition to parenthood but only a part. A time of high emotion and rapid adjustment continues in those first few days. It would be wrong, however, to give the impression that this is necessarily a negative experience.The difficulties are almost always outweighed by the joys. What is remarkable is to see a woman who, in labour, was feeling intensely distressed, half-an-hour after the baby is born sitting contentedly holding the baby as if she had been doing it for years. Two hours later the same woman may be in tears at her struggle to 'latch the baby on' to the breast. The first few days are about all of these conflicting feelings, emotions and experiences.You are nowlearning your new roles of mother and father. First, let's think about the baby.

Forming a relationship with your new baby During labour it is possible to lose sight of fact that there is a baby arriving at the end. You may feel so caught up in dealing with the contractions or Forming a relationship with your new baby 111.

feel numbed by the effects of drugs that you may feel you just want to recover but the baby is thrust upon you, often literally. Suddenly you have a totally dependent and needy baby whom you must learn to care for.

Your first few moments with the baby New mothers spend an enormous amount of time just looking at, holding and exploring their new baby. Parents quite spontaneously look in great detail at this new person trying to get to know him and beginning to respond to him.The baby's tiny movements, expressions and vocalisations promote a response in the baby's parents and the very rudiments of communication begin here. Parents quite spontaneously start to respond to the baby: he is not simply held in a completely static way. The psychoa.n.a.lyst and paediatrician, Donald Winnicott emphasised the importance of not interfering with this process which happens naturally and spontaneously. It is not something that parents need to be taught. If you watch a new mother shewill spontaneouslychangethe baby's position in response to his movements. She will often move her head or face in a similar way to the baby, especially if the baby is awake and alert. If he begins to cry, she will attempt to soothe him, perhaps by rocking or beginning to feed. This clearly is a learning process, the parent does not know what to do yet, but the curiosity and eagerness to learn seem almost instinctive.

Mothers will often be encouraged to feed the baby if he is awake and both seem relaxed. The baby may of course be sleepy (especially where there has been use of medication during labour) and therefore you may just watch him sleeping. For many new parents this is a wonderful time of elation, of feeling closer to each other as a couple and feeling enormous relief at the baby's arrival. However, it isn't always so, depending on how you are feeling at this point: exhausted, overwhelmed, confused, and so on. The bond with your baby is not always instant and in many ways you are strangers who need to get to know each other. Not everyone feels that connectedness straightaway, it can take much longer but that doesn't mean it won't develop. Unfortunately the hospital setting may not always facilitate this process. Staff may not be available to help or may be preoccupied with different concerns.

The initial a.s.sessment of the baby Very soon after holding your baby the medical staff will wish to check the baby is well and complete an Apgar score (see The Pregnancy Book for an explanation of the Apgar score), clip the umbilical cord, clean the baby and 112 put on an ident.i.ty tag. Most of this may happen while you are delivering the placenta, being prepared for st.i.tches or whatever medical procedures are necessary for you.

What can newborn babies do?

In recent years as research techniques have improved we have become much more aware of the capabilities of newborn babies.We have known for a long time that babies are born with primitive reflexes. Clearly the sucking and rooting reflexes are crucial to a baby's survival. If you stroke a baby's cheek he will turn his head and start to suck. Babies can hear from birth but remarkably they quite quickly learn to recognise their mother's voice from others. They are able to focus on objects at a certain distance, this distance being roughly that between them and their mother's face during feeding. Quite quickly too they are able to discriminate their mother's face from others. It is perhaps important to remember when you are finding it a struggle, that your baby is primed to get what he needs i.e. to feed and also to develop a relationship with you. So he will be helping out too: babies appear almost programmed to develop relationships. Most of their early behaviour ^ crying, making eye contact, vocalising or smiling ^ is all designed to engage the parent and form an attachment.

Getting to know your new baby: bonding/attachment Often when professionals use words like'bonding' parents feel intimidated as if this were something complicated and technical but really we are talking about you and the baby getting to know each other and feeling a closeness or connectedness. Many parents will say that they did not feel an immediate bond with their child and for some it may take many months to have that strength of feeling. The development of an attachment between parent and baby is important as this relationship provides the secure base from which the baby can go on to develop and explore his world. He does this secure in the knowledge that usually if he feels hungry or upset, his cries will bring the intervention of his mother or caregiver to provide the necessary comfort and security.

There can be a number of reasons why the relationship with your baby doesn't get off to the best start. For the mother it may have been a traumatic delivery, she may have been ambivalent about becoming a parent, or it may be the result of a poor relationship with her own parents in her early years. It may be that usually you are a very anxious person and the sense of Forming a relationship with your new baby 113.

responsibility overwhelms you at this stage. There may be lots of reasons that you feel less'in tune' with your baby and therefore find being with him less rewarding. If you are terribly anxious about how much milk your baby is getting and how much weight he is gaining, then you will be less relaxed and able to enjoy feeding him.

As well as issues that you bring to the relationship, there are also factors to do with the baby. If your baby is born healthy and a good size, begins to feed quite easily and sleeps a lot, you are much more likely to feel relaxed and able to respond to your baby and in turn feel that you are making a reasonable start at being a mother. However, if the baby seems to come out screaming or doesn't seem to want to feed, you are more likely to feel anxious, miss the signs that the baby is giving you and start to feel scared and uncertain about your ability to look after the baby. Feeling close to the baby is going to be hampered by feeling overwhelmed by the needs of the baby. Should your baby be in an incubator, you may find it much more difficult to obtain the closeness with the baby and to manage your fears about what is happening to him. You will be encouraged, however, to feed your baby and hold him as much as is possible.

An attachment to your child almost always develops and if you don't feel it straightaway, try to relax and give yourself and the baby some time to get to know each other. If you are concerned try to speak to your midwife or health visitor (see'Who can help?' on p.131).

Jenny's story Jenny first came to see me when her daughter was about three months old. She spent most of our first session in floods of tears and almost everything that she tried to talk about would unleash her tears (during this time her daughter was sleeping quite happily in her car seat). Jenny and her partner had eagerly awaited the arrival of their daughter and were very pleased to have a healthy baby. However, Jenny was concerned that since the birth she had felt very 'cut off' from her baby.

Although she said she knew she loved her, she didn't feel that things were 'right' between them. She felt particularly guilty about this as she said Hannah was such a good and contented baby. It became clear that Jenny was so anxious about every aspect of looking after her baby, that it had practically paralysed her and she barely found time to get dressed in the day let alone start going out and meeting anyone else or looking after herself. It became clear in time that Jenny had always been very 114 anxious and the new responsibility of the baby had overwhelmed her coping resources. She was making life very hard for herself as her anxiety meant she missed any cues from her baby. Despite the fact that Hannah was gaining weight Jenny could not convince herself that Hannah was getting enough milk. She was supplementing her breast-feeding with extra bottles 'just in case' her milk wasn't enough and also because she had a better idea of how much milk she was having. She was having her weighed every week and would leave the baby clinic feeling devastated if Hannah had not gained 'enough'

weight. These worries were stopping her from enjoying her interactions with Hannah or getting to know her baby and trust her reactions.

With some exploration and challenging of her self-critical thoughts Jenny began to gain confidence as a mother. Her partner and those around her were crucial in helping her not to escalate a small worry into a 'disaster' such as when Hannah later caught a cold and had a high temperature. She did start to feel she was doing a good job and Hannah began to turn into someone she could enjoy being with, rather than a huge source of worry.

Caring for your baby : feeding, sleeping and being held The early relationship with your baby consists of three basic building blocks: feeding, sleeping and being held. In the early days the baby will probably do little more than sleep and wake for feeding with perhaps short periods of wakefulness. Sometimes it may feel as if the baby is always with you in the sense that even though he is asleep you do not feel separate from him or able to'get back to normal' when he is asleep.This can make those initial days feel completely overwhelming and it may be difficult to do anything else other than attend to the baby.

Feeding the baby You may be encouraged to feed your baby quite soon after his birth if he is wakeful and you are feeling fine. Most mothers will have decided during pregnancy whether they want to breast-feed or bottle-feed and many will keep an open mind to'see how it goes' with breast-feeding.

Caring for your baby: feeding, sleeping and being held 115 Breast versus bottle Recent years have seen an increase in numbers of women in this country breast-feeding, partly due to the efforts of Health Education programmes which highlight that nutritionally breast milk is the best food for babies.

Breast-feeding confers health advantages for both baby and mother. Breast milk is easily digested, provides certain immunities for the baby and requires no sterilising or preparation. For mothers it reduces the risk of certain health problems later in life and certainly can help with weight reduction following pregnancy. In fact in recent times there are also attempts to encourage mothers to introduce solid food later and breast-feed exclusively for the first six months. However, a balance needs to be struck between what might be nutritionally best for a baby and what is best for parents. Probably very many women chose to bottle-feed because of the initial struggles with establishing feeding or because of a lack of support generally regarding feeding.

Breast-feeding If you do decide to breast-feed, those first 48 hours are a critical time in terms of establishing some confidence about being able to breast-feed and not switching to bottle-feeding. During this time you are feeding your baby with colostrum and waiting for your milk to 'come in'. It may feel as if the baby wants to feed a great deal and it is this action in turn that will help to stimulate your milk production. Your milk 'arriving' can be extremely uncomfortable, often women wake to find their b.r.e.a.s.t.s enlarged and painful and this in turn can make it difficult for the baby to latch on.The basic task to be achieved in these first 48 hours or so is to get the baby into a comfortable position for feeding and to 'latch' him on correctly so that he is not sucking on the nipple alone. Breast-feeding is something that can only be learnt through experience and you will need your midwife to guide you initially to get the positioning established.

The midwife will usually want feeding to be established before you leave the hospital and it is important to get as much help as possible while you are there.

Until you get the hang of breast-feeding, there may be a lot of anxiety for both parents. You may worry that the baby is not getting enough milk ^ this can be particularly acute if the baby was of low birth weight.There can be a number of difficulties initially with getting the baby into a comfortable position, which can in turn lead to sore nipples. Your b.r.e.a.s.t.s may 116 become engorged as your milk comes in, making it difficult again to'latch'

the baby on.

More often than not, breast-feeding is shrouded in a Madonna and child image and the initial struggles are glossed over in order perhaps not to put women off. However, these initial problems are very common and perhaps if you are prepared for a rough-ride in the first few days you will be less likely to personalise the problems and feel it is because you aren't any good at it. The image of the breast-feeding mother does not convey the possibility of sore nipples, the mother still in bed at lunchtime because she has been feeding all morning or the endless fiddling around with pillows in order to get the baby into the 'right' position. It is at this point that the bottle can seem very attractive, particularly as you can see how much the baby has had. If breast-feeding seems not to be going well, all your fears about being a mother may resurface and you perhaps believe that the baby would be happier with the bottle. Here partners can be very supportive in terms of trying to just keep encouraging and acknowledging the difficulties. They should try to rea.s.sure rather than get carried away with the anxiety.

For some mothers breast-feeding seems to happen almost automatically or initial problems can disappear very rapidly. However, these first few days can seem like a lifetime and it can be difficult to remain positive.

Many women move to bottle-feeding in this stage and it is important not to feel completely defeated if this is the case.To struggle on for too long may be hampering your relationship with the baby and your own ability to survive as a new mother.'How long should I struggle with breast-feeding?'

is a question that can only be resolved by you, your partner and the midwife.

It is not unusual for difficulties getting started with feeding to coincide with your being discharged from hospital. Usually midwives like to establish breast-feeding before you are discharged from hospital but often many other considerations overtake this decision. Although you may have been longing to get home to your own bed and away from other crying babies, it can feel difficult to get the help that you need at this stage. The community midwife does visit daily but this can seem like a lifetime to wait if your baby is not settling to feed. You may also find yourself with a houseful of smiling family visitors when you just want to be alone with the baby. It is important therefore to be a.s.sertive and get exactly what you need at this time. This is again an important role for the partner. He must be prepared to say 'no' to people, even to the doting grandparents, if that is going to hinder the mother's recovery.

Caring for your baby: feeding, sleeping and being held 117 'How often should I feed my baby?'

At this stage it is much too early to worry about whether or not you will feed your baby on demand (and we shall look at this in the next chapter), or any questions of how long and how much.You should feed your baby as often and for as long as he seems to want to.Your baby is learning too and as he learns and grows, his pattern will change as he manages to take in more milk. The newborn's stomach is about the size of a large walnut, so feeding has to be fairly frequent initially.

Feeding will be the focus of your early days with the baby. Almost all mothers seem to have worries about feeding at some point: is the baby getting enough milk? Is he putting on too much/too little weight? Should I start solids yet? It may be an anxious or difficult time now especially where you are recovering from a strenuous labour or struggling with sore nipples, but it is important to remember that all babies get enough to eat eventually and it takes time for feeding to establish. If things are going well, then try to relax and enjoy your baby: the action of being held and given nourishment in a relaxed way is an important aspect of your baby's emotional development.

Crying (the baby, not you!) At this stage crying is really integral to feeding and sleeping. Newborn babies do not cry to manipulate you or annoy you or because they are bored. They are usually crying to signal the need for feeding. Sometimes they cry because of discomfort (perhaps they're wet) or possibly as a prelude to sleep but mostly it will be that they are hungry. In the next chapter the developing patterns of feeding and sleeping will be considered and questions such as whether or not we should pick up a crying baby or feed on demand. In the first few days of a baby's life it is important to learn about him and respond to him freely.

Babies do seem to be born with a temperament and some will appear to come out screaming whereas others will seem to be sleepy or 'easy to soothe'. Therefore from the first few hours of life, aspects of personality can already be seen. The 'temperament' of the baby is the beginnings of their personality. Psychologists have developed a number of ways of categorising people and one way developed by Thomas and Chess (1977) describes the early temperament of the child: 'the easy baby', 'the difficult baby' and the 'slow-to-warm-up baby'. The easy baby tends to develop feeding and sleeping cycles without too much trouble, is generally contented and reacts to new experiences without too much difficulty.The 118 difficult baby is less easy to settle, reacts strongly to anything new and generally cries more. A third group are those who do not react strongly and tend to be more pa.s.sive in their behaviour.

Although these may seem like generalisations as all children can behave in these different ways at different times, it is perhaps useful to consider that the way the baby behaves may affect how you feel about yourself as a mother. If your baby sleeps for the first 24 hours and you sleep and feel recovered, you may get off to a very positive start. If the baby is awake and crying a lot and you are exhausted, you may feel you don't really want to be a mother.Whether the child's early temperament is something fairly static or whether the child's personality is created in those early interactions is obviously a complex issue. The environment of the womb may have already contributed to early aspects of temperament, as may have the process of labour. What you need to remember at this stage is that the responses of the baby may not be what you expected and you need to give yourself time to get to know each other.

Returning to the issue of crying, therefore, the cries of the first few days while feeding is established are not necessarily predictive of later behaviour and are also something that you are still getting used to. Research has shown that baby's cries are pitched at a frequency that gives maximum discomfort to the human ear. Clearly there is an evolutionary purpose to making sure that the baby's cries are heard and that he gets fed and looked after. Your baby's cries have evolved over thousands of years in order to make you respond.That is what you need to do in these first few days. In the next chapter we will consider how behaviours such as crying start to change in their meaning. In the later weeks babies may develop more persistent crying known as colic.

Sleeping More likely than not your baby will spend an awful lot of time sleeping.

However, those first couple of days may be affected by the labour and the baby may be particularly wakeful or particularly sleepy. At this stage it is important to concentrate on your own sleeping too. The baby has no concept of day or night and will sleep and feed in short cycles of a couple of hours that will gradually lengthen. In the early days the baby may seem to be feeding all the time but this will settle into more of a pattern in the coming weeks as the baby becomes more skilled in his feeding and takes in more milk at one time and therefore sleeps for longer.

The task is for you to learn to adapt your own sleep pattern for these early days, trying to get some rest/sleep while the baby sleeps. It is Babies requiring special care 119.

tempting in those first few hours to spend the time the baby is asleep chat-ting with visitors, phoning relatives, admiring the baby and sorting yourself out. However, when night comes, the baby may be wakeful and suddenly you feel exhausted and on your own with this little bundle of demands! Sometimes mothers can be so overwhelmed with the feelings of responsibility for the baby that they are almost frightened to go to sleep and not watch the baby. Many mothers have admitted that while in hospital they worried that the baby might be stolen if they fell asleep or that it might be confused with another baby. Also common is to worry that they would sleep through its crying or that the baby might not wake to feed. Babies are programmed to get what they need and their cries are designed to wake you. What is more common is that you are woken by every little shuffle or noise the baby makes.

Despite the fact that babies sleep a lot in the early days, it can often feel, with a first baby, as if you never get a moment to yourself.You may find in the early days that it takes half of the day to get showered and dressed. Even when a baby is asleep, they still take up a lot of the attention of the new mother. Many mothers will say 'he hardly sleeps at all', which is partly related to this preoccupation with and sense of being overwhelmed by the care of the baby. Dylis Dawes, a psychoa.n.a.lyst, refers to the baby's sleep as the first 'separation' between mother and baby (Dawes, 1985).

Perhaps in those early days you may find it difficult to disengage from the baby when he is asleep. He still fills your thoughts and your actions are all to do with concerns about your baby. If this is the case, you will find it more difficult to have time for yourself as you feel that the baby is always with you. Often when mothers have a subsequent baby, they cannot believe how they found it so difficult and time-consuming to look after the first.

This again is about the enormous life shift that the mother has to make in order to care for her baby.

Sleeping and feeding are very closely related in this early stage and just as feeding will have no pattern in these early days, nor will sleeping, and expecting a routine can lead to disappointment. Gradually, over time, the periods of sleep and wakefulness will lengthen and longer periods of sleep will take place at night but this happens over the next six months or so.

Babies requiring special care What we have talked about above may be totally different where a baby needs special care or is born with disabilities or needing surgery.Where a 120 baby is born early or 'small-for-dates', it may be just a case of special monitoring or help with feeding or keeping warm. A Special Care Baby Unit (SCBU) or Neonatal Intensive Care Unit (NICU) can seem a very frightening or intimidating place at first with all its equipment and medical atmosphere. The staff, however, will encourage you to be with your baby as much as possible and to try and hold or touch the baby and feed where possible.You will need to get lots of information as every child's prognosis is unique.This can be a very upsetting start to your baby's life and to your life as a parent. Also for babies that are born very early or small-for-date, it may take some time to a.s.sess whether they are catching up with their peers or what the longer-term implications are.

Where a child is born with disabilities, a very long process of adaptation begins. Often the nature of these problems can only be a.s.sessed over time.

Even where a child is born with a recognised syndrome such as Down's Syndrome, there is a wide range of possibilities in terms of how that child will develop and what level of independence he will attain. Other children may be born without a clearly defined syndrome but early a.s.sessment of reflexes and so forth may suggest that there will be developmental delay.

It is difficult at this stage to a.s.sess the extent of disability that may occur which can make the process of coming to terms with this situation much more difficult. In such situations a whole range of supportive services may need to be put in place. There are usually voluntary organisations for particular problems and disabilities where it may help to meet other parents who are dealing with similar problems.

Again, where babies are born with medical complications or needing surgery, it may be difficult in the short-term to a.s.sess the extent of the problems. Parents will need information from professionals and also the careful support of relatives and friends.

When your baby is 'different', it can be very difficult to get support from other new mothers. It may be that you feel resentful of their complaints and feel that they 'don't know how lucky they are'. Many people around you may find it difficult to know what to say and may be nervous, for example, about holding the baby or upsetting you. Here you may find organisations that deal with similar problems useful so ask your midwife or doctors for any information on them. Usually parents of children with disabilities will go through a process of bereavement: a sadness for the loss of the healthy child they were expecting.This process may take a very long time particularly where the extent of a child's disability or illness is not known. It may be that the loss is experienced at points where the child does not achieve the milestones at the time of his peers. It is important as a parent to look for support at a time when you need it.You may find that as Babies requiring special care 121.

time goes on you will be expected to have accepted the situation but this process is unique for every family.

Sally and Georgia's story Sally was referred to me for depression and I met her when her daughter Georgia was six. Sally had known quite early on that Georgia could not hear. She didn't have a lot of contact with other mothers, as a single parent she had always worked full-time. Perhaps too she had avoided mother and toddler groups because her daughter was'different'. She really felt she had come to terms with her daughter's disability but it was the progression to school that seemed to bring everything crashing down for her. She had been told in the past that her daughter had learning disabilities also, but it was only when she went to school that Sally was really having to face this fact. She had told herself that a learning disability would mean that her daughter would not be able to learn to read and write. However, the lack of progress in areas of physical development such as being continent gradually made it more difficult for Sally not to face up to the extent of her daughter's special needs.

Discharge from hospital A mother's stay in hospital has become shorter over recent years: women tend to be healthier, are less likely to have general anaesthetic, there is more pressure on hospital beds and perhaps women to want to remove themselves more quickly to a home setting where they will still be visited regularly by the midwife. This may all seem very positive but there is evidence that shorter stays in hospital can lead to a higher incidence of post-natal depression. That shouldn't make you determined to stay in hospital but it should encourage you to think carefully about what is right for you. In many cases this may be to get away from a noisy and inst.i.tutional setting to your own home. For others it might mean some precious time away from other responsibilities, to have time to get to know your baby, sleep when he does and have your meals cooked for you.

The midwife will encourage you to stay in hospital until you have 'established feeding'. Before being discharged you will need to be seen by the ward doctor and the baby will need to be seen by the 122 paediatrician. These two things in themselves can mean that it is a long time between you deciding that you want to go home and your eventual departure home.

The experience of new parents The physical recovery of mothers Considering the exhausting and strenuous nature of labour, the speed at which most mothers recover really is quite remarkable. More often than not mothers are able to sit and hold their baby and chat quite happily within a very short time of delivery. However, almost all women need some time to recover. Most first labours may have been fairly long, you may have missed a night's sleep and almost certainly will have missed meals.The labour itself may have involved drug and/or practical intervention.With increasing numbers of women having epidural anaesthesia, the effects of this take time to wear off.You may have a catheter and will need to be monitored to see that you can urinate normally again.There may have been a.s.sisted delivery of forceps or ventouse, which may mean you have a tear or an episiotomy and possibly bruising or swelling to go down. The st.i.tching following a tear or cut may take quite some time to carry out and lead to discomfort in sitting for some days. You will also bleed for some time following the delivery, usually lessening but possibly lasting a number of weeks. Breast-feeding your baby initially causes tiny contractions of the womb, helping it to return to normal size.These initially may be painful and cause your bleeding to be heavier. Caesarean births are become much more common and may even be seen as an easier option than labouring. It shouldn't be forgotten, however, that you have had a significant surgical procedure and have a wound that will take some time to heal. Generally, women do recover well without complications but it should be remembered that you are recovering from surgery and you may feel more uncertain about how to lift and hold your baby in those early days.

Recovery in hospital and after discharge does tend to focus on physical outcomes: are your st.i.tches healing? Has your womb reduced in size? Are your bowels and bladder functioning? For some women this process can take a very long time and residual physical problems can mean a woman doesn't feel she has recovered properly for a very long time. Your physical recovery can have an enormous impact on your ability to parent your baby: if you cannot sit down easily, if you have become anaemic or are struggling The experience of new parents 123.