Transcript: Patient Centered Care During the 4th Trimester

This is a text transcript from The First Time Mum’s Chat podcast. The episode is called Patient Centered Care During the 4th Trimester and you can click on the link to view the full episode page, listen to the episode and view the show notes.

Helen Thompson: I’ve spoken with many wonderful women on First Time Mum’s Chat who help women during their 4th trimester, including lactation consultants and doulas. I’ll include links to some of these episodes in the show notes, so please listen to the conclusion and I’ll let you know where you can find them.

This week’s guest, Dr. Cindy Rubin, is a general pediatrician, International Board Certified Lactation Consultant and breastfeeding medicine specialist. Dr. Cindy, is disillusioned with the tight limits that the American insurance system imposes on doctors so has taken the step to operate her practice outside the US insurance system so that she can provide quality care without the clock constantly ticking. Yes, quality versus quantity comes to mind here.

During our chat, you’ll hear Dr. Cindy talk about the many benefits of having a pediatrician who visits your home during the 4th trimester, which for many mums is a particularly challenging time, an explanation on the causes of biting during breastfeeding, and ways to help ease this, what she offers parents in the Chicagoland area during the first 6 weeks after your little one is born.

And so, so much more.

Hi Dr Cindy and welcome to First Time Mum’s Chat. I’m delighted to have you here today and can we start by just getting you to introduce yourself and tell us what you do and what you’re passionate about.

Cindy Rubin: Sure, well, thank you so much for having me, I’m really excited to to chat. My name is Cindy Rubin. I am a pediatrician as well as an international board certified lactation consultant and breastfeeding medicine physician, and I have a small practice in the Chicagoland area, where I provide home visits for general pediatrics and breastfeeding issues, as well as some cool fourth trimester in home packages that I offer.

Helen Thompson: So, one of the biting questions that parents always ask me about breastfeeding, is that their baby bites when they’re breastfeeding. Why is that and what can you do to help that?

Cindy Rubin: Yeah, so this is very, very common and usually happens around the time that babies are getting teeth, so around 6 months or so or after but it can happen before because you can bite with just your gums, without teeth and it can be very, very painful and babies can do it for a number of reasons.

It’s never, well, I wouldn’t say never, but it’s usually not intended to hurt the mum but it does hurt. It is actually often a form of learning. So the baby feels something different with their teeth and so is trying to figure out where do these teeth go when I’m breastfeeding, I’m not used to having them there and they’re experimenting. That’s how babies learn anything by experimenting. So a baby bites, gets a response, learns from that response, whether positive or negative and it tends to happen more when babies are not really actively eating.

Yeah, women are always worried about their baby starting to bite, worried about it just getting painful to breastfeed once there are teeth there. Actually when a baby is actively eating, if they are using their tongue correctly, the tongue should cover up the lower teeth and so biting shouldn’t be able to happen really while a baby is actively eating well.

Helen Thompson: It is interesting you say about the tongue because I know that’s a big issue sometimes with tongue tie and with so many other issues around that area because I know sometimes babies find it hard to suck. It could be because they’re tongue tied, but it could be for many other reasons.

Cindy Rubin: Right, for sure and sometimes babies do bite when they’re very, very little and learning how to breastfeed as well. They bite or they more chomp with their gums on the nipple and ariola. And that, again, can be very painful. It’s akin to biting. It’s similar to that and there’s various techniques to try to improve that. Either stop biting or improve the latch to prevent it from happening. It kind of depends on where the baby is in their breastfeeding journey. If they’re two weeks old or if they’re, six months old, what you might do.

Helen Thompson: I would’ve thought that if a baby doesn’t have any teeth, it might not be as sore as a baby does have teeth. You just mentioned that they chomp, so that could be why it’s painful. I was just imagining a baby with no teeth, how can it be painful?

Cindy Rubin: Yeah, it can be very painful and usually if a baby is able to do that, that means that the tongue is not covering the gum the way it’s supposed to. So probably the tongue is doing a lot of things not quite right, and so that combination of probably that baby being a little bit shallow and using their gums more than their tongue to hold onto the breast and to try to draw that milk out, combination of those things causes breast pain or nipple pain.

Helen Thompson: I think as you said, it’s trial and error with the baby. The baby’s just learning what to do. I know it’s a natural instinct, but still babies have got to learn how to learn that natural instinct.

Cindy Rubin: Right and I think that’s the important thing for people to realize when babies are a little bit older and they do start to bite, is that it is not intended, it’s not intentional and babies have to learn from the response whether they’re going to repeat it and this is the same with a lot of different behaviors.

It can be really hard as a parent to not react the way you may naturally react. If I’m hurt, I’m gonna yelp, but that actually might be interesting to the baby to have their mum yelp loudly. They may not interpret that as stop. They may interpret that as something exciting and interesting essentially, and so then they may try to repeat the behavior in order to get that to happen again, but it’s super hard not to yelp if you’re not expecting it and it hurts. So that’s a natural response and sometimes we can get into a little bit of a vicious cycle if we’re not prepared for that and we don’t know other techniques to prevent it from happening or how to respond when it does happen.

Helen Thompson: And you don’t want to frighten the baby either because they might not want to breastfeed after that. If you frighten them and you say, ouch that really hurt, and try and pull them away from the breast, they’re gonna get frustrated because you are pulling them away and they’re not gonna understand what they’ve done.

Cindy Rubin: Right, yeah, it’s tricky. So what I usually recommend is this, if they’re the older baby, 6 months and above, babies also get very distracted around that time and so might not be eating well throughout an entire feeding and mums can usually kind of sense when the baby’s into the eating and when they start to kind of slow down and do more comfort sucking, or they’re getting more distracted and trying to pull off.

Those are the times when babies are more likely to bite. They’re kind of not really eating so much. They’re not really trying to get the milk, but they’re still sucking and they’re still there because they’re still getting comfort, but they’re more shallow and they’re not necessarily extending their tongue the way they were when they were eating, and if a mum can preempt that, if she senses that they’re getting to that point in the feeding, then just taking the baby off at that point can hopefully prevent getting to the point where the baby starts to bite. It’s a learning curve to figure that out but I think that’s a really good technique if the baby tends to be doing this fairly regularly.

Helen Thompson: Yeah, because when they’re 6 months, they maybe starting solids as well, depending on the baby. That’s roughly when they may be starting solids, so they’re used to chomping a little bit harder on things if it’s a baby led feeding . So they may be thinking, oh, this is something I can chomp on. So when they see the breast, they might think, oh, I can chomp a bit harder now.

Cindy Rubin: Right, right. It makes sense that it would be potentially a factor at play.

Helen Thompson: You also said at the beginning that you help parents in the home with your pediatrician work and care and comfort in the home. So what does that look like when you are going to somebody’s home? From from your website, I think you say something along the lines, you’re a doctor with only your best interest in mind, which I like.

Cindy Rubin: Yeah, well, so I’m in the United States and we have kind of a messed up healthcare system right now. Yes, somebody needs to invent the perfect system. It’s so hard the advantages and disadvantages to everything, but one of the problems now for us is this time limitation that is put on physicians because it’s all about productivity, and physicians and hospital systems are reimbursed so little for seeing patients that they have to see so many in order to survive. So, with that model, I was not able to practice the kind of medicine that felt good to me. I was just too rushed. I couldn’t handle the issues that were going on and especially with breastfeeding, you can’t do that in 15 minutes, if you even have that long. So my practice is outside the insurance system, so it’s cash pay, and that allows me to focus on the patient, the problem, and take as much time as is needed, which includes the time. Inevitably a visit in somebody’s home is going to be take longer.

Helen Thompson: Of course.

Cindy Rubin: Yeah, it just lends itself to that no matter what the problem is or what you’re seeing them for and I absolutely love it. I love it in those first weeks because mum definitely does not want to be trying to put herself together, get this infant out the door to the doctor, on time, especially if there’s an older sibling, like a toddler in tow. I’m in Chicago and you know, half the year it’s blizzards and that’s the worst possible scenario. So I love being able to offer that, just comfort and peace of mind for parents to know that they don’t have to leave the home for these pediatrics visits and and then beyond that, it’s just a more comfortable environment, with the breastfeeding, it really lends itself to home visits because parents are where they are doing this, right? So, We’re working with their environment and figuring out how to fit them into comfortable positions using what they have at home The other day, the family, I was giving all of these recommendations and they’re like, well, maybe you should come up and see what our bedroom really looks like.

That was so helpful in terms of trying to troubleshoot for them and figure out what might work and so I really, really love that aspect of home visits as well. Just having that time allows me to just take the insurance companies out of the situation and do what I as a physician am trained to do and what I feel is appropriate for a patient on a certain day, at a certain time.

Helen Thompson: So taking out the insurance part, I don’t how it works in America, but does that mean they can’t get you through the insurance company?

Cindy Rubin: Well, so it’s tricky. It depends on the type of insurance they have and insurance companies, they all do different things. There’s certain rules that they’re supposed to go by, but everybody interprets things differently, and so I’m considered an out-of-network physician. I’m not directly contracted with any insurance companies, so if somebody sees me it kind of depends on the service that they’re seeing me for, but especially for breastfeeding and for much of the fourth trimester packages that I provide, I can give a receipt to the family that has all of the information that’s necessary for them to then submit that to the insurance company to hopefully get some money back but it really varies what people get depending on their particular insurance.

Helen Thompson: With the fourth trimester packages, what are they?

Cindy Rubin: So this is my personal favorite part of my practice right now and my particular way of doing this is that I offer 6 weeks. So after a baby is born, I am your pediatrician in your home for 6 weeks. So I will come do that first visit after you leave the hospital or after you have a home birth, however that your baby is born.

Then I will do the weight checks and the well checks up until your baby is 6 weeks. In addition, because I am trained in lactation, I will be your lactation consultant as well. So that is included in the cost of the package is for me to help you with whatever breastfeeding issues might arise from simple, just assistance with latch at that first visit to something more complicated that might come up.

Then again, because I’m doing home visits, I’m able to delve in a little bit deeper. Sometimes siblings and fathers or partners don’t come to the doctor’s office for the visits and in this sort of situation, if the partner is still home on family leave of some sort, then they’re there and I get to meet them and I get to meet the sibling and I get to kind of see the dynamics and check in, not only on mum, but on dad. How is Dad doing? How can he help? How is he getting support or able to take time to take care of himself too? Unfortunately, the mum is not focused on usually and the fourth trimester package the main point is to have support for this mother who is usually kind of put on the back burner during this fourth trimester time, but the partner also needs to be included in that and so that’s part of it and I monitor, I screen for mental health problems and I screen for whether or not somebody needs to have an evaluation for pelvic floor therapy. So, even if I can’t do everything that’s needed, I can kind of be the relay person and make sure that this family is hooked into all of the other resources that they may need during that time.

Helen Thompson: Yeah, I think that’s great because I know mothers are the ones that have the babies, mothers are the ones that go through all the trauma with the breastfeeding and everything else, and I fully appreciate they need support. I also believe that the father and the siblings need to be involved as well. As you say, the father might be stressed as well. The father might be having problems with all the sleep deprivation and dealing with the siblings and dealing with the crying baby. They need the support just as much as the mother, so I think it’s great that you do home visits to support the whole family because I think that’s important because the siblings might be stressed as well. That’s something I know from my childcare. Siblings can get very jealous when the new baby’s born.

Cindy Rubin: Yep, yep.

Helen Thompson: They’ve been number one whether it’s 9 months, 10 months, a year, or whatever it is, or 2 years they’ve been the number one focus and then suddenly number two comes along and mum’s taking the time to breastfeed the baby and dad might be taking time to get the clothes ready for the baby or getting the bath ready.

Cindy Rubin: Right, right. Similarly, it depends on the dynamics of the family and what works, but sometimes what happens is dad is just taking care of the older sibling and mum is just taking care of the baby but that’s not fair to anybody either, right? So dad wants time with the baby, and mum misses her toddler and toddler misses mum.

So figuring out a way that everyone can get time with everyone else, and it’s really tricky and that is something I spend a lot of time trying to finesse with parents and nobody can get it perfect because you just can’t be in 10 places at one time. Special time is what I usually call it’s that I recommend for mums in particular who are going to have these older siblings who they’re separated from now more than usual and where that older sibling is really starting to have that jealousy and just having a dedicated period of time every day that that child can count on having time with mum because you can’t take away the fact that breastfeeding is breastfeeding and if a mum’s doing that, she’s going to be doing that very frequently and she’s going to default, be the main caregiver for the baby but that even 15 minutes a day can make such a big difference in how that older sibling feels still being important to mum and that it seems like such a little thing, but it can go a long way.

Helen Thompson: Yeah, absolutely. Even if it is just reading a story to the little one while they’re breastfeeding. Yeah. I know pediatricians generally work with children.

Cindy Rubin: Pediatrics.

Helen Thompson: Oh, okay you obviously have a lot of knowledge with the kids as well to be able to support the whole lot, the whole package, which I think is great.

Cindy Rubin: And there’s different people who do this sort of care and some are family physicians, so like general practitioners who see adults and kids and might actually be able to do some of the post-op OB (obstetrics) care for mum. I am not an OB. I can treat mums in the context of breastfeeding and lactation, and I can check a wound and I can take a blood pressure and I can do some of that, and I can do the mental health screening, but I’m not going to really feel comfortable managing an actual obstetric issue that might come up and so that’s where I work with a patient’s team, because everybody has their general doctor or their OB or midwife, and so then I work with those people to try to bring the best care to the mother.

Helen Thompson: Yeah, I’ve interviewed doulas and I know they’re not trained. I won’t say they’re not trained, but in medically trained, but from what I’ve picked up by talking with them. Having somebody like you who’s in the home working with them, can be very to the mum as well, because you can give them the medical side, but if you are not there, the doula can then come in and say, all right, well let’s try it this way because this is what Dr. Cindy had suggested, so you can work together, I assume with doulas and lactation consultants as well.

Cindy Rubin: Absolutely. Absolutely we’re just part of that team. It’s funny that you say that because I have a new baby in my practice and I went to see them for the first visit and they had had a doula help them out the night before and I felt like I didn’t have to do anything. They didn’t have any questions for me because the doula had pretty much gone over everything, had stayed with them overnight and answered a lot of their questions. So yeah, doulas are amazing.

Helen Thompson: Do you do overnight care because you’ve got kids yourself, I know.

Cindy Rubin: Right. Yeah. I have young kids, so I do not do overnight care though I think it would actually be a cool thing to do. I’ve thought about just being a doula. Sometimes it, it feels to me like I would love to be able to just be the support person and not have to think about all of the other medical stuff going on. So there’s part of me that almost wants to become a doula also but it would be hard to take that out.

Yeah I could probably offer that kind of service as a pediatrician. I do know another home visit doc who had a family hire her. This wasn’t a service she offered, but the family asked, said, you know, we want you to just stay at our house with us for four hours every day for a week, just to help with everything that’s going on with the baby during that time, the breastfeeding, this, that, and the other thing.

So it’s kind of like being a doula in a way but with a little bit more of the medical knowledge as well. So, yeah, I haven’t gotten that ask yet.

Helen Thompson: Yeah, well, I think you all do great jobs for mums. I think the medical side is great, but I think the other side is also good when combining the two together. I’m very much more of a natural person myself, but I do appreciate the medical side is important as well, but I’d go more the natural route to begin with, and if that didn’t work, then I would go to the medical side but I do know they’ve gotta work well together.

Cindy Rubin: Yeah,

Helen Thompson: I think it’s very valuable to mums to have both because sometimes a mum might want the doula or might want the the natural side, but they also might then think, oh, okay, well let’s mix this up and have a bit of the medical advice as well.

Cindy Rubin: Right. Right and then you figure out what works for you, ’cause you know it’s gonna be different for everyone.

Helen Thompson: So is there anything else that you feel that you would like to add?

Cindy Rubin: Yeah, so here in the United States, as we said there just isn’t enough support, I think for mums and babies. Women’s healthcare is not a focus and we are constantly fighting for things like maternity leave and breastfeeding support and all of those things and so that is what I am passionate about, being able to provide some of that myself directly, but also working on changing our systems so that that is not just an afterthought like it has been in the past. Women are half the population.

Helen Thompson: Yeah, well, that’s right.

Cindy Rubin: Yeah, it’s kind of crazy how long it takes for change to happen.

Helen Thompson: Yeah, I don’t know what the maternity leave is like in Australia, but I do know somebody who’s just had a baby, she’s Brazilian and they’ve gone to Brazil for a while. I don’t know how long the maternity leave is here, so I don’t want to say. I think in the UK they have quite a long maternity leave, which is good. I think the dads have it as well. Dads get dad’s leave too, which I think is very valuable.

Cindy Rubin: I think it’s so important. Here we’ve got, I think the law is still 6 weeks and it’s not guaranteed paid. It’s just 6 weeks where you can be off and still guaranteed to have your job when you come back but it’s not automatically paid. Each individual employer can decide whether or not it’s paid and then can decide whether or not they wanna extend you more time paid or unpaid. So some people do get more than the 6 weeks, or if you have a C-section, I think it’s 8 weeks but it’s absolutely not enough. No, and if it’s not paid, you know, people are going back to work after a week or two weeks ’cause they just can’t afford to be off that long.

Helen Thompson: So, it’s not good. If anybody wanted to get in touch with you and find out more about your services, how do they go about doing that?

Cindy Rubin: Yeah, best way to find me is just through my website. The name of my practice is In Touch Pediatrics and Lactation, and my webpage is www.InTouchpediatrics.com. So my email address is there, phone number, you can contact me just sending a message but that’s the best way to reach me and I can do virtual services throughout all of Illinois. I don’t think I can extend it out of the country legally at this point, but but I can do virtual services locally.

Helen Thompson: Well, thank you Dr. Cindy, thank you very much for coming on to the podcast. I’ve actually learned a different perspective of what support mums can get. So thank you for being here. I appreciate it.

Cindy Rubin: You are welcome and thank you for having me. I’ve really enjoyed talking and hearing your perspective as well.

Helen Thompson: Dr. Cindy shared some great tips during our chat and I do hope that you’ve picked up some tips to help reduce those biting issues when you’re breastfeeding. I’m a big fan of what she’s aiming to achieve in a space that clearly has many shortcomings for mums that are commencing their parenting journey. I’ve included links to the In Touch Pediatrics and Lactation website and social media in the show notes, which can be found at MyBabyMassage.net/podcast/134.

Next week I’ll be chatting with Kirryn Lee, who is a matrescence mentor and energy coach. We’ll be talking about what is matrescence and what can women do to prepare for it. Be sure to listen to this episode when it comes out and please subscribe to First Time Mum’s Chat via your favorite platform so you get quick and easy access to all our episodes when they are live.