The Pathways

TOPIC 7: The pathways

This is where the map takes shape, this is where we are now putting in place the serious considerations for each possible decision point. We take time to consider the different pathways by weighing it up in the context of our own circumstances. The expected and contingency pathways mean that we will not leave our dignity at the door. We are going boldly, we are going with confidence, we have honour and respect, we know our worth, we move forward with our dignity and use this to help us communicate with our care providers.

We have a series of questions that we will be using and these start on page 67 and go through to page 93 and are summarised on pages 95-100.  As a family, a woman, a partner use this book the white space in the print copy allows them to make notes as they go, so they don’t forget details after their appointment or before their appointment they might come across other questions they want to ask, or some information they want to check and put past their care provider, they can actually write that into their book so they don’t forget when they get to their appointment what they were going to ask, then the book becomes a record of their journey. Some women like to use the book and decorate it and place art and poems throughout the book and use just use the summary pages for recording their decisions, some people prefer the digital version.  As they go through, this section is broken down into the stages and then the division between vaginal and caesarean.  So the expected pathway is going to be exactly as the name suggests – the expectation.  If you know there is a genuine, proper reason to be having a caesarean birth then the expected pathway is that caesarean birth and the contingency might be birth before the caesarean or it might be a caesarean that hasn’t unfolded as smoothly as expected and that perhaps there is a separation between mum and baby that was not anticipated, sometimes that separation is expected so that is factored in.

This is all about communication if the expected pathway is a spontaneous pathway the contingency pathways are going to be the medical pathway on the vaginal side, how they are going to move from point to point as well as a caesarean birth pathway. There will be an order of, if this, then that, and they will know exactly when they are going to shift to a different pathway based on particular circumstances that are unfolding.

So before we are in labour we are discussing various scenarios with the care provider and running them through, using the questions in the book to guide it. As a person is starting to prepare for the antenatal appointment they might be flicking through the book and see something that jumps out at them and that is what they want to start asking questions. They might not be moving though the book, one page at a time, one question at a time they might have an ‘ooh epidurals, sounds to me like there is a lot more to an epidural than I understood, I’d like to explore that first’, so you might jump around a little bit between the different areas depending on what is most important to you. Maybe delayed cord clamping is your first question, because you want to ask these big questions sooner so that if you are not in alignment with your care provider you can seek an alternative. 

All this comes together to inform the written document which those summary questions on page 95-100 are going to guide for that written document. The partner embodies the birth map, they are so well tuned with what is going on because they are involved with the whole process, that they know the if this, then that and they recognise how things flow but when things are written down it gives a much greater sense of power; it works then like an advanced care directive with very clear instructions if the circumstances are like this, then this is the decision that is going to take place. If those conditions are not met then this is the decision we are moving forward with and that will be based on the BRAIN approach. Some of these decisions might be made in the moment but they are being made having filled knowledge gaps in advance, so they can decide perhaps using the ‘I’ in BRAIN that intuition of going yes, what feels good right now and that might be that the couple comes up with a code word or a set of circumstances. For example, if you want an epidural you are going to have to ask three times before we take you seriously and she knows that, so she might ask very quickly three times in a row for that epidural, but she does so knowing that not only does she have to ask three times but its also going to be a ‘we need to wait for five contractions’. Then it is going to depend on the time of day or night, sometimes you might have to wait for 20 contractions.  If the anaesthetist is on site you might have to wait half an hour for an epidural, but if its late at night and the anaesthetist is called in you might be waiting a couple of hours. So if this, then that, will consider those type of circumstances.

Let’s return to our map and work our way through it, remembering that the birthing woman determines the direction. She is using these questions from the book and the others that pop in, she is coming up with new questions, the ones in the book are the minimum that she might ask, she might only ask three of them. She is working out for herself; what are my knowledge gaps, what do I need to fill, what really matters to me, how do they work together so that she is having realistic decisions being made.  As we discussed, these form different possibilities, those general circumstances will determine which of these pathways she is on. If she knows she is expecting a caesarean, then she has got a different set of considerations and we will come to that in a moment.

Then there is the spontaneous vs induced so she might have a list of conditions that she either understands indicate that an induction is a good idea, but also has a standard of circumstances that she is prepared to not have an induction for. She might understand that she is going to be offered an induction at 39 weeks because she has gestational diabetes, but she is going to base that decision on other measurements; how is the baby tracking, what is the baby’s position, how is she feeling, how well is the gestational diabetes managed, there may be a scan at some point to determine the size of the baby.. so there will be other information she can bring into play that will inform that decision and the set of circumstances, including the ‘I’ for that intuition; what is my gut telling me I want to do.  Is it an assumption based on me being scared or just really tired, because it is Summer, Christmas is coming, these circumstances that might be influencing that decision and she can break it down and either decide she accepts those influences as important, or she can say no they are assumptions and I can actually push them aside and make a different decision because she now understands where she is coming from. That is very variable but it also comes into play with the policies at the hospital but particularly for rural women if their local hospital has a policy that at 42 weeks you are transferred to the city hospital which might be a couple of hours away, that might influence whether or not you accept an induction rather than continue the pregnancy because you are then now taking into consideration circumstances that involve a lot of travel and potentially isolation away from support networks so all is balanced up to make that decision. 

As we move into the vaginal pathways; depending on how we entered, we are either on a spontaneous or we are on a medical pathway which is an assisted pathway where we will be more closely monitored depending on how our body reacts to the induction, certain other procedures may take place.

Let’s use take that example of the epidural because it’s the most common decision point, or assumption point for women as they prepare for their baby and their birth. The idea of contraction management, the perception of pain, very individual. There is a brilliant tool that you will find in the member area resources list that you have access to, which is called ‘The Penny Simkin pain management and perception scale’ (PMPS). This scale is a fantastic tool that you can use for yourself or your clients to try and get an idea of what your attitude towards pain is.  Are you prepared to have a caesarean section without any anaesthetic at all – in fact I’ll perform it myself! Or are you at the other end of the scale where you want to completely not feel anything and that twilight birth sounds really good, I’d rather be knocked out and presented with my baby several hours later, completely unaware of the whole thing!  Those are the two extremes, and the idea is you want to try and shift into something more realistic, because obviously you can’t perform your own surgery and its really not in the best interests of yourself or your baby to completely disassociate. 

You want to try and find a happy medium and then look at the what ifs. What if you did need immediate pain relief, what if there was a time gap in receiving that, what kind of techniques do you have. On page 72 of the book it goes through some non-medical options as well as some medical options that might be available in that particular area and that helps a lot of people to work out different methods that they can use. It might also raise the idea for people that it is also important for them to perhaps consider independent childbirth education, such as Calmbirth, or hypnobirthing, She births, birth beat, there are a few options out there and these independent childbirth classes help to teach you some of these non-medical techniques that can help you manage contraction and possibly even enjoy your birth and so change your perspective if you are at that fear or concern, or anxious part of your perspective of birth. You can use these classes to help shift your perspective, and this helps to take you from a place of fear to understanding and it helps shift your partner from that protector to supporter space.

This is an area that may actually take much of the pregnancy to work through, this is where most people are going to be focusing their time and preparations and unfortunately this is where most birth plans stop, this is as far as it goes with maybe a little bit of detail about some skin to skin and a physiological third stage with delayed cord clamping which we will come to in a moment.  When women can understand that the decisions they make at this point will impact what happens downstream, it can help them to become more open to the non-medical techniques and explore those pathways a little bit more seriously rather than just dismissing them offhand because as what happens downstream is not as benign as we might think.

For example, with the epidural when we talk about the risks of an epidural before we are in the moment, we’re calm and we are not facing it, we are not feeling pain, we are not feeling tired, we are not fedup, we can hear what the benefits are, we can hear what the risks are and as we work through that we can then move on to down the track from that point. We come to understand that the epidural does go into our spine and we are then hooked up to a machine that allows us to control the dosage so that we can keep it going for as long as we need it to.  It is limited so we can’t overdose ourselves, but because of the epidural we are numb from the waist down, so we need to have a catheter put in so that we can keep our bladder empty because we are not going to feel that sensation, we are not going to have control over our bladder. The catheter is placed into our bladder and the catheter also has risks involved with it that we need to take into account. Some people, in discovering a catheter is involved that can be the turning point for them to say “I’m not actually super comfortable with that, I would like to know what my other options are” and so they starting looking at alternatives quite seriously.

There is more, because you will also need an IV in for fluids to keep you from dehydrating, so after the epidural your labour might slow down a little bit, if you haven’t already received synthetic oxytocin you will most likely be receiving it after the epidural, so that is another IV going into you. You may end up with 1, 2, 3, 4 points of needles and they all come with their own risks and benefits, so we weigh this up for understanding that if we do reach a particular set of circumstances, such as we have tried all of the non-medical things and we have reached a point where we are feeling pretty tired and we need a rest, the epidural starts to become a more attractive option, the benefits are starting to outweigh the risks and the balance point shifts. We do so knowing that having an epidural also includes those other aspects, we also do that knowing that as we move into second stage knowing if we had that epidural with all the bells and whistles attached we are most likely birthing on our back and we may be at higher risk of needing an assisted delivery.  This is where forceps or a vacuumed extraction might be used and its also where an episiotomy may come into play, or without the episiotomy we may experience a third- or fourth-degree tear.  Whilst these are still lower risk overall, the risk is increased if we are having an assisted delivery, which is also increased because of the epidural.  So we work backwards, what do we want to avoid, how can we best avoid it and if we do have to accept that intervention, we know what else we can do to help minimise any damage that comes into play or any potential trauma that comes along because we simply didn’t know what was happening but what the map does is mean that we actually understand why things might be playing out the way they are, which makes it easier to accept because we actually understand them.

So that second stage, if we are really wanting to make sure that we minimise our risk of tearing we want to make sure we are as mobile as possible so that we have more control over the positions we can put our body in and hopefully we are not getting too tired so we stay hydrated and nourished throughout that first stage – moving, using the shower and bath, and our other techniques we may find at this stage we are breathing our baby down and we might actually know about the ‘ring of fire’ as well. This was a really useful piece of information that I was very fortunate to have mentioned to me in one of those circumstances of new information where people choose to just tell you stuff, just because. A very flippant remark from my sister-in-law about a week before I had my first baby was “oh by the way, if you feel the ring of fire don’t push through it, just breathe it out because you need to open up a bit more”.  It made no sense to me at that time, but sure enough a week later I was in the bath, the baby was emerging and I had the thought “wow, that burns, burns, fire, ring fire, breathe”. She had given me one tiny special piece of information, didn’t make a lot of sense in the moment that I received the information, but when I was in the circumstances, she had given me something quite powerful – just breathe, don’t push through it. So I was able to do that and the fire went away and on the next contraction my baby emerged and I didn’t tear, but if I had pushed through that ring of fire I may have experienced a tear. That was really useful information, and this is the kind of things that when we know about it we can prepare for it, we are not afraid of it when it happens because we understand it and if it doesn’t happen that’s fine too because we know that it might or might not happen. There is no absolutes, birth might not be predictable but that doesn’t mean its not preparable, we can prepare for several possibilities.

Into that third stage now, the baby has emerged and is skin to skin and most birth plans will say at this point, this is our golden hour, we want to be skin to skin allowing that first breast feed to happen and we want it to be a physiological third stage with delayed cord clamping. So if you have had a spontaneous birth up until that point then a physiological third stage is perfectly warranted, but if you have had any intervention then a physiological third stage is probably not a good idea. Once you have started interfering it’s usually warranted to keep interfering because with the artificial hormones in play our natural hormones will be inhibited, so it is really useful to understand that in certain circumstances having a managed third stage might be your best option compared to the physiological. So when you know which circumstances warrant an intervention and which ones don’t, you are much better equipped to be able to navigate which way you are going to go.

In regards to the delayed cord clamping and choosing our words carefully, this is where those discussions in advance with our care provider really help, because we either come to understand the hospital policy is one minute or three minutes. So we can now express ourselves and we will have done so in advance with our care provider to let them know that we will not be cutting the cord or I will be telling you when and it will be at least an hour before I say so, or we would like to wait 10 minutes. Whatever explicit instructions you have, based on your definition of delayed cord clamping, is what you would place into that section of the written map to ensure that it is a reminder on the day. But your partner will also be poised to be watching this point in time carefully. This is when things get busy, the baby is out, it is now a separate entity and the game changes somewhat. It can get very busy, there are a lot of people poised, someone has a syringe ready to put it in your thigh, somebody is wanting to press on your stomach, somebody is wanting to look at the baby, there is a lot happening.  If our expectation is that this is going to be a quiet, peaceful, blissful time we are going to be very confronted by that and understanding what that is going to look like will help reduce trauma, confusion, or stress. Knowing how the care providers will respond to a particular scenario and what circumstances they deem necessary for separation of the baby. So if a birth plan, written document, that is being used states ‘unless medically necessary’, then what you have done is give the care provider the power, given them the responsibility, its their determination of what the circumstances are, not yours.  So in a birth map we would very carefully write down that the baby is to remain on mum and because this discussion has happens in advance you know what is possible and what’s not, that if the baby needs to be attended to, the baby will be attended to on mum and sometimes that means they move the resus trolley across to the bed, sometimes  it means they need to move the bed across to the trolley. Discussing that in advance gives your care provider the opportunity to prepare for that scenario as well, it’s beneficial to everybody to have had that discussion in advance.

When we go across to the caesarean pathway remember we have got four different types. One of those is going to be an expected pathway. This is the before labour, non-emergency pathway. We understand why the caesarean is happening, we know the conditions that are going to surround that caesarean and whether or not there is going to be a likelihood of separation with the baby and the mother. So we can put in place our support systems that are going to be necessary depending on whether or not the baby is in the care unit or whether or not the mother is in a care unit and what that circumstance is.  This particular pathway might also have the opportunity for a discussion about maternal assisted caesarean. This is the kind of caesarean where perhaps a mother is helping to pull the baby out, so being able to reach down it’s the kind of caesarean where they are lowering the drapes so she can see, perhaps they are explaining things, maybe they are walking the baby out rather than rushing things and the baby is likely to be able to go to skin to skin contact with the mum and the first breastfeed happening fairly quickly and the baby being able to stay with the mother throughout that time. 

The father or partner will be well versed in what to expect, particularly if there is a 10-minute wait where they are dressed up in theatre garb but been asked to wait in the waiting room until someone comes to fetch them, that can be the longest 10 minutes of your life. You sit there thinking no one is coming, they have forgotten, what is going on, has something terrible happened, if you don’t know that that is going to happen it’s very unnerving.  So we can have those discussions in advance, it can be very well known who is going to be involved, you have probably met your anaesthetist as well as your surgeon and discussions have been had. It is a much calmer situation and can still be a very beautiful birth. 

Before labour emergency is only every going to be a contingency pathway. This is where something has arisen quickly, maybe its an issue with the baby, an issue with the mum or both, perhaps there has been an accident, it may even be that things are happening prematurely. There are things happening quickly and not a lot of time to consider. So this, as a contingency plan, becomes a backup situation where you have people in mind that you would call on in such a situation so that in the event of separation, who is going with baby, and who can come to be with mum, you know that there are certain support networks around in your area that you can call on, or you might know what that scenario might look like and who you might meet. You don’t spend too much time on that particular contingency, a handful of questions during one appointment will probably give you all you need to know setting in place that contingency pathway. 

But this particular contingency pathway can be very helpful if you have got an overbearing relative who is assuming that they are going to be involved in your birth but you are unsure of how to tell them that they are not invited. What you can do is put them on as your backup, because chances are you will actually want them in that circumstance because now they know they are there in a very important capacity but also hope that they are not going to be called. You can actually ask that perhaps their job is to prepare your home for your return, or to be there as backup and be on standby ready just in case you have to enact your emergency contingency plan.

The in-labour non-emergency is particularly interesting. This is a maternal request situation in most cases, not always. This is based on the work of Michel Odent, he suggests and you will find this in the further reading, that the birthing pool test be conducted before any interventions occur in a spontaneous pathway. It might be an induced pathway where labour has kicked on but basically a vaginal exam ascertains dilation and then we give the woman two uninterrupted hours in a warm bath, dim lights, completely uninterrupted.  If she has made no progress in that two hours, say she was 4cm before she got in the bath and she was 4cm two hours later, statistically she is likely to end up with an emergency caesarean or an assisted delivery. Neither of these scenarios are particularly nice to think about but Michel Odent suggests she actually has a couple of options at this point, chances are she is going to be offered synthetic oxytocin which may also lead to an epidural to try and speed things along, to get things happening and she may decide that she does actually want accept an epidural but do so in preparation for an in-labour, non-emergency caesarean birth. She may end up still having to wait a couple of hours for that caesarean because its not a priority, but she can move forward on that pathway knowing that the process is underway so that it doesn’t become an emergency only option for that caesarean or she can reduce her chances of an assisted delivery.  He suggests an in-labour non-emergency caesarean is a better option over an augmented labour where the baby and mother are exposed to drugs for a much longer period of time and are more likely to become tired and stressed which means that their recovery is going to be harder in the short term but also in the long term that exposure to the drugs may have longer term effects, but we are still coming to understand the science behind. He suggests that an in-labour non-emergency caesarean on balance is perhaps a better option, of course as we know, this is a decision that only the birthing woman can make and she will know in herself which direction she wants to go in, she can weigh those up but knowing that it is an option can often be very reassuring. So because that is a maternal request most of the time, sometimes it will be quite suitable to the hospital to go forth with the caesarean, but it is perhaps preferable for the hospital to avoid a caesarean unnecessarily. If they don’t feel it is warranted you may have to push quite hard to get that point, again that discussion in advance really helps to put this one into play. It means that you know that you can ask for it, they know you might ask for it, and they can let you know in advance whether or not that is going to cause friction or not, you get rid of the friction beforehand so that in the moment you can enact that part of the map and you might still be waiting sometime because it won’t be considered urgent but it enacts that pathway.

Then there is the in-labour emergency which is again a contingency pathway rather than a pathway of choice, this is where we are accepting that a caesarean has become necessary for the life of our baby. Now, for some people they may actually refuse this emergency caesarean and they are well within their rights to do so, we have the legal right, it’s a human right and the Australian College of Obstetrics states this right for us, we have the right to refuse medical care even if it causes our death or the death of our baby or if it causes us injury. We get to determine for ourselves what we need. Now in this particular case an emergency caesarean might be refused because a woman’s circumstances – perhaps her religion, perhaps her cultural situation, perhaps there are other factors that come into play, use your imagination to fill what you may imagine. We will discuss these possibilities in the thread, this is an important discussion. If she refuses that care, what she is doing is making an informed decision. So the obstetrician may say to her if we do not perform an emergency caesarean now the baby is going to die, and she may say “ok, then my baby is going to die”. The obstetrician may again seek to ascertain that the person does indeed understand what that means, and then once it is established that they both understand what death means, that can be documented, then nature can play out.  It is her decision to own, it does not mean she is callus, she will grieve that baby as much as anybody else would. What it means is that her circumstances have influenced her decision and she has had to weigh things up based on her circumstances. This might include refusing blood, it might include refusing medical treatment based on philosophy, religion or some other circumstances that are coming into play and it may change from one pregnancy to another. Only the woman can make that decision. It is the job of the care provider to provide information and ensure understanding and then accept whatever decision is made. It is not their job to assume consent or coerce consent, because the decision that they want the person to make is being influenced by their own biases or their own opinion of what would be the right decision in that choice. I look forward to hearing your discussion on what challenges you in regard to those particular kinds of decisions.

When we come to post-birth, the case of separation is a really important consideration because this can avoid stress; who is going to go with the baby, who is going to stay with the mum, is someone going to be called in as the backup, what is going to happen in the case of needing to breastfeed the baby. For example, in my third birth which was still called a birth plan at that point, it was a very detailed birth plan with multiple steps in it but it was between baby no 3 and baby 4 that I started referring to it as a map and conversations were so much better when I used the term map instead of plan. But what I did for my worst case scenario day, which unfortunately for my care provider, happened to be the day that the student midwife was taking the lead for that particular appointment.  She said, “ok Catherine do you have any questions?”

I said “yes, I do, today all my questions are related to my worst case scenario”.

“Right” she said, “we’ve got your back you know, I assure you that we are more than capable of looking after you in any circumstances, you are quite safe.”

I said ” I know I am very safe, that’s not my concern. I just what to understand what that pathway is going to look like, because my husband in particular is going to need to know who he is going to meet, what kind of options he might have available to him and what he might need to do, because it would be quite stressful making it up as we are going along”.

She said “oh well, that is pretty reasonable, what is your worst case scenario?”

I leaned forward, and I said “it’s like this, we’ve had an emergency caesarean and I’m in a coma.” 

“Right, that’s not going to happen Catherine, its really unlikely.”

 I said ” I know that, I’m not afraid of that, I just want to know what that scenario looks like.”

“Ok, go on, Catherine”, she says. 

“In this particular scenario it is very important to me that my baby is breastfed, so this is what I want to have happen and I want to know what I need to do to make that happen, or to allow my husband to be able to make it happen, because as you recall I am in a coma”.

She said, “ok, what needs to happen?”

I said, “well, the first thing that needs to happen is that my husband is supported to put my baby to my breast and try and support the baby to feed directly from me, is that likely to be possible?”

” Whew, it is a bit unusual, but yes we can do that, we can definitely support that.”

“OK, cool. If that isn’t possible because perhaps the baby isn’t well enough to do that then I want you to support my husband to express my colostrum so that you can give my colostrum to the baby, is that possible?”

“Yes, absolutely” she said, “we can do that, no worries.”

“Excellent. Alright, if that can’t happen then my friend is going to come in and feed the baby directly. “

“Right, now we starting to get into NO territory, that’s not going to happen.”  

I said but “I want that to happen and I give permission for that to happen, she is happy to do that, she has already indicated to me that she would be prepared to do that and my husband is prepared to support that and make that happen.” Our baby, our choice.  She said, “Yes, but while the baby is in our care that one would be a little tricky.”

“Ok, well, she is also prepared to express milk for me and bring it in.”

he said, “ok, again there are certain rules around that so basically the way around that is that you just don’t say it’s not your milk”. If whatever milk I bring in, its just going to be assumed its my milk.  Ok, well that’s good to know that’s useful to be given the language that my husband would be able to use in that particular circumstance.  Then, and only then, if all those four options have been exhausted, only then will the baby be offered formula. 

That set of processes was based on the WHO guidelines for breastfed babies and because it was evidence based she couldn’t argue with it, so we had to work around what the hospital policies were to work out how we would do that because it wasn’t default care. This was an important consideration for us to have in advance because in that particular scenario if I were to awake from that coma and find that my baby was completely unknown to me it would be incredibly, incredibly upsetting. It would also be extraordinarily stressful for my husband to try and navigate that process without that knowledge.

I shared that plan when I was in a mothers’ group, a ‘due group’ on Facebook and shared with everybody I had just had this discussion, and this is what I’m going to be putting it in my birth plan and a woman wrote back and said “that’s brilliant because its made me realise that what I need to do in my birth plan is say  under no circumstances is anybody to touch my breasts or to attempt to put my baby to breast if I am unable to do so myself’’. Because she had sexual trauma related to her breasts and this process that I’d gone through about expressing something that was really important to me gave her the confidence to then go to her care provider and say there is something about me you need to know, because if you did this to me after my baby was born you would cause me a lot of stress, trauma even. Incredibly important to express your personal needs, values, philosophies, history to your care provider. These conversations are incredibly important because they help us avoid stress.

Then there are those standard procedures that are presented as consent points which of course, we are learning to use consent to mean informed decision so we use that in advance so we take the pamphlets that we are given, we seek out as much information as we need to feel ready to make an informed decision.  We might have a set of decisions based on circumstances, so with the Vitamin K for example, we may decline the Vitamin K under one set of circumstances but want the Vitamin K under another set, we may want oral Vitamin K under one set of circumstances and the injection under others.  So when we can understand the different options we can work out for ourselves what is our safest way forward.

That takes us to the end of the point of the written discussion that we have with the care provider, but there are other areas of discussion care providers should take the responsibility to ensure that people understand, but as individuals these women and their partners need to take the time and responsibility to prepare for. This is where that word matrescence is so important, understanding that we are not going to go back, we cannot go back, we can only move forward and we can move forward with confidence knowing we are growing, we are coming into our summertime phase of our life. This is where the work of Jane Hardwick Collings is so beautiful to explore, it is about the difference phases that we go through, from maiden, through mother, the maker and the crone – these are lovely terms to explore and come to understand. Some women will explore them more deeply than others but even at the superficial level understanding that we are transitioning to a different phase and that a matrescence is taking place, and just like adolescence our body is transformed, our hormones change, our brain rewires, we become a different person, our values will change, our interests will change and yes, your feet are going to get bigger!

At this point we extend that birth plan, birth map, birth preparation sections that we communication to our care provider into a breast feeding plan that helps us through that fourth trimester, that newborn phase which is considered to be the first three months. Breastfeeding is a learned skill, it takes time, it takes support, it takes understanding and when we know where we can seek that support, this process can be much better for us. So this is the point where we are setting in our support network, so we understand what is available within our community, perhaps what is available through national helplines, perhaps what is available through our own resources within our own family.

A great way to set ourselves up for this time is by having a gathering of supporters before our baby is born. This is pretty much an anything goes scenario and we are going to talk a little bit more about this in the next module in terms about how it plays out beyond. It is important to consider this before the baby arrives so we are setting in those systems that help that transition. Sometimes it is enough just to understand that a transition is going to take place and recognise that it’s not just a few weeks, the newborn phase is a few months. Then of course, you have an exponential time of growth throughout that first year.  So having a mental game plan ready for that first year can make an enormous difference in how a couple transitions from coupledom into that parenting phase and we boldly go into parenting then, and that parenting trifecta is about aligning that reality with that expectation so from all the elements involved in the actual birth, as well as the early weeks, and then going through that first year and beyond, having good realty expectation alignment and then bringing in support – that trifecta, the more they overlap the more powerful that transition is going to be, the more confident they are going to be.