I NO longer see private patients at this time! Please go to ILCA.org to find a lactation consultant near you! Feel free to peruse my blog, which still has good information on it!

ENGORGEMENT Part II

What are Tips for Treating Engorgement?

• Cold Compresses- use for 10 to 20 minutes before breastfeeding as well as between feedings for 20 minutes at a time. You can use bags of frozen peas or corn, or a disposable diaper that is dampened and put in freezer for 20 minutes.  Use a layer of cloth between your skin and the cold compress.  
• Gentle Breast Massage-  Around your breast like the numbers on the face of a clock. 
• Moist Warm Compresses for only a few minutes- Just before you breastfeed or pump- or run your fingers lightly over your breasts and use deep breathing and relaxation to stimulate the milk ejection reflex (milk flow or let-down).  Contrary to much that you will find in books, articles,online, or even from practitioners, current research shows that heat for more than a few minutes can increase swelling and inflammation, making your situation worse.
• Reverse Pressure Softening- if your breast is so hard and swollen that it is difficult for baby to latch, use reverse pressure softening.   Surround your nipple with your fingertips from both hands, flatten your fingers against your breast as best you can, and press firmly towards your chest wall for about two minutes.  This will force fluid out of the cells, softening the areola, so that baby can latch-on more easily.  When switching breasts, do the same on the second breast.
• Remediate Let-down Inhibitors- In order to empty your breasts, you need to have multiple “let-downs” during a feeding.  You can have the baby at the breast for hours, but if you don’t have multiple let-downs, you will not be emptying your breast.  Some mothers feel the let-down and some don’t.  If milk is flowing and the baby is swallowing, you have had a let-down.  There are a number of things that interfere with having a let-down, including pain, fatigue, stress, and anxiety--ironically, all things that most new mothers are dealing with.  Try to nap several times a day with the baby, get all the help and support you can, and use deep breathing and relaxation techniques when you start feedings and when you notice the baby falling asleep or not sucking and swallowing.

•   Breast Compression- can be  used when baby’s sucking pauses.  Take a broad part  of your hand or fingers and compress somewhere (especially on hard areas) distant   from the nipple.  Press and hold it until the baby pauses, then lift and repeat. 

• Empty First Breast, then switch- When baby is no longer sucking and swallowing at  the first breast, even with compression, it is time to switch sides.  If the baby pulls off or falls asleep it is time to switch sides as well. If baby still hungry, you may go back to  first breast after doing both sides.

• Skin-to-Skin- should be done when switching sides.  Burp the baby, change if needed,then put skin-to-skin until ready for next breast.  The baby may rest up to 20  minutes between sides, and this is still considered part of the same feeding.  STS does amazing things for you and your baby! 

• Good Latch and Positioning- A good latch should not be painful after 30 seconds.  If it is, get help so that the baby can empty your breasts completely and efficiently, thus softening your breasts and stimulating your milk supply. 

• Protect Your Milk Supply- If the baby is not breastfeeding well and emptying your breasts, protect your milk supply and decrease your engorgement by using hand expression or pumping.  Use deep breathing to relax and help yourself to have more frequent let downs, thus emptying your breasts more thoroughly.  If you use an electric pump, set it on the minimum setting and gradually increase it to the highest comfortable setting.  Lubricate your nipple with olive oil when pumping.

• Expect Cluster Feeding- the baby will cluster feed at times.  This is most common in the late afternoon and  evenings.  This is normal newborn behavior and stimulates your milk supply. 
• Use Pain Relief- if needed, you may take over the counter Acetaminophen (Tylenol) alternating with Ibuprofen to decrease the inflammation and for pain relief if OK with your healthcare provider. 
• Use Cabbage Leaves- Yes! Cabbage leaves!  Chilled, green cabbage leaves have been used to treat engorgement for many years.  There is much anecdotal evidence for it’s effectiveness, as well as some research showing that it causes a significant reduction in pain.  When compared to gel packs, two thirds of the mothers preferred the cabbage leaves because of a stronger, more immediate effect.

           How to use Cabbage leaves:

•   Get organic, green cabbage if possible
•   Remove the outermost leaves
•   Take the next 2 or more leaves, wash, dry, remove hard middle vein
•   Crush leaves in your hand
•   Place leaves inside your bra over all of engorged areas- including area by armpit if that is also swollen  and tender.
•   When leaves are wilted and warm, remove and replace with fresh leaves
•  Continue to treat between feedings until you feel relief and are able to empty your breasts by breastfeeding or pumping. 
•  Stop using as soon as relief is obtained.

What Should I Avoid?

• Do not apply heat to your breasts between feedings.  Current research shows that this causes an increase in the swelling and inflammation of breast tissues.  It is best to use cold between feedings.  If you are unable to have a let-down, you can use heat for just a few minutes to help your milk start to flow.
• Do not restrict fluid intake.  Drink to thirst.  Fluid restriction will not decrease engorgement.
• Avoid tight fitting, restrictive bras--they can lead to plugged ducts and mastitis
• Don’t allow visitors to interfere with or delay feedings.  Politely tell them you need to feed the baby.   As much as you want to share your joyful new arrival, while you and baby are learning to breastfeed and trying to establish a good milk supply, privacy and minimal interruptions are important.
• Avoid pacifier use in the first 8 to 10 weeks.

When Do I Need to Contact my Lactation Consultant (IBCLC) or Health Care Provider?

• If engorgement is not relieved by these measures.  The sooner you can get help, the better!
• If your baby is unable to latch or is not having enough wet or dirty diapers.
• If you have symptoms of mastitis : hot, reddened, painful area on breast, chills, body aches, flu-like symptoms, temperature of 100.6 degrees F or more.
• If you have questions or concerns.

This is part II of a two part article on Engorgement.  If you would like the full article with endnotes, please contact me.  

May reproduce once for personal use only.  Otherwise request permission to reprint.

Copyright:  November 2010  Kathleen L. Gale RN, IBCLC, RLC

ENGORGEMENT

ENGORGEMENT

Is This Supposed to Happen?

Every new mother will notice some degree of fullness in her breasts as her milk supply increases after delivery.  Your breasts will feel heavier and warmer, and sometimes uncomfortable.  It usually occurs between day 2 and 6 after your baby is born, and won’t last more than 24 hours.  If your breasts and areola remain soft and elastic, and your milk is flowing well and the baby is able to latch without a problem, there is no need for concern.  Some mothers have several peaks of this fullness, which then resolves. 

What Can I Do to Prevent or Minimize Engorgement?

• Breastfeed your baby as soon as possible after birth. 
• Alternate the breast that you offer first for a feeding. 
• Breastfeed the baby every 1 to 3 hours--at least 10 times or more in 24 hours. 
• Do NOT skip feedings. 
• Watch for the baby’s feeding cues to determine when to feed ( mouthing, bent arms, clenched fists, fists near face    or mouth) Feed as soon as you see any of these feeding cues.  Crying is a late feeding cue.  The baby will feed better if you feed him before he starts crying. 
• If baby is very sleepy, during the day, wake to feed every 2 to 3 hours.  At night, or sometime within a 24 hr period,   you may allow one 4 to 5 hour stretch between  feedings. 
• Make sure the baby empties the first breast before switching sides.  Don’t limit time at breast.
• With good positioning and latch, the baby should feed well and the breasts should be soft after a feeding.  If that is not the case, be sure to get help from a qualified professional lactation consultant.      
• Avoid using a pacifier during the first month of breastfeeding.

When Does Engorgement Typically Occur?

• Engorgement usually begins on the 3rd to 5th day after the baby is born. 
• If you had a cesarian section, it could occur 24 to 48 hours later. 
• With proper treatment, it should subside  within 12-24 hours.  Without good management, it can last up to 7 to 10 days     
• Prolonged engorgement causes milk stasis and predisposes a mother to mastitis as well as decreasing milk   production. 

What Are the Symptoms of Engorgement?

• Every mother experiences engorgement differently, but there are typical symptoms.
• The breast will feel hard with taught skin.  The skin may appear shiny with distended veins.  The skin may feel extra warm, throbbing, and be somewhat tender.
• These symptoms can occur in one or both breasts, part of the breast, or all of the breast.
• Some mothers have engorgement that extends up into their armpit.
• Engorgement in the areola can make the nipple more flat and make it difficult for the baby to latch-on well.
• Some mothers experience a low-grade fever.
• Some mothers experience a peak of engorgement which then decreases.  Others have several peaks.  Some have quick resolution, others resolve more slowly. 

More to follow about how to treat engorgement....


Full text with endnotes available upon request.

This is copyrighted November 2010 Kathleen L. Gale RN, IBCLC, RLC

Post Partum Depression Video

Here is a link to a video about post partum depression from Kathleen Kendall-Tackett's website.  Please take the time to watch it.  If you are concerned about how you are feeling emotionally, don't discount your feelings.  Being a new mother is a major life changing event!  Not only that, if you had a difficult or traumatic delivery, or if it just didn't go the way you had dreamed, that can also add to the emotional struggles a new mother has.  


New mothers are often so busy, that they don't take time to take care of themselves.  We know that it is very important that a mother be emotionally engaged and available for her baby--not just taking care of physical needs.  So, if you have any concern about  feeling depressed, don't delay calling your OB/Gyne or other health care giver.  If you are having irrational thoughts of wanting to hurt yourself or your baby, call 911 right away.  Get the help you need.


Crisis Hotline for post partum depression:  1-866-364-6667

Post Partum Depression Video

How Can I Increase My Milk Supply?

There are a number of things you can do to increase your milk supply.   There are a number of things you can do.

1. Make sure you have a good latch (see latch videos listed under resources)  If latch is painful or nipples are sore, get help from an IBCLC qualified lactation consultant
2. Increase your frequency of nursing to 12 times or more in 24 hrs. Make sure you breastfeed or pump at least one time during the night.
3. Do lots of skin to skin with the baby (mom or dad) Put only a diaper on baby, put baby on your bare chest,  and cover with blankets as needed.  Skin to skin does amazing things for the baby and also stimulates mother's milk producing hormones.
4. Pump 8 to 12 times in 24 hrs after every feeding for about 15 minutes.
5. Check for proper flange fit--nipple should not be touching the sides of the flange tube when pump is working
6. Use breast massage or compression
7. Use herbs that increase your milk supply such as More Milk Plus. You should notice a difference within 48 hrs if it is going to work. 

Breastfeeding Tidbits

• Babies thrive on direct contact and social interaction with you.
• Car seats are for when you are traveling in the car

Don't leave your baby in the car seat when you are out of the car. Babies need to be in different positions in order to strengthen all the muscles of their neck and torso. Hold the baby, or use a sling or baby carrier if you need to get some things done. These things will also help prevent the flattening of the back of their head. Carrying the baby around in the car seat is terrible for your arm and back as well.

Breastfeeding Tidbits!

• If you are breastfeeding, avoid using the gel hand sanitizers.

Just wash your hands with soap and water instead. Why? The gel sanitizers have alcohol in them. Alcohol can irritate your hands as well as the sensitive skin around the nipple and areola when you hold your breast to latch baby. The alcohol fumes are toxic to baby. I've seen cases where babies have had "breast aversion" because their mommy was using hand sanitizer after all diaper changes.

The Best Way to Avoid the Flu

The flu season is here! Protect you and your family in a very simple way.

• Wash your hands with soap and water for 30 seconds

When? Before you eat, after changing diapers or using the bathroom, after sneezing or wiping your nose or eyes, when you get home after being out...this goes for your children's hands as well!

• Try to keep your hands off of your nose and eyes

• Avoid touching public hand rails and door knobs as much as possible. Keep your paper towel in public restrooms, use it to open the door or push the door open with your back or shoulder instead of your hand.
• If you or a family member are coming down with "something", do everyone a favor, and stay home. There is no heroism in keeping an appointment and pushing yourself to do something if it is going to spread disease to someone else. Be considerate of others.

Breastfeeding Tidbits!

• The best breastmilk storage containers are either glass, or BPA free hard plastic containers

Why? Research has found that the a large percentage of the immunoglobulins that are in your breastmilk will stick to the sides of the plastic bag breastmilk storage containers. So...baby never gets those stuck cells that protect her from infections.

• When storing expressed breastmilk, never add your warm, just expressed milk to a container with frozen milk. Cool the just expressed milk in the refrigerator first!

Types of Lactation Visits

I do three types of lactation visits. Fathers can be included in the instruction.

1. Prenatal assessment and breastfeeding instruction

This can be done in the home and includes:

• a mother's health history
• instruction on how to get a deep latch
• various feeding positions
• how to avoid sore nipples
• how to avoid engorgement
• how to know when your baby is hungry
• the importance of skin to skin
• soothing techniques
• nutrition
• the importance of having the baby put on her tummy right after birth while the placenta is being delivered
• the importance of having the baby's first breastfeeding take place within the first hour of birth
• how to avoid being separated from the baby while in the hospital, and much more

2. Early postpartum visit for one of baby's first feedings
This visit can be done in the hospital soon after baby is born. If I haven't seen you before, it will include:

• mother's health history
• history of your labor and delivery
• physical assessment of the baby
• breast exam of mother
• feeding observation/instruction
• latch and positioning assistance as needed
• feeding and satiation cues
• breastfeeding management for the first few days
• the importance of skin to skin with the baby
• pre-term or late pre-term instruction if appropriate
• assistance with other issues that may arise
• customized care plan

3. Home visit after hospital discharge
This visit can take place in the days soon after discharge, or later, and includes:

• mother and baby health history
• physical assessment of baby
• breast assessment
• observation of feeding
• assistance with latch and positioning
• nude weight, and pre and post feeding baby weights
• hunger and satiation cues
• how to know if baby is getting enough milk
• when supplementation is needed
• alternative feeding methods if needed
• pumping and storing human milk
• management of sore nipples
• management of engorgement
• dealing with low milk supply
• cluster feedings
• dealing with over abundant milk production
• poor weight gain
• dealing with a fussy baby
• nutrition
• adequate rest for mom
• information and/or screening for postpartum depression
• provision of appropriate supplies and literature
• a personalized care plan
• follow up phone calls and emails, timely report to your physician.

Any of these visits may include more or less of what is listed, but this gives you a general idea of what is involved. If you can have only one visit, I would suggest that the visit after discharge would be the best one to select--as that is when many breastfeeding challenges start to show up. Having a prenatal visit can give parents enough knowledge to help prevent many breastfeeding problems. A visit for baby's first feeding, can help mom have a good latch and positioning from the very beginning, as well as breastfeeding management tips that will help to prevent problems as her milk comes in.
Most mother's and fathers are greatly encouraged and much more confident after a visit. It is my aim to make sure the baby is well fed, and that things are going in a way that is good for the baby and the parents. Breastfeeding involves the whole family. I want to help you meet your breastfeeding goals. I also want you to enjoy the precious new life in your growing family!

Breastfeeding Tidbits!
Keep your eye out for various "Tidbits" about breastfeeding. Today, I'd like to tell you one about cleaning breast pumps.

• Do you know that you should never, never wash your breast pump tubing?
• If you notice condensation in the tubing after pumping, leave the pump running for a while after disconnecting the bottles--this will dry it out.

The reason you don't need to wash the tubing, is that the tubing has nothing but air going through it.  The expressed breast milk never touches the tubing.  If you wash the tubing, chances are that it will get moldy.  If that is the case, you must get some replacement tubing.

This blog does not give medical advice, but is meant to be an encouragement and to give you up to date information about breastfeeding. You should always call or see your physician or your pediatrician for medical advice or care. If you are having breastfeeding problems, you should seek the help of a professional lactation consultant or a breastfeeding friendly physician who can see you in person.

I am making a new service available! If you are looking for

"The Best Baby Shower Gift!",

you've found the right place!

I am now offering prepurchased private lactation consultations to use as a gift for that special new mother that you know! It is one of the best gifts you could ever give to a new mom. You can go together with friends, or if you are a big spender, do it on your own.

I have various packages available. You can buy one, two, or three visits. The new mother can choose when she wants the visits.

I can do 3 types of visits:

1. Prenatal assessment and breastfeeding instruction (private in home)


2. Hospital visit for one of baby's first feedings


3. Home visit after discharge from the hospital

All of my visits include individualized teaching, as well as printed information about breastfeeding issues. When I do a home visit, I will give you a superbill that you can submit--along with a claim form and your doctor's order to your insurance company for possible reimbursement. Getting a properly worded doctor's order will make it more likely that you get some insurance coverage for the visit.

Coming up next! More information on what may happen at your private lactation visit.

Breastfeeding Resources

Compiled by Kathleen L. Gale RN, CLS
773-501-4238

Here are some resources that may be of help to you!

Latch Video

< http://www.ameda.com/breastfeeding/started/latch_on.aspx>

Latch Video

< http://redir.ameda.donet.com/breastfeeding/>
as well as lots of information on different positions, breast-feeding stages, dad’s involvement.

Hands on Pumping http://newborns.stanford.edu/Breastfeeding/MaxProduction.html

Newborn care

<http://www.nlm.nih.gov/medlineplus/infantandnewborncare.html>

The American Academy of Pediatrics http://www.aap.org/healthtopics/breastfeeding.cfm

Reflux / GERD

<http://www.cdhnf.org/wmspage.cfm?parm1=43>

Car Safety Seats

< http://www.aap.org/family/carseatguide.htm>

Your Baby’s Physical Development <http://www.aap.org/family/2004PAFBrochure.pdf>

Post partum Depression
<http://familydoctor.org/online/famdocen/home/women/pregnancy/ppd/general/379.html>

Crisis Hotline for post partum depression 1.866.364(.MOMS 866.364.6667).

Laleche League International

<http://www.llli.org/Web/Illinois.html>

Breast feeding and parenting

< http://kellymom.com/>

Breastfeeding after Reduction (or other breast surgeries) http://www.bfar.org/faq.shtml

Looking at Your Newborn—What’s Normal? http://kidshealth.org/parent/pregnancy_newborn/pregnancy/newborn_variations.html
Breastfeedingonline.com

Compounding Pharmacies: (for APNO ointment-all purpose nipple ointment)
Parkway Drugs 2342 N. Clark St., Chicago 773-549-2720
Ballin Pharmacy 3330 N. Lincoln Ave., Chicago 773-348-0027

Sacral Cranial Therapy for Infants:
Dr. Sean Mannin of "Well Adjusted World" in Oak Park, IL

Physicians that do clipping for “Tongue Tie” at Children’s Memorial Hospital
Dr. Marletta Reynolds 773-880-4292
Dr. Brant Giessler 847-390-0330

copyright, K.Gale, 2009

Here's a picture of my sweet grandbaby and my son! They live a long ways away from us, so I have to get time with other peoples babies!

It's a marvel to see the next generation starting their own families!

If you have grandparents nearby, make sure you accept any help they are willing to give you, and give them the opportunity and joy to be involved in their grandchild's life. Of course, you have to set reasonable boundaries....but you know what I mean!

Myth: Breastfeeding is "natural" and easy

Many people think that since breastfeeding is a "natural" thing to do, that it should be easy. New mothers and fathers are often shocked when they find out that it doesn't just come "naturally", and they're struggling along to make it work. Breastfeeding is a
learned behavior by both mother and baby. In contrast to the past, today, in our country, most new mother's do not have aunts, sisters, and mothers surrounding them in an extended family to offer help when breastfeeding isn't going well. If you do have them around, it is very likely that they bottle fed their babies and don't have experience with breastfeeding.

If you find yourself in a difficult breastfeeding situation, you are not alone! The best thing you could do for yourself, your baby, and your family, is to get the help you need. Sometimes LaLeche League or a friend who is experienced at breatfeeding is all you need. At other times, you need to recognize the need for a professional lactation consultant. Yes, it costs money....but it is money that will be well spent, and make a huge difference. It is money that will save you lots of dollars on formula and visits to the doctor. Do yourself a favor. You ARE worth it!

When I had my first child, I had some of the most miserable 8 weeks of my life. I was too cheap to pay for a lactation consultant. I knew I needed help, and would call and talk over the phone, but never spent the money to have one come and help me. I had mastitis 5 times in 8 weeks. Eventually, a doctor told me I had to stop breastfeeding. To tell the truth, I was never so relieved. As a mother, I wanted the very best for my baby, and was willing to do whatever it took to give her the benefits of breast milk...but it was making me constantly sick.

Now, I know a whole lot more! In hind sight, I recognize many things that were not done right, and many things that I could have done to help the situation. I would like to be able to share my experience and knowledge in a way that can help you reach your breastfeeding goals.

Why Breast Is Best!

Breast milk provides perfect nutrition for your baby, as well as customized health protection that supports his developing immune system. These things are especially true for exclusive breast feeding and increase with the increased length of time the baby is breastfed. The protection is geared for their particular environment—both in terms of infection and allergy protection. Because of its “packaging”, breast milk is always fresh, never spoiled, the correct temperature, and has the perfect ingredients. The content of the milk changes according to the baby’s age and needs. The benefits are not just for the baby, but for mommy, too!

Benefits for Baby

• Life long disease protection from bacteria, viruses
• Increased attentiveness, crawl and walk sooner, earlier language development.
• Greater intelligence and increased neuromotor ruses, allergy, and protozoa
• 22% decrease in infant mortality rate of those breast fed within the first hour of birth (Edmond, Pediatrics 2006)
• If immediately after birth, baby is colonized with mother’s bacteria instead of “hospital” bacteria
• Skin to skin regulates heart rate, respiratory rate, temperature, blood sugar
• Protects against childhood cancers (lower incidence)
• When grown up, reduces rate of female breast cancer
• Reduces risk of chronic and autoimmune diseases including: Crohn’s, juvenile diabetes, diabetes II, juvenile arthritis, multiple sclerosis, celiac disease, hypertension, high cholesterol, heart disease, childhood and adult obesity
• Less sleep disordered breathing
• Less bedwetting, anxiety disorders
• Increased social skills
• Fewer orthodontic problems
• 19% decrease in otitls media if br. fd. one year
• Milk contains specific antibodies to germs mother is exposed to
• Breast milk contains thyroid hormones
• Decreased incidence of SIDS if b.f. at least 16 wks
• Colostrum—promotes gut closure
  Seals gut lining to prevent adherence of pathogens
  Laxative effect clears meconium
  Comes in small amounts for ease while infant
  Learns to coordinate suck, swallow, breathe
  Has immunoglobulines
  Establishes bifidus flora

Benefits for Mother

- Greater mother-infant bonding

- Decrease incidence of cancer of uterus, endometrium, breast, and ovaries

- Decreased incidence of Type II Diabetes

- Decreased incidence of post partum blood loss

- Better emotional health

- Decreased insulin (which is good)

- Decreased osteoporosis

- Psychoneuroimmunological benefit

- Decreased heart rate

- Decreased cortisone level from stressors

- Increased sexual motivation

- Better parent child relationship when older

- Increased attachment and caring behaviors

- Decrease in overprotective behavior

- Optimal child spacing (due to natural birth control)

- Decrease in health care costs

- Decreased absenteeism from work due to infant illness

- Save over $2000 per year for formula

- Convenience

- The joy of providing what only you can provide for your baby

- Time to fall in love with baby

- Time to be still

- Time to do one of the most important things you will ever do!

Welcome to The Baby Cafe!

Are you a breastfeeding mother? If you have chosen to breastfeed, you probably know that the American Academy of Pediatrics is a staunch supporter breastfeeding. Breastfeeding provides a myriad of benefits for the health and well being of both you and your baby! Unfortunately, breastfeeding does not always go as smoothly as expected.

I am an RN and Certified Lactation Specialist with years of experience working with moms and babies. Let me help you through the rough spots and empower you to meet your breastfeeding goals. It is my privilege and joy to work with young families. I want to help you experience the success that will allow you to enjoy this very special time in your life!

Services

• 
  
  Lactation Consultations
  
  
  
  
• 
  
  Home or hospital visits for maternal or infant issues.
  
  
  
• 
  
  My visits include mother/baby assessment, breastfeeding assessment and assistance with various positions and latch. I can help with just about any issues--engorgement, sore nipples, plugged ducts, breast refusal, jaundice, reflux, weaning, tongue tie or thrush. I can help you know how much milk your baby is getting by doing before and after feeding weights. I teach you how to recognize early hunger cues and how to know if your baby is getting enough. I can work with adoptive parents as well.
  
  
  
• 
  
  Prenatal assessments for mothers with previous breastfeeding difficulties or breast surgeries etc.
  
  
  
• 
  
  Pumps for rental or purchase
  
  
  
• 
  
  Other breastfeeding supplies for your convenience
  
  
  
• 
  
  Fussy Baby soothing techniques
  
  
  
• 
  
  Private or group classes: Prenatal breast feeding class, Breastfeeding your newborn, The Amazing Benefits of Breastfeeding for You and Your Baby, Soothing Techniques, Going Back to Work, Newborn Care.
  
  
  
• 
  
  Information on maternal medication safety for your baby during lactation
  
  
  These are just some of the issues that I can help with. My visits include a timely report to your physician, and a follow-up phone call within 24 to 48 hours. My clients can continue to call me as needed, or they may request repeat visits.
  
  I am paid at the time of service and will provide you with a superbill / receipt, which you can submit to your insurance for reimbursement. Sliding scale fees are available. Request a doctor’s order from your physician to submit with your claim.
  
  
  Remember, getting help sooner is better than later! Then you can reap the many long-term benefits for both you and your baby!