Expecting Parents issue 2 by Mediaplanet UK&IE

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How to improve your lifestyle to prepare for pregnancy Dr Daghni Rajasingam from the RCOG P4

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IN THIS ISSUE NHSCC Dr Phil Moore The importance of investing in perinatal mental health

Royal College of Paediatrics and Child

“I felt completely alone” Bliss Scotland ambassador, Lady Sarra Hoy, on her motherhood journey P5

Health The vital importance of vaccinations for your child and the wider community

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Mothers know best For the overwhelming majority of people their legacy is their children: their pride, their joy. Birth should be a wonderful start. In the NHS, birth has never been safer.

hairing the Maternity Services Review for England, I was determined our report would mean better births. We travelled the country and listened. Women wanted a safe birth with one health care professional to be alongside them through pregnancy, birth and after care. This reduces stillbirths, premature births and miscarriages. It was clear that women and their clinicians should have close relationships: the woman as the pilot in charge, the clinician as the navigator.

Pregnant women must not be passed around the system We heard wonderful examples of where this was working well, but sadly, we also heard of many examples where the needs of women were not being met. Follow us

In one case, a woman had seen 40 different health professionals, repeating the same story of losing her first baby each time. A trusted, single care-giver listens and acts. Systems, on the other hand, don’t listen; they process. This is more important now than ever before. More women now have complex health needs and must be supported to be as fit and healthy as possible to prepare for motherhood. They should feel fully informed and equipped to make decisions about their care. Women and their partners want choice on how and where to give birth, they want their options explained and their choices respected whenever possible. More than 19,000 women have been given a notional Personal Maternity Care Budget, which is an important step. I believe we need to build on and expand that. MediaplanetUK

Healthcare professionals need to work as a team to support pregnant women

Baroness Julia Cumberlege Chair of the Maternity Review for England

“No hospital should ever think of pregnant women as a revenue stream.” @MediaplanetUK

The Better Births report sets out to change NHS culture. Clinicians order their lives around shifts and health professionals do not always act as a team. Simple payment-for-activity regimes drive some of this. Our payment system must not get in the way of providing women with the care they need, in the setting they want, to give them a safe and personal birth experience and to strengthen professional teamworking. No hospital should ever think of pregnant women as a revenue stream that is ‘theirs’ by right. Our review found midwives working with a caseload of women to whom they gave continuity led to high job satisfaction.

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By 2021, most women should have one care giver with them before, during and after birth Our challenge is to change the mindset of the NHS. We must provide the facilities, staff, training and incentives to give a modern service that parents want. Changing the prevailing culture is not easy. By March 2019, we expect that 20% of women should be on a pathway that means they have continuity of the person looking after them before, during and after birth and the majority of women should receive this by 2021. We want staff satisfaction but also options available with parents in charge of what can be the most wonderful life-changing event for a mother and her family.

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All your pre-natal screening questions answered

Have you ever felt a lack of control during pregnancy? From predicting the sex and even how many children you’re expecting, to worrying about complications or hereditary conditions, uncertainty is a common concern. Pre-natal testing can help parents find answers. SPONSORED

hether you’re newly pregnant or planning a pregnancy, you might be wondering about pre-natal testing. The good news is, advances in technology mean there are more options for early and more accurate screening. A simple blood draw can usually give you the information you are looking for from as early as nine weeks into the pregnancy.

What is non-invasive pre-natal testing? Non-invasive pre-natal testing (NIPT) is a simple blood test, taken from the mother during the pregnancy, that can screen for certain abnormalities in the baby’s chromosomes. Using this technique, it is possible to look for some of the most common chromosomal abnormalities, such as Down syndrome. With some NIPT tests it is possible to test for a wider range of conditions, for example 22q11 deletion syndrome, in which part of chromosome number 22 is missing. These conditions are less well-known than Down syndrome, but may have important consequences for the baby’s health. Knowing about these and other conditions before birth can give parents and their healthcare team early information which can help with managing the pregnancy, birth, and ongoing care.

What are the benefits of testing? Ultimately, preparation and reassurance are the main benefits of these tests. Some conditions are difficult or even impossible to detect with traditional ultrasound scans, so earlier NIPT

Dr Johan Estellon Territory Manager, Natera

“Not knowing the outcome of hereditary conditions until much further in the pregnancy - or even at the birth can be incredibly stressful.” testing can help to answer many of the initial queries you may have. For mothers carrying twins, the ability to distinguish whether twins are identical or not can impact the care plan your healthcare provider creates. Some NIPT tests can determine not only the likelihood but also identify the sex of each twin.

NIPT tests can check for Down syndrome and more Although most babies are born healthy, parents

often worry throughout the pregnancy. After NIPT, most women find out that the chance for certain chromosome abnormalities can be less than 1 in 10,000. This low-probability result provides many parents with the reassurance that they are hoping for. Families that find out that the chances of a chromosome abnormality are increased can choose to have a definitive test such as amniocentesis or chorionic villus sampling (CVS). If the baby is affected, they can learn about the condition and work with their provider to make a pregnancy care plan that is best for them.

NIPT vs traditional measures Traditional prenatal screening tests don’t return results until after 11 weeks of pregnancy. Some NIPT tests can be done as early as nine weeks. High probability results from both traditional and NIPT screening tests need to be confirmed by an invasive test. In cases where there is a high-probability result, having this information earlier in pregnancy gives the family the option to do an earlier invasive test for confirmation, called chorionic villus sampling, or CVS. A further advantage of NIPT over traditional prenatal screening is that it can detect more cases of Down syndrome, and that it is less likely to give false positive results. A false positive result is when a high-probability result is given when actually the fetus has normal chromosomes. With traditional screening, about 1 in 20 women will receive a high-probability result, but very few of those 20 will be carrying an affected baby. With NIPT, only about 1 in 200 women will receive a high-probability result, and more than half of those 200 will be carrying an affected baby. However, with NIPT, only 1 in 200 women have to decide whether or not to take this next step instead of the 1 in 20 women having to make this decision with traditional screening. If a woman is carrying a baby with Down syndrome, the traditional combined first trimester test will indicate a high probability 80 out of 100 times. NIPT will indicate a high probability

over 98 out of 100 times, meaning that NIPT can detect a higher proportion of all of the cases of Down syndrome. It is important to know that a high-probability result doesn’t mean for sure that the baby has Down syndrome, and should be confirmed with a diagnostic procedure such as amniocentesis or CVS.

Can my healthcare professional advise? Absolutely. From your GP to your midwife, trained professionals will be able to advise you about NIPT and whether it is the right choice for you. They will be able to offer more details about the tests involved and your existing risk factors. Whatever questions you may have, qualified professionals will be able to tell you about the standard timeline for getting the answers you need and explain any non-invasive testing that may be offered. Most importantly, if there are any concerning results after an NIPT, your healthcare professionals can arrange to talk you through the implications to help you to prepare in the best way possible. Whether that’s getting ready for an adapted birth plan, or to help healthcare professionals to offer the best care after your baby is born, the information provided by the test and the support from your healthcare team can help you to prepare. Whatever the outcome, genetic screening and pre-natal testing may give you the answers to many of the questions you have. Words by Gina Clarke Edited by Samantha Leonard CAP accredited, ISO 13485, and CLIA certified. © 2018 Natera, Inc. All Rights Reserved Find out more at natera.com or contact Johan Estellon directly on jestellon+expectingparents @natera.com.

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Mental health and pregnancy: ensuring new mothers get the support they need

Dr Phil Moore Chair, NHS Clinical Commissioners’ Mental Health Commissioners Network and Deputy Chair (Clinical), NHS Kingston CCG As many as one in ten mothers will experience mental health problems during pregnancy or after giving birth, regardless of whether they have previously experienced mental health problems or not. Dr Phil Moore explains how commissioners are working together to support women.

ithout appropriate treatment, there can be long-lasting effects not only on the mother but also on her child, partner and family. Depression and anxiety during pregnancy can affect the child’s mental health and result in poor attachment between mother and child. Suicide is a leading cause of maternal deaths during pregnancy in the UK and within the first six months after childbirth, so early intervention is vital.

A changing picture of provision Historically, there has been variation in specialist perinatal mental health provision across the country - including specialised in-patient mother and baby units, specialised perinatal community mental health teams, and maternity liaison services. But that picture is now changing. One ambition of NHS England’s Five Year Forward View for Mental Health was to support 30,000 more women access perinatal mental health services by 2020/21. An additional £365m funding was announced in May 2018 to set up new or enhanced community services. The funds should also reduce variation so expectant and new mothers can access appropriate treatment close to where they live, wherever in the country that may be.

Commissioners and providers working together to reduce variation in care In Coventry and Warwickshire, the death of a woman who had experienced perinatal mental illness prompted a redesign of services in the area. Patients were previously referred to core adult psychiatric services, but now sharing resources and funding between three clinical commissioning groups and two health trusts meant the team was able to capitalise on economies of scale to redesign services and provide specialist services.” A consistent mental health training package means that staff are now clear about what to look for, and who to refer to at what point. Since 2015, all women in the area have been able to access the same range of specialist support, and reports show that early intervention is making a difference. Additional funding received earlier this year is helping to widen the referral criteria so that more women can access support. All areas in England now have substantive plans and funding for full specialist perinatal mental health services. Work continues to back these up with good community provision of early support for those with less severe difficulties. None of us ever feels fully prepared for parenthood but with investment and improvement in perinatal mental health services, healthcare professionals will be better placed to support those with mental health challenges to enjoy this special time in their lives. Learn more at expectingparents.co.uk

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Healthy living is the most beneficial step a woman can take to ensure that she has a good pregnancy and give her baby the best possible start in life.

ating a healthy and balanced diet, taking part in regular exercise and making good lifestyle choices before and during pregnancy are all vital to increasing the chances of conceiving naturally, reducing the risk of pregnancy and birth complications and ensuring a healthy baby.

How’s your pre-conception health? A woman’s health prior to conception can have an impact on the growth, development and long-term health of her baby. Adopting a healthy life course before becoming pregnant will not only benefit women during pregnancy but it will help them recover after birth and set them up for healthy future. A new ‘Planning for Pregnancy’ app, developed by the RCOG and Tommy’s has been developed for women to provide tailored information on what to do before conception to ensure a healthy pregnancy and baby. The tool encourages women to achieve and maintain a healthy weight and BMI before stopping contraception to improve the health of a pregnancy and baby.

The older you are, the greater the risks during pregnancy Women must be supported in their choices over when they become pregnant. Most importantly, they must also be empowered with accurate information about family planning. Over the past few decades, the age at which woman are having their first baby has increased due to a variety of social, professional and financial factors. As well as potentially taking longer to get pregnant, later maternity can involve a greater risk of miscarriage, a more complicated labour and medical intervention at the birth. More accurate and balanced information about the impact of age on fertility, pregnancy and birth will empower women and their partners to make informed decisions about when to plan a family to ensure a healthy pregnancy, birth and baby.

Your maternal weight can affect your baby In the UK, around one in four

Dr Daghni Rajasingam Consultant Obstetrician and Spokesperson for the Royal College of Obstetricians and Gynaecologists

“Many women believe they need to “eat for two” during pregnancy, but this isn’t true.”

pregnant women are overweight or obese. Women who are overweight during pregnancy are at an increased risk of having a miscarriage and developing conditions such as gestational diabetes, high blood pressure and pre-eclampsia. They are also more likely to have a premature baby and require a caesarean section. In addition, overweight women are more likely to have bigger babies who become obese and have health problems. If women are overweight, the best way to protect their health and their baby’s wellbeing is to lose weight before they become pregnant. There is plenty of advice and support available to support women to make this important health change. Dieting or weight-loss programmes are not recommended during pregnancy as they may harm the health of the baby.

change in the first six months of pregnancy. It is only during the third trimester when pregnant women need an extra 200 calories a day. This is the equivalent of two slices of multigrain toast with olive oil spread or a small handful of nuts, seeds and dried fruit. Women should begin taking a daily supplement (400 micrograms) of folic acid two months before they conceive until 12 weeks of pregnancy to prevent neural tube defects such as spina bifida. Pregnant women are also advised to take 10 micrograms of vitamin D a day to improve the baby’s growth during their first year of life and reduce the risk of developing rickets.

Exercise and lifestyle habits There are many benefits to keeping active during pregnancy. Exercise can reduce fatigue, lower back pain, varicose veins, and swelling in the ankles. It can also reduce feelings of stress, anxiety and depression, and promote a sense of wellbeing. In the majority of cases, it is safe for both the mother and baby if a woman exercises during pregnancy. As a rule, she should take extra care not to exhaust herself and she should seek advice when trying new exercises to avoid risk of injury. For women with health conditions or complications, it is important for her to speak to a healthcare professional for advice.

Diet advice and supplements you should consider taking A healthy, well-balanced diet before and during pregnancy, is crucial to maintaining a normal weight and ensuring the baby receives the nutrients its needs. Many women believe they need to “eat for two” during pregnancy but this isn’t true. Energy levels do not

“7/10 women plan for a holiday for 3 months or more in advance... Only 2/10 women prepare for a baby for 3 months or more in advance.” PHOTO BY JOEY THOMPSON ON UNSPLASH

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Baby Callum Hoy’s foot. He was born via emergency C-section at just 29 weeks into the gestation period.

PHOTO CREDIT: LADY SARRA HOY

Callum’s birth weight was a tiny 2lb, 2oz and was on the neonatal unit for 60 days before he could go home.

Callum now. A strong, determined young man.

“From nowhere, I was given lifelong membership to a club I never wanted to join” When Lady Sarra Hoy learned she was having a baby with her husband Chris, she was excited and apprehensive in equal measure. “There was a history of pre-eclampsia in my family,” she recalls, “so I spoke to a GP who dismissed my concerns. I continued taking care of myself throughout my pregnancy and was confident I would have a very standard delivery.”

owever, things changed dramatically at 28 weeks, when a doctor announced during a scan, “Oh this is not good. Not good at all.This baby has to come out.” Callum Hoy was born via emergency C-section, weighing 2lb, 2oz, at 29 weeks gestation. Sarra remembers: “I was in a state of shock for a long time. I found myself doing mundane, everyday tasks like going to the supermarket or picking up dry cleaning in between hospital visits, where I would sit for hours beside an incubator, willing my son to live. It was a surreal and horrifying time and could not have been further from how I imagined I would spend the first few months of motherhood. I was a new mother but had no baby at home with me. Even in the hospital, it was hard to recognise myself as the parent of this incredibly frail, fragile and vulnerable baby.”

The hospital wing with huge responsibility for tiny lives Parents like Sarra must quickly become familiar with the unknown world of the neonatal unit. These specialist hospital wings take care

of the UK’s smallest and most vulnerable babies. Sarra said: “From nowhere, I was given lifelong membership to a club I never wanted to join, nor even imagined existed. We were terrified our baby would die. I learned the terminology for all the equipment that kept him alive. I learned how to read the monitors to tell when Callum was uncomfortable or needed something. “I discovered the pressure to produce breast milk. I understand the loneliness of a breast pump at 3am; how devastating it is to have to try and trick your breasts into producing milk, when your body barely knew it was pregnant, let alone knew it delivered a baby. I also know about the intense feeling of loss, having had a pregnancy so rudely interrupted and ended.” Callum spent 60 days on the neonatal unit receiving specialist care before he was allowed to go home. Although Callum has grown into a strong and determined little boy, the experience has stuck with Sarra. “Despite the unfailing support of our families, the encouragement we received from the public, and the 24-hour medical care given to Callum, I felt completely alone,” Sarra said. “I had never heard of babies

being born so early, so I couldn’t comprehend this was an experience that many families endure. Even now, almost four years on, rarely a day goes by when I don’t think about those first few months and the impact it has had on me.”

An experience that sticks with you indefintely Lady Sarra Hoy Celebrity Ambassador, Bliss Scotland

“It was a surreal and horrifying time, and could not have been further from how I imagined spending the first few months of motherhood.”

Soon after leaving the neonatal unit, Sarra became involved with the work of the premature and sick baby charity, Bliss Scotland. In 2017, she became the charity’s celebrity ambassador. “I am such a proud and passionate supporter of the work Bliss Scotland does. They provide information and offer essential emotional support, both on the neonatal unit itself and beyond. This empowers parents and families. It helps them to care for their babies, in a situation where they often feel powerless and out of control. “There are thousands of parents across the country who understand all too well the very difficult neonatal journey my family has gone through. The more we can do to let families of babies in neonatal care know that they are not alone, then the better the outcomes for the babies.” Sarra, Chris and Callum have

since welcomed another new addition - baby Chloe - to the Hoy family, who was born only slightly early in September 2017. Sarra would like her story to not only empower other mothers-to-be, but also provide some comfort and reassurance. “First and foremost I learned to never be afraid to question and query anything you feel might be unusual when you are pregnant. I was so certain I was healthy and well, it came as a real curve ball to discover my pregnancy was actually making me ill. Never wait, always ask. It saved my life! But not only that, after our experience with Callum’s birth, I never thought we would decide to have another child. However, time is a great healer, and with excellent support from our local hospital’s obstetrician and midwives, I was able to actually relax and enjoy my second pregnancy. We are just so thrilled and feel so lucky to have both Callum and Chloe in our lives.” Megan Grifﬁths

Learn more at expectingparents.co.uk

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Why the internet really does makes parents’ lives easier

Justine Roberts Founder and CEO, Mumsnet

It’s 2am, your newborn is bawling and you don’t know what to do. So what next? Why, the internet of course.

elp for parents has changed. There was a time when family or friends would have been your first port of call. Nowadays, living in the bosom of your extended family is increasingly rare, and friends – even if they have their own children, and might have some advice – almost certainly don’t want to be woken in the middle of the night. Hefty child-rearing books, written by self-proclaimed experts, may have some general tips buried somewhere, although they won’t necessarily apply to your specific set of circumstances. And sometimes, specific advice isn’t as useful as knowing that millions of other parents know exactly how you feel and can tell you consoling stories and jokes until your baby finally drops off. Advice online supports parents Websites like Mumsnet make parents’ lives easier, providing a space where they can talk and support one another. You can ask specific questions any time of the day or night and discover tips like the magic of holding them upright as they feed (Hooray! The crying’s stopped!). Alternatively, just send out a general cry for help and watch as the support floods in. A virtual community to tackle loneliness Parenting can be a lonely job, especially in the middle of the night when nobody’s had a decent sleep for as long as they can remember. Online communities provide all the advice and comfort of neighbours, friends and family, with the added benefit of anonymity and 24-hour coverage. And they’re not just there for the baby stage: there’s advice and support for everything, from sourcing speech therapy to motivating lazy teens. There’s nothing new about wanting advice. What’s changed is the size of the crowd that can be reached. Read more at mumsnet.com

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Understanding the benefits and difficulties of breastfeeding Breastfeeding is more than the basic nourishment necessary for growth and life. It activates the baby’s immature immune system, offering protection against disease, infection and allergy.

reast milk is more than just a food. It is a living, complex fluid containing antibodies, enzymes, hormones and long-chain fatty acids that interact with a baby’s gut, triggering a host of healthy responses. Among the many longer-term benefits, breastfed babies will have a reduced risk of obesity, diabetes and dental problems and their mothers benefit from lower rates of breast and ovarian cancers and postnatal depression. The ultimate convenience food, breast milk is ready-made, warmed to the right temperature and perfectly matched in nutrition and supply to the needs of your baby.

World Health Organization recommend breastfeeding for up to two years The World Health Organization recommends exclusive breastfeeding for the first six months of a baby’s life, continuing for up to two years and beyond with appropriate complementary solid foods. While breastfeeding is as nature intended, it is not always easy to establish. Many mothers and babies struggle to get off to a flying start; pain, engorgement, flat or inverted nipples and tongue tie are some of the issues that arise in the early days and can cause real distress to parents. Midwives, health visitors and other maternity staff will be able to offer advice and assistance to women in and out of hospital. Sometimes a change of feeding position is all that is required. Occasionally, further investigation will reveal an underlying problem, such as tongue tie, and may lead to onward referral

Clare Livingstone Professional Policy Advisor, the Royal College of Midwives

“Midwives will support and advise women, whatever their baby feeding choice is.”

to specialist services for diagnosis and treatment. Most early hiccups are not insurmountable and can be resolved with appropriate support.

Social stigmas can put women off breastfeeding We know that society has barriers that can get in the way of breastfeeding and many mothers regret stopping breastfeeding before they are ready, due to work and financial pressures, or because they feel

awkward feeding in public. Breastfeeding rates in the UK do not compare favourably with other developed countries and this has been partly attributed to the social stigma that still exists in some sectors of the community. It is illegal to ask a breastfeeding mother to leave a public place and many companies, restaurants and cafes are making considerable efforts to welcome and facilitate breastfeeding mothers.

Peer support in breastfeeding can help Specialist breastfeeding and peer support services can be extremely helpful and health professionals will be able to signpost parents in the right direction. It can be very comforting indeed to meet and share experiences with other mothers, exchange tips and ideas for what works and what doesn’t. Companionship too, is very important – no one should struggle alone. Sometimes, for a whole variety of reasons, mothers decide not to breastfeed, and this choice must be respected. Bottle feeding is a safe alternative and a range of formula milk products are readily available in the UK. Mothers should receive advice and information on sterilising, milk preparation, storage and feeding their babies with formula. Midwives will support and advise women whatever their baby feeding choice is. Feeding a baby provides a unique opportunity for closeness and bonding. Nothing comes close to this quiet, calm and deeply satisfying time shared with your baby and can be some of the most precious moments in parenting. Read more at expectingparents.co.uk

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Q&A with expert dad: How to make sure your pushchair fits your lifestyle

For any parent-to-be the world of pushchairs and prams can be daunting, so perhaps it is no surprise that this is where most of our at-home research is centred. A quick look at the options available often produces more questions than answers. Here to answer them is expert Paul Walker, the Head of Product Development at iCandy. Walker not only has more than two decades of experience, he also has a three-year-old and a six-year-old of his own. Here are his tips on how to get a pushchair to fit your lifestyle.

Q: What are key considerations I should think about when buying a pram/pushchair? Check the ratings and the weight limit I often find the first things parents do is research the ratings for a pushchair and then look at how it will fit with their lifestyle. From the texture and padding that their new-born will sit in for large amounts of time, to the way the wheels glide when you first push the pram around the store, pushchairs are personal choices. But there are practicalities too. My top tip is to look at the seat weight limit

and see the maximum it goes up to. Bigger babies, plus infants staying in prams for longer, mean a greater maximum weight will last you and your baby longer. “Pushchairs which have seats with a class leading weight limit provide a good indication of the overall quality of the product.”

bags and footmuffs can add individual style. Most of all, look for a pushchair with a good re-sale value. You may pay more originally, but with some brands fetching as much as 30% on re-sale, you could be getting more for your money long-term.

Q: Can a pushchair fit into my

Q: How will pushchair design

existing lifestyle?

innovation affect me? Paul Walker Head of Product Development at British pushchair brand, iCandy

Different models are designed to suit different lifestyles We all have different needs for a pushchair, so look at their selling points. Will it fit in the car boot? Can the grandparents fold it away easily? These are practicalities that you will thank the designers for! If you lead an active lifestyle, there’s no reason your pram can’t join you, from rugged wheels and increased suspension to just smoothly handling those curbs. It should make your life easy, not cause problems.

Q: Should I buy for just the one baby or think to the future? Get a convertible! No, seriously. Look for a pram that can be easily converted should you choose to expand your family. A lot of pushchairs can now add

“Pushchairs are personal choices. But there are practicalities too.” on a seat or convert the basket area. A single to double pushchair does not compromise on the functionality of the pushchair, either. When in double mode the pushchair retains a single footprint like it does in single mode, and does not restrict basket access. Essentially, always be mindful to choose a single to double pushchair where there are no compromises to its functionality when used as a single pushchair. Darker colours are often better to wipe clean, whereas accessories such as parasols, changing

Innovation is what makes life with your pram easy From bigger baskets, now possible thanks to mechanical developments, to a one-handed fold that takes just seconds. The good news is that pushchairs are constantly being innovated thanks to product testing and parent feedback, so I would always suggest looking for a brand that is well known and also offers product servicing; that way it’s sure to last. Gina Clarke SPONSORED

Find out more at icandyworld.com

Breastfeeding: 6 tips for new mums

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Your baby is properly latched on when their

For any new mum, breastfeeding is a huge part of looking after your baby, and the tips below can help you prepare. Feeds can take 10 to 40 minutes so get comfortable, relax and take your time.

mouth is wide open and they have a big mouthful of breast. Once attached you will notice their sucking pattern changes from short sucks to long deep sucks with pauses.

Never restrict the time your baby feeds. Your

Hold your baby close with their nose opposite the

nipple so they can reach the breast easily. Their head, shoulders and body should be in a straight horizontal line.

Wait until your baby opens their mouth really

wide (brushing baby’s lips with the nipple encourages this) then move them quickly, with their head back and chin towards the breast, so their bottom lip touches the breast as far away from the base of the nipple as possible and your nipple is pointing towards the roof of your baby’s mouth.

Hannah Harvey Midwife, Emma’s Diary