Tongue Tie - Assessment and Treatment. Louise David IBCLC

This post is dedicated to all the mums who are seeking answers for the difficult breastfeeding journey they have unexpectedly found themselves on. 

Keep following your gut, don't give up. That feeling... it's never wrong.

The Basics...

Tongue tie (TT)– When the piece of skin (lingual frenulum) attached from the underside of the tongue to the floor of the mouth or gum ridge restricts the mobility and functionality of the tongue due to its length, thickness or inelasticity.

This frenulum may be attached anywhere along the underside of the tongue from the back (posterior) to the tip (anterior). Likewise it can be connected to the floor of the mouth at the back or all the way up to the gum line.

Posterior TT- Commonly health professionals who might diagnose a TT don’t look beyond the obvious foremost TT most people are familiar with. When the frenulum isn't attached at the tip of the tongue it is not very easily seen, therefore, missing or dismissing a PTT is an easy mistake to make. 

I think too much focus is put on the terms anterior and posterior, these terms only refer to where the conection is in the mouth, in simple terms, in the back halk or front half.

Most studies indicate that between 3 and 10 % of babies have tongue tie. The rate may be more due to ties being misdiagnosed because of practitioners lack of experience in examining the mouth correctly and a poor understanding of the relationship between breastfeeding problems and ties (kotlow 2017).

  Upper Lip Tie (ULT) – When the piece of skin (labial frenulum) connecting the underside of the top lip and the upper gum is too tight or too low down the gum affecting the ability for the lip to flange out.

Frenotomy – The procedure of releasing TT and or ULT. The frenulum is cut with scissors to allow free unrestricted movement of the tongue and upper lip.

Minutes old the lingual frenulum is captured in this photo.
Photo property of Louise David IBCLC

Ties and Breastfeeding...

There is great conflict amongst medical professionals in regards to their views on TT and how TT affects breastfeeding. The most common conflict is between pediatricians who believe TT in no way impacts breastfeeding and lactation specialists who believe undoubtedly their role in causing breastfeeding difficulties cannot be denied.

When one understands the mechanics of breastfeeding and the oral function of the baby and how milk is removed the role a TT plays in interfering is understood. This purely comes from experience. Recent practice has seen the role of ultrasound technology to view the inside of the mouth while the baby is breastfeeding. This is absolutely not necessary when the experienced lactation specialist assesses a breastfeed.

For parents it can be a rough road to finding answers when they’re dealing with practitioners whose practice is not supportive of bf. Its hard for any practitioners practice to be evidence based in the area of breastfeeding and TT as research in this area whilst its emerging its still lacking. Anecdotal evidence is insurmountable and common sense prevails. 

A tongue and lip tie cannot be diagnosed without a thorough oral assessment and its impact on breastfeeding cannot be assessed with out a feed being watched. All too often I hear mothers saying the doctor said “she doesn’t have a tie” and "the doctor didn’t even look" under the babies tongue. 

Whilst some TT are so glaringly obvious others, further into the underside of the tongue, takes correct technique to expose the frenulum. 

It is not a difficult difficult technique and it is very easy to learn. With practice any practitioner can become experienced in TT diagnosis and should be able to assess the restricted tongue. 

The correct and most reliable way to assess the mouth, the baby should be placed with her head in the assessors lap with her bottom and feet supported by mum or dad. The tongue can then be elevated and the level of restriction noted (Kotlow 2017). 

Then, and even more importantly i believe, a full breastfeeding obeservaion by a practitioner who knows what they are looking for can complete the tie assessment, putting together how what the finding in the mouth is affecting the action at the breast .

The breastfeeding relationship can be highly successful, that is comfortable, pain free with a thriving content baby, when the right practitioner is employed for support and intervention if necessary. The language the practitioner uses and the answers to your questions are a dead give away about how much your practitioner knows not only about TT but also more importantly about breastfeeding.

Furthermore, there is skill in a practitioner acknowledging their limitations and referring to another practitioner when they are not confident in assessing TT, rather then denying a TT or dismissing the parents concerns.

The same baby as above. Nipple feeding. Her latch did not
improve until the tongue tie was corrected.
Photo property of Louise David IBCLC

 Signs and Symptoms of Tongue and Lip Tie...

Mother

• Pain during feeding
• Squashed or ridged nipple
• Cracked/bleeding/blistered nipples
• Nipple vasospasm
• Mastitis
• Low milk supply
• Oversupply

 Baby

• Difficulty latching or staying latched
• Clicking sound
• Milk spilling/leaking when feeding
• Poor weight gain (from birth)
• Poor weight gain following good weight gain (delayed)
• Tongue “snap back” or “biting” action when feeding
• Long and frequent nursing sessions
• Fast nursing sessions with extreme fussiness
• Falling asleep quickly as if tiring out, then waking soon after wanting to feed again.

Children at birth.

Homebirth and siblings .

As a privately practicing independent midwife in Wollongong, one of my favourite aspects of home birth is that it is a family affair.

If it is not the first baby being born, the involvement of siblings in the preparation for birth, the lead up to labour and welcoming their new baby earth side is such a wonderful learning experience and a special time that bonds the whole family, especially baby and sibling from well before baby is born.

The girls would greet me at the door screaming
 "Midwife is here!!!!"

The midwife and children develop quite the
bond of their own over months of antenatal care.

In this blog post i'd like to address a few commonly asked questions about siblings and children at birth.

1. How will they handle it?

2. Will the noises scare them?

These two are best answered together. The key here is in the preparation. As a client recently described to her friends who were concerned for her girls aged two and four watching the birth, "It's not like I just sat them in front of me and said, here watch this. The girls had months of lead up, checking the baby with the midwife each home visit, reading books and watching videos, setting up the birth space."

There are lots of age appropriate recourses to help in the preparation. One of my favourite books is Hello Baby by Jenni Overend. This book shows the home birth of a family, their midwife and the labour. It talks about the noises mummy will make and shows the baby being born.
ABC Homebirth is a great free e-book. Like these, there are many other books available, some only in e-reader format but a quick google search should produce plenty to work with.

As well as books, videos can be used to help prepare little ones for what they are about to see and hear when mummy is birthing. I would recommend mum or dad watch the videos before they are watched together.

The beautiful book Hello Baby
by Jenni Overend, Illustrated by Julie Vivas.

3. What age is best?

I believe homebirth is appropriate for all ages. I don't think you can be too young or too old; each age has different challenges and advantages.

0-2yrs - these little ones are usually oblivious to what is going on. I think it's really important to have a spare set of hands in another support person. While often this age group is clingy to mummy when labour is under way, they almost seem to sense something is going on and can be unusually content being entertained and cuddled by another care provider.

Add caption

2-4yrs - the attention span of these little ones matches their years in minutes. They'll seem captivated and inquisitive one minute and then be running away to the toybox the next. They'll have more interest in the Paw Patrol DVD they've watched a thousand times than the noises or the body that is coming out of mummy. Don't be surprised if that same attention span is displayed when they are introduced to their new brother or sister for the first time.

Big sister is captivated...
Little sister... has ice in a cup... enough said.

4-8yrs - intrigue and mystery. These guys are fascinated and don't want to miss a second of the action. Action being the important word here. Normal birth can be slow and boring so these guys will sometimes be drawn to their younger siblings Paw Patrol DVD with strict instructions to be summonsed when something interesting happens. They love the noises, they love the gross bits and feel the love as much as mum and dad when that little baby finally emerges. Most of all they love telling all their friends and family how the baby was born in a swimming pool in the lounge room and how mum pushed it out her vagina and there was blood and even a placenta. If they're lucky enough daddy will even pass the scissors when its time to cut the cord.

Beauty and normalcy of birth being
imprinted for life.

8-12yrs - boys will often fake apathy and disinterest but keeping themselves in ear and eyeshot so to make sure all is going smoothly. Girls at this age are all over it; mini-midwives who want to do it all. They're in there with the torch and mirror trying to spot the first glimpse of babies head. They're giving mum sips of water and ice, heating wheat bags and changing towels and pads.

12 + - this age, whether boys or girls, get the most out of the home birth experience. While they may not know it at the time, they are getting a serious education; mum is setting the finest example of having faith in ones body, trust in birth and how birth is just normal. I believe these concepts are being seeded in each age group, but it's this adolescent group that will have a firm grasp on what it's all about.

4. Will i wake them in the night?
You might... usually not, but you might. When little ones wake in the night to find the exciting happenings of labour and birth, they usually find it pretty anti-climatic and grow weary of it and fall back asleep or asked to be tucked back into bed. More often than not they'll sleep undisturbed and wake in the morning to catch the last bit of action or meet their new sibling.

5. Will they annoy me?
Probably just a little bit. I do think it is a good idea to have a back up plan incase you find your little ones presence too distracting, Grandma or someone else could pick them up for a sleepover or take them out for a play. Usually with the right support your midwife or doula can help keep your mind in focus and dad can tend to the child. Often mums are good at tuning that little pixie voice out and indulging guiltlessly in the surges and what ever she needs to do to get through. Ultimately its up to you and how you feel at the time.

One by one these guys all arose from their beds,
 the excitement was contagious.
"shhhh" says grandma, little giggles continued
to cheer their mum on from the side line. 

6. Who will look after them?
I would say at the majority of births I attend it's only mum and dad and myself present. Between the two of us, myself and dad manage pretty well. By the time birth comes around the children are very familiar with the midwife. the children and myself have built our own little relationship and they are quite comfortable sitting back with the midwife watching on or flicking through a story book.
Mum can anticipate how much support she may need so if she's predicting dad and midwife will be tied up helping her through each surge, having another person to be on child duty makes sense.

They all jumped for joy when they laid eyes
on their new little brother.

Having a private midwife, where your pregnancy is completely normalised and your care is carried out in your own home, is just one of the perks of home birth. Children exposed to this are so very lucky and I believe it's setting them up to make informed decisions about their bodies when it is time for them or their partners to birth. Whether they witness the birth or not is not important. The benefit is in the time spent together, learning, preparing, trusting and bonding.

Thank you mum.
You're my hero.

Until next time,

Louise x

Natural Births and Hospitals... Do they go together?

Having a Natural Birth in Hospital - You have more choice than you think.
Louise David Private Midwife & Lactation Consultant.

If you follow me on Facebook, you'll know that I am a privately practicing (independent) midwife, and that I mostly attend home births. You'll also know that I share a lot of info about the safety and benefits of home birth over hospital birth. I share a lot of articles about how the hospital system often does a disservice to the pregnant and birthing woman and how intervention and medically managed births are the norm and poor outcomes, as far as her birthing plans and wishes, for the mother common.

This post is a little different. this post is about how achieving natural birth in hospital is possible and how you can best navigate the system to have great birth outcomes that don't just result in a healthy baby but a happy and empowered mum too.

1. Know the system and be prepared to stand your ground.

The norm in hospital is medically managed pregnancy and birth; tests are offered as routine not options, time restraints are put on labour and 3rd stage is actively managed, for example. Your birth plans may differ slightly or vastly from what is standard in the local birth unit. While I would like to point out that if you are aiming for a natural birth, your best place to achieve this is at home with a private midwife, we already know that's where I stand and this isn't what this blog is about.

Knowing that your wishes are not standard practice means you have to voice your desires and having a written plan to present to your carer is even more helpful. Your request may be met with some resistance, therefore it is important to have a thorough understanding as to why you desire what you do so that you can stand strongly and firmly in the belief that what you are choosing is the right choice for you.

At the end of the day, the issue of consent becomes very important. Know that you have the final say in all that is done to you and nothing can happen without your full and informed consent.

Having been induced 2 weeks early with her last two pregnancies, this mamma wanted to go into labour on her own this pregnancy. She waited ever so patiently. With the support of her private midwife she felt supported and confident in her choices to wait it out.
As her due date came and passed, together with her midwife she came to the decision  it was time to be induced at 40 weeks and 10 days.  The last labours were spent uncomfortably on the bed and restricted due to drips and monitors. This time, with the support of her private midwife as a guide, she was encouraged and helped to ambulate and be active. To use the shower, where she stayed to birth baby upright, something  she had not experienced before.

2. Have continuity of carer.

This means that ideally one person or one (small) group of people provide your care. Your philosophy and wishes become known and understood quite early on in your care and are carried right through out your pregnancy with no surprises at the end. For example, if you ask for a water birth when you're already in labour and it's the first time your carer has heard this request, don't be surprised if you're met with "oh no we can't offer that".

3. Have a known midwife for your birth.

Often in continuity of carer models, your care provider will follow you right through your pregnancy and also be the person who attends your birth. This is ideal and the birthing woman is secure in the fact she is with a known person she has come to trust. This is proven time and time again in the literature to result in better birthing outcomes.

With her 4 births prior to this, mum had always birthed up on the bed on her back. While she'd not had what she would call "bad" births, she wanted to not be told what to do and just do as her body  felt right. As this little one emerged, her private midwife encouraged Dad to come in and receive the baby. Her private midwife was acting in a support role only and the hospital midwives were more  than accomodating and happy to stand by and encouraged Dad also. Dad was thrilled to be able to help bring his daughter into the world. It's not something he'd planned on doing but felt he would never have been given the opportunity without the guidance from their own midwife.

4. If number 3 isn't possible have a known private midwife as a support person or hire a doula.

If it is not possible that the person caring for you in labour is someone you know and trust and someone that has previously been involved in your care, you can easily replace this void with an outside person. A private midwife who has done some or all of your antenatal care with you or a doula. The role of these people in a hospital birth environment is as a support person; someone who knows and supports your wishes and can advocate for you with the hospital staff.

Birth is beautiful no matter where it takes place.
One thing the mum and baby need is time. Mum needs time to catch her breath, to greet her babe, to rest. Baby needs to come to terms with all that just went on, to catch her breath, to find her Mum. When all is settled, Mum can be made comfy, cords can be cut and placentas birthed all of their own accord. This whole time baby has never left Mum's grasp.

5. Ask questions and trust your instinct.

One tool I used to teach in prenatal classes is the accronym BRAIN. The tool helps the user question, assess and rationalise that which is before them and come to a decision they feel at peace with.

B- what are the BENIFITS?
R- what are the RISKS?
A- what are the ALTERNATIVES?
I- what is your INTUITION telling you?
N- what if we do NOTHING?

Having the support of an educated individual beside you can help get the most out of this tool. Someone like a private midwife or a doula who can discuss the ins and outs of an intervention or a procedure and help you come to a decision that you can own.

BRAIN on having your waters broken artificially.

Benefits - Possibly speed up labour.
Risks - Intensify labour, mum has difficulty coping. Unexpected meconium stained liquor (baby has had bowels opened) leading to mum needing to be  monitored continuously. Time constraints put in place, how long membranes are ruptured is watched closely, risk now of needing IV antibiotics if goes on too long.
Alternatives - Waiting and reassessing as indicated. We can do it later, at anytime if we need to.
Intuition - My gut says everything seems to be going smoothly and I'm coping well so why would we do this now at this point?
Nothing - By doing nothing labour continues and if the need to augment the
labour presents itsself sometime soon we can still do the procedure then.

Wishing you the best of luck on your birth journey. Wherever you may be birthing, whichever birth number this is is for you, trust yourself and your body.

Until next time,

Louise x

All photos taken my me, Louise David private midwife, lactation consultant and birth photographer.

This is how its supposed to be....

The most recent home birth I attended was the most humbling birth I've seen yet. It’s my wish that the norm for all mums is to birth in this way, especially first time mums like the mamma here in this post. All too often it takes a horrible, traumatic birthing experience for mums to wise to the system, learn of other options, learn how different it can be... how it’s supposed to be.

Mums like this new mother never cease to amaze me, and make me proud to have met them and, better, get to know them. This mamma trusted her body from the moment her pregnancy was realised; she grew a healthy girl inside and our midwife/client relationship flourished with honesty, trust and encouragement. Mamma was all-embracing of all that was to come with labour and birth and baby.

Jack the puppy watches on..

Baby Audrey decided to come earth side on her due date. Mamma was ready after her water broke two days earlier and finally it all came together on a lovely lazy Sunday. When mamma is in the right mindset, prepared without fear, the midwife’s job is an easy one. It’s a role of observer and I like to pick up the camera and become birth photographer. Other roles often ensue too; dish washer, clothes folder, bed maker... because when it’s like this, how it’s supposed to be... birth is quite boring. Beautiful, amazing and life changing, but, blissfully boring. 

Mamma progressed gently and steadily and soon baby Audrey arrived. This birth was textbook; when people ask how it went I reply that nothing could have gone better. Mamma was left well alone, she had this all along and it was let be... this is how it’s supposed to be.

Welcome to the world Audrey Storm, Thank you mum and dad for letting me be part your most wondrous day, early weeks with baby... life. 

Until next time...

Louise x


Louise David is a Private Midwife in Wollongong and The Illawarra areas. Louise provides all types of pregnancy, birth and postnatal care, including home birth and hospital birth support.
Louise is a International Board Certified Lactation consultant and offers private lactation consultation from her home in the Wollongong area.

Sunshine, cups of tea and yellow cards.

The forgotten world of private midwifery care.

Having a baby is the most special and anticipatory time of most people's lives. The care you receive in your pregnancy is of utmost importance. Knowing that you and your baby are in the safest of hands for your prenatal care is essential to rest easy at night.

I want to talk about today, something that is not well known and understood, and even not necessarily readily available, in our culture - private midwifery care. Having your own midwife who looks after you and your baby and guides you safely on your pregnancy journey and beyond.

Here are a few misconceptions about private midwifery care:

• It's alternative, or for hippies
• It's only for if you're having a home birth
• It's very expensive
• There's no health fund or medicare rebates
• If something goes wrong you don't have a doctor or hospital available

Let me clarify...

Private midwifery care is available as an option for every woman. It's a flexible model of care that can be adapted to suit every woman no matter what their health status and intended mode and place of birth.

With recent progress with medicare, private midwifery is now more available to more women. If your midwife is a medicare eligible midwife then your care is likely to attract a medicare rebate, with some midwives completely bulk billing all ante and post natal care, add to this some health fund rebates and private midwife care is now more affordable than ever.  

Finally, a midwife, even working in a private capacity, is part of a multidisciplinary team. If difficulties arise at any stage there is a smooth process of collaboration and referral with other care providers, be it your GP or local maternity unit. Your midwife and you work together to adapt your care to your changing needs. 

Private ob v Private midwife

similarities - 

one on one individualised care

differences - 

• wait time - your midwife comes to you and you're never waiting in busy, overbooked clinics

• you really get to know and trust each other 

• you form a team together - planning, discussing and choosing every step of the way. Not just the 'pilot guiding his ship' to quote an obstetrician I know.

• ob antenatal appointment 5-10 min, midwife 45-60+ min

• There is little need for prenatal classes with private midwife care as every midwife appointment is filled with little bits of information and education, it's a pregnancy worth of prenatal education sessions. We talk about the baby to be and the role it's being born into.

Your midwife comes to you.
You get to know and trust each other over many
 relaxed friendly antenatal appointments.

Trusting, relaxed, confidant - you're in safe hands.

this is going on in the background -
No need for babysitting or dragging bubs to boring,
long wait-it-out doctors appointments.

He's learning about becoming a big brother.

Care options...

Depending on your situation your care plan is tailored to suit.

In a normal, healthy, low risk pregnancy your care is taken on by the midwife and if any need arises she works together with the multidisciplinary team to support you in your care. This care is best suited to a home birth plan, but can also be adapted for hospital birth.

Midwife shared care is a great option to get the 'best of both worlds'. This is the same as the common GP shared care model with added perks: being in your own home, no wait time, private care continued postnatally.

This model works best for women who are planning to have their baby at hospital and also for women planning a home birth if there are minor complications in their pregnancy i.e. diet controlled GDM or history of complications in previous pregnancies.

The reason it works best for these cases is the women becomes familiar with the hospital, she books in, she sees the staff obstricitan and then carries on her care with her midwife with intermittent visits back to the hospital (at 30 weeks and then from 37wks). When time to birth arrives or transfer (in case of a home birth), the hospital and woman have a relationship and the transition of care is smooth and problem free.

Postnatal care...

Probably the best thing about private midwifery care is the relationship that has been fostered and grown in the pregnancy continues through the postpartum period. Your midwife you've come to know and trust visits you as needed in the postnatal period. Postnatal care continues into the 6th week postnatally. this care is usually included in the care package and is also eligible for medicare and private health rebates. 

Hannah and Andy enjoy the perks of private midwifery care.

If you are interested in private midwifery care in the Wollongong area and its surrounds don't hesitate to contact me by Email. Remember midwife care is a valid option for every woman and care can be tailored to suit your individual needs. Lastly, it's never too late to employ the services of a midwife, if you are unhappy with the care you are receiving this pregnancy (remember it's not just pregnancy, but birth and beyond) don't wait "until next time", take action, choose the care you deserve.

until next time, Louise x

Brown paper packages tied up with string.....

These are a few of my favourite things.....

About being a midwife at a home birth.

Not being welcomed at the door... 
tippy toeing in, following the sounds...finding this.

Estimating the progress of labour, 
just by being with and watching.

just waiting...
getting close now...
secretly wishing she births in this spot where the light is amazing!

Alas... 
back to the safety, warmth, comfort of the darkened birth pool.

that cord...

The relief, when all is done, from all involved....
The idea that bed is near....

Sneaking just one with the flash ;-)

Counting 10 and 10.

Saying goodnight, you were amazing x

What a joy and privilege to be present for this families birth of their new daughter. It was on the spur of the moment when their midwife fell ill and asked me to cover her as back up until she could be back with her clients.

Lucky for everyone their midwife came good, the family had two happy midwives present (one wielding the camera). 

Birthing at 3am poses some difficulty for the birth photographer, trying to maintain the calm and darkened birth environment without compromising the quality of the pics too much.

The birth photos here are quite fuzzy and grainy from the lack of light, but they still tell the picture here so beautifully.

Thank you to this family for welcoming me in to their home for their birth and to my friend and colleague Rachele Meridith for being a support and teacher.

Until next time,

Louise x

The silent arrival of baby Lucas and the Joyous Cheers from the side line....

Louise David RM RN IBCLC

No matter how many births i see i am forever reminded of these three things...

1- Every birth is different

2- We never stop learning

3- The amazing power and strength of the birthing woman

Im going to share with you some of the precious moments of baby Lucas' birth i attended and photographed recently. This birth was so special to me as it was my first birth back as a home birth midwife. Ive recently received my medicare eligibility stauts and with this i welcome the next phase in my working life inviting more and more home birth clients, as a medicare eligible midwife. If Lucas' birth is anything to go by we've a lot of joy ahead.

The atmosphere if this birth was like no other I've attended, the children were nestled in bed and the grandmas were chatting and sipping coffee as midnight approached, revelled in calm anticipation. Pregnant mum was ready; the only bit of angst in the house was present in dad... just, if you looked hard enough, that was ok, it gave just the right amount of "buzz" to the air. 

Grandmothers

Im reminded that every woman labours differently, ill never forget this one. I remember reading some time ago that Katie Holmes was required by her Scientology faith to birth completely silently. I believed this just wasn't possible. How could there be not a grunt, a groan or a secret swear word slip out? 

Well here i stand corrected. 

As this mama laboured away the only sounds to be heard were from the sidelines...

The pitter patter of exited big brother feet down the hall...

brother waits

the whirr of the camera...

Midwife waits

more footsteps down the hall...

laughter and shushing....

learning...

the shower....

the shower....

"will it make your job difficult if she stays in the shower like this" - grandma #1

"i don't have to do anything, my job is to watch" - me

And the crowd goes wild... 

This was the happiest family affair. 

What a joy and blessing for me to bear witness to such a special moment.

Welcome baby Lucas you are one lucky little man to be born in to such great love.

Louise x