September 2021
This month, we spoke with Lise Martin – a family nurse practitioner and clinic director of Seattle Women’s and Moms’ Clinic. Martin shares her experience with breastfeeding and how that fueled her decision to become a International Board Certified Lactation Consultant (IBCLCs). We also explore why patient follow-ups are so critical to a patient-centered philosophy and the tangible steps practitioners can take today to improve outcomes.
Lise Martin, ARNP, IBCLC, NCMP is the clinic director of Seattle Women’s and Moms’ Clinic. She is a family nurse practitioner who is passionate about the personal care she provides her patients and believes that working in women's health is her calling. Martin’s depth of clinical experience ranges from Planned Parenthood to ZoomCare, to the Obstetrics and Gynecology Department at The Everett Clinic. She has developed an integrated clinic that is thorough, patient-centered, and fiscally efficient.
SHWI: As a family nurse practitioner, you became motivated to go on and become certified with North American Menopause Society (NAMS) and as a lactation consultant. What motivated you to get so much additional training in women’s health concerns?
The more my skills and knowledge of women’s health increased while practicing as a nurse practitioner, the greater my awareness of providers’ profound deficit in lactation education, biology, and physiology became. So, I thought, “Be the change you wish to see in the world”. I figured if more providers become better educated in breastfeeding medicine, we could work to reduce the stressors mothers and infants experience in the postpartum period by specifically targeting the perinatal window and preparing patients while they are still pregnant.
International Board Certified Lactation Consultants (IBCLCs) are heroes. They truly are miracle workers with mothers breastfeeding, fathers (transgender males who are chestfeeding), and infants nursing at the breast/chest to improve patient outcomes. Many IBCLCs are either registered nurses, doulas, or occupational therapists (OTs), and fewer IBCLCs are physicians, advanced registered nurse practitioners (ARNPs,) and physician assistants (PAs).
Unfortunately, with the current insurance-based medical model, perinatal lactation counseling and education do not always cover IBCLCs, so few patients have access to breastfeeding services. There is a much-needed opportunity for providers to fill a gap in the accessibility of lactation care. Providers who see patients throughout their pregnancy could be integrating lactation education into the perinatal timeframe, so patients are empowered and prepared for the natural, yet complex, art of breastfeeding.
On a personal level, I was motivated to become an IBCLC after my first child Amelia was born. She was a full-term, vaginal birth with no complications and no epidural; I mention that because factors such as preterm birth, c-section, anesthesia medications, and more can have an impact on lactation at onset. Here I was a women’s health care provider, with all the resources in the world and great perinatal care, and I had severe breastfeeding challenges.
For the first six weeks, I had to exclusively pump because she was losing weight and not transferring milk from the breast. I would attempt to nurse her for a bit at the breast, to assist with the oxytocin release to facilitate breast milk production and attachment for me and Amelia – even though she was not actually receiving much milk from this. It was important for us to do this so she continued to want to “be at the breast” and I continued to see her precious face at the breast and not only the “monster” (what I called my breast pump). Then, my amazing husband would provide her with a bottle of my breast milk while I pumped. We had multiple medical appointments with pediatricians and lactation consultants to triage the issue, and it took an outstanding IBCLC (Dr. MaryAnn O’Hara, MD-MPH of Seattle Breastfeeding Medicine) to diagnose her subtle, but severe posterior tongue and lip tie, which were inhibiting her ability to breastfeed effectively.
By the time we got to our appointment, six weeks had passed, as well as hours and hours of time at the pump, many tears and frustrations expressed, and lots of asking myself “What was I doing wrong? Why was breastfeeding so hard?” After a very quick procedure to have Amelia’s tongue and lip ties released and with minimal distress from her, she was placed at my breast and instantly latched effectively. It was like a switch turned on. I recall saying “OH! This is how it is SUPPOSED to feel!!” and it all made sense. That was when I first felt the phenomenal rewards of breastfeeding. Prior to that latch in Dr. O’Hara’s office, I knew in my brain that “breast is best”, so I continued to strive for it with Amelia, but my heart and emotions were taxed as the superiority of breastfeeding felt complicated, exhausting, and unsustainable.
Once I mentally recovered from those difficult first six weeks, I reflected on all the breastfeeding individuals out there that did not have the privilege I had. I thought about those new parents that weren’t a health care provider working in women’s health; that were single parents; that didn’t live in an area with an exceptional care team like the IBCLC and OT who supported us until Amelia’s procedure; that didn’t have extended family support helping to manage all the details of exclusively pumping and bottle feeding a newborn; that encountered providers that didn’t believe in tongue tie release; that might have been experiencing postpartum blues or depression.
That reflective period empowered me to become an IBCLC to help other breastfeeding parents, predominantly during the perinatal window, so they have the tools to be successful and are informed about challenges that might occur and how and when to seek out resources and support. I genuinely believe that if more time were spent on educating parents on lactation prior to the birth of children, breastfeeding would be more successful and less stressful for all involved.
SHWI: Your practice has a patient-focused philosophy. Why do you believe follow-up patient care is so critical to outcomes and what recommendations do you give other practitioners for improved outcomes?
Follow-up patient care is so critical to their outcomes, as it provides time and space for information and treatment options to be further processed by the patient at their own pace and allows them to make an informed decision regarding their treatment plan. When patients have time between visits to absorb the information and try some of the options presented to them, they can advocate at the follow-up regarding what is and is not working for them and ask questions. If you try to cover everything in one visit, patients can often feel overwhelmed and not actively participate in the decision-making regarding their care.
Follow-ups allocate time to re-evaluate the treatment plan to see if the plan is effective and beneficial, or if it needs to be adjusted. Also, each follow-up further develops the patient-provider relationship, creating greater depth and understanding between them. The greater the depth of the relationship, the more safe patients feel sharing information regarding health conditions.
My best recommendation for providers to improve patient outcomes is to put themselves in the shoes of their patient every time they walk into a new appointment. Be present and mindful of the person and what has brought them in on that day. Too often providers get derailed by the business of medicine: keeping to a fast schedule, the sensation of being bombarded with patient messages, lab results, prescription renewals, and feeling a need to hustle back to their desk to tackle all those tasks.
If we as providers take a deep breath before each visit, have gratitude that the patient trusts us with the care of very personal and vulnerable topics of their health, and put everything else on hold for the small amount of time we are in the visit together, we facilitate an environment for improved outcomes.
SHWI: What topics do you feel needs to be addressed more in the sexual health community? How are you working to improve both patient experience and outcomes in your practice?
Topics I believe need to be more widely discussed in the sexual health community include menarche, coitarche, preconception/infertility, miscarriage, perinatal mood disorders, postpartum mood disorders, sexuality needs, sexual dissatisfaction, sexual violence, emotional/verbal abuse, genital health, correct hygiene, non-pharmaceutical treatments for women's health concerns, and so much more. That is just the tip of the iceberg.
To improve our practice care, we first strive to make the clinic a calm, welcoming, and empowering space for patients. For instance, we constructed the entrance to our building to be soothing and inviting, with views of an enclosed courtyard with a garden. Additionally, we have essential oil diffusers in every room dispensing calming scents, soothing nature sounds playing throughout the clinic, and simple chandeliers over our exam tables to give patients something beautiful to view during their appointment. We want our patients to know they are welcome and safe in our clinic, and details like these enhance the sometimes intrusive experience of a medical appointment.
We also work to reduce some of the medical blandness that so often encompasses medical care and can even raise blood pressure for patients. For example, we keep our sharps bins out of site but accessible under the sink, we cover any tools needed for any procedure from a vaccine to an IUD insertion with a cloth as they often look more intense than they are, and we always offer and encourage that our patients do not look at their weight when they hop on the scale, just to name a few. If the visit is more enjoyable, the patient is much more empowered to make their health a priority and not avoid needed medical visits out of fear or discomfort.
Additionally, we work to improve patient outcomes by collaborating with a multidisciplinary team. For instance, in addition to the care and treatment plan we develop for them, we routinely refer to: pelvic floor physical therapists for assistance with pelvic pain and urinary incontinence concerns; sexual therapists for vaginismus and dyspareunia; and mental health providers like psychiatric nurse practitioners, psychiatrists, and therapists for a range of conditions from endometriosis to premenstrual dysphoric disorder (PMDD), in collaboration with our treatment plan. We also refer to massage therapy and other body work, and inform patients on the benefits of CBD and THC for different clinical concerns, and dispensaries to access quality products and information. The list goes on and on.
In the end, making sure to have a holistic perspective on conditions and engage a collaborative and integrative team for care can help the patient find the treatments they can benefit most from, while also allowing the different modalities to complement each other.
SHWI: What drives your work with postpartum women to help them connect with their partner and rebuild intimacy post-pregnancy? What have you seen in this population that motivates you to challenge the stigma and teach methods that rebuild intimacy?
I am driven to work with my patients on connecting with their partner(s) and rebuilding their intimacy postpartum in light of the risk factors that are placed on this intimate bond due to breastfeeding and the birthing experience.
We know that the neurobiological nature of breastfeeding creates an extremely rewarding attachment for mother and baby. It was necessary from an evolutionary perspective to secure survival of the young, making reproduction naturally rewarding and beneficial to humans and our species’ survival. It is well described and studied in Esch and Stefano’s article The Neurobiology of Love:
“Together with vasopressin, prolactin, and endogenous opioids, oxytocin reduces HPA axis (re)activity, and it further reinforces the attachment between mother and child, e.g., by changing olfactory characteristics and preferences to parent’s/mother’s odors [26]. Interestingly, milk contains high levels of oxytocin and prolactin, thereby additionally facilitating infant-mother attachment and bonding, as well as infant’s nervous system development and the structural tuning of stress response mechanisms [26]” (p 182). (Esch, T. & Stefano, G. “The Neurobiology of Love” Neuroendocrinology Letters, 2005; 26(3): 175-192; PMID: 15990719.)
Given how significantly a mother and child are chemically rewarded by breastfeeding, the mother and her intimate partner(s) need to be intentional about giving their relationship more focused attention than ever before. There are many reasons why their intimacy is vulnerable and requires extra effort in the postpartum phase:
Lactational Amenorrhea
When exclusively breastfeeding, a woman experiences lactational amenorrhea, meaning she is not ovulating or menstruating, and this can range from 2 months post birth until as many as 18 months or more for some. Thus, when a woman is not ovulating, she is not experiencing the biological peak in sex drive that occurs mid cycle and can result in the most rewarding sexual experiences of the month for many women. Reminder, women on combined hormonal contraceptives (pill, patch, ring), progestin only pills, depo Provera shot, or Nexplanon implant do not experience ovulation while using those methods, so they too might benefit from some of the approaches used to restore intimacy in post-pregnancy sexual relationships.
Discomfort During Sex
During breastfeeding, the mother’s hormone levels are altered. They have less estrogen, which can result in:
- Decreased vaginal lubrication with intercourse
- Reduction in vaginal tissue elasticity with intercourse
- Labial/vulvar dryness
All those symptoms can make intercourse more uncomfortable for women postpartum, and the brain typically learns to avoid tasks/actions that result in pain. So, instead of the positive feedback loop that the mother is getting via oxytocin from breastfeeding their child, they can develop a negative feedback loop and aversion to sexual intimacy.
Postpartum Depression
There are many other variables, outside of breastfeeding that can impact the intimacy of the mother and partner, for instance medications to support a woman or trans man with postpartum depression, which one in seven women will experience (I am unsure the rate it presents in transmen, but I suspect it is higher). An effective medication for postpartum depression, that is also safe with breastfeeding or chestfeeding, is Sertraline (generic name) or Zoloft (brand name), yet a known side effect of Sertraline is decreased libido and sexual dysfunction.
Physical Birth Trauma
Too often women experience trauma related to their birthing, which can result in long term consequences for their sexual intimacy. These traumas vary in severity and type. For example, if an individual has a very physically painful childbirth, they may associate that pain with sex in a heterosexual relationship, since sex (with exception of IVF) was the action that resulted in pregnancy. In addition, when recovering from birth traumas, they might fear becoming pregnant (rationally or irrationally) or not be ready for pregnancy yet and avoid sexual intimacy to avoid any chance of pregnancy.
Additionally, if they experienced physical birth trauma and the area is still tender to touch or friction and they attempt sexual intimacy that results in pain, their nerve endings can become extra sensitive and their brain develops an association with sexual intimacy and pain, reducing their sexual desire. This then needs to be unlearned via biofeedback and creating positive associations with sexual intimacy.
In conclusion, there are many challenges that individuals experience postpartum that directly impact their sexual desire. Knowing that there are so many negative forces at play impacting sexual intimacy, it motivates me to counter the negative forces and work to empower my patients to overcome these barriers. As the mother-child connection with breastfeeding is extremely biologically beneficial to them both, so too is the intimacy sexual partners experience.
SHWI: In a previous interview with Good Clean Love, you reference essential oils as a “sexual medicine.” Can you explain how certain essential oils act as aphrodisiacs and help to restore sexual function?
To explain how essential oils work, in short, think about how you feel when you walk into someone’s house and smell chocolate chip cookies baking. For most, it brings about a sense of joy and reminds them of good feelings they had when consuming cookies in the past or of places where they last smelled that scent (like their parent’s home, for example). We are olfactory beings, which means there are parts of the brain that can get triggered by scents and bring about joy, lust, and security, from the memory of that scent and what emotions it evoked when it was smelled.
I have found little evidence regarding how aphrodisiacs restore sexual function, but based on clinical experience with patients, essential oils can act as an aphrodisiac in that they provide a positive olfactory experience which triggers a positive feedback loop and neurochemical association with sexual experiences. I referenced this in much greater depth in my previous interview. Just as how I practice holistically, I also encourage using multiple methods to reach positive health outcomes. The benefits of essential oils are not a solution on their own, but can be combined with other treatment options such as physical therapy, taking hormones, or mental health counselling, among others, depending on each patient’s individual needs.
I suggest Good Clean Love’s Love Oils throughout my practice both to engage the olfactory sense as well as using it as a moisturizer on the vulva or even for massaging their partner or self. Caribbean Rose is my favorite and if I polled my patients, I think they would agree as well. I have a bottle in each exam room and place a pump on their hand for them to sense the smell and texture of the Love Oils.