friday follow-up

regarding the perils of hombirth

so the today show did a recent scare segment re homebirth (originally titled 'the perils of midwifery' but later changed to 'the perils of homebirth' and naturally the birthing blogosphere has been abuzz

http://blackhillsportal.com/npps/story.cfm?id=3430
http://www.rhrealitycheck.org/blog/2009/09/11/nbc-today-shows-homebirth-scare-segment
http://mybestbirth.ning.com/forum/topics/the-perils-of-journalism-ricki

of course the topic of home birth has been a contentious one for quite some time as these earlier links attest.

http://www.babble.com/CS/blogs/strollerderby/archive/2009/04/18/home-birth-a-right-or-a-must.aspx
http://www.timesonline.co.uk/tol/comment/columnists/melanie_reid/article6101189.ece


some of the debate focuses on the rights to even have a homebirth, some on the safety of homebirth



the australian healthcare system has been duking it out over homebirth for a while . heres some of the latest from over there http://www.thepunch.com.au/articles/homebirth-wars-confusing-a-right-with-whats-right/



despite the evidence regarding the safety of homebirth http://www.bmj.com/cgi/content/full/330/7505/1416 the american college of obstetrics and gynocology has been on a campaign to remove the choice of homebirth... they put out a press release in february 2008 in which they re-iterated their stance http://www.acog.org/from_home/publications/press_releases/nr02-06-08-2.cfm and now they are using the media to skew public perception as to the dangers of homebirth and the competancies of midwives.

heres the thing though....

i think most women do take their own health factors into consideration when preparing for a home birth. most wome will change their plans when the situation requires it. there may be some disagreement as to what requires a change of plans: breech baby? twins? higher order multiples? postdates? what about vbac? but in other situations theres just not as much grey area and most women and midwives recognize that and respond appropriately.

according to this study http://www.jmwh.com/article/S1526-9523(08)00338-3/abstract a perception of GREATER safety was one of the major factors involved in planning a home birth.

The percentage of women choosing to birth at home has remained fairly steady for the past 2 decades http://www.uptodate.com/patients/content/topic.do?topicKey=~l0l0wKntyU7Dhn1

"From 1989 to 2003 the rate of home births in the United States declined from 0.69 to 0.57 percent of births, or by an average of 0.01 percent annually. The 2006 figures represent a very slight increase in both absolute numbers and rate, reaching 0.59 percent of all births [5]. This rate is comparable to that in other industrialized countries with two exceptions: England has experienced a slight rise in its home birth rate from 1.0 percent in 1989 to 2.7 percent in 2006 [6], while the Netherlands has maintained rates of home birth of approximately 30 percent [7]."

acog recently released a statement http://www.acog.org/from_home/publications/press_releases/nr09-11-09.cfm that basically says obs are practicing in a manner that is highly concious of the risks of litigation.

here are the results from the listening to mothers II survey http://www.childbirthconnection.org/pdf.asp?PDFDownload=LTMII_report this shows women are suffering as a result. rather than focus on the less than %1 of births that occur at home why not focus on improving the care women recieve during the %99 of births that occur at hospitals or birthcenters?

homebirth is already 100% LEGAL in every state in the us. the legality of attendance by a midwife is fast becoming just as legal.

In addition to the Lamaze 6 Care Practices that support Normal Birth http://www.lamaze.org/ChildbirthProfessionals/ResourcesforProfessionals/CarePracticePapers/tabid/90/Default.aspx

the coalition for improving maternity services has already created the mother friendly initiative in order to give hospitals and providers some concrete goals to focus on in improving their maternity care http://www.motherfriendly.org/mfci.php these steps are a good focus point for anybody involved in birth reform.

this is a good year for legal birth reform: we have a new president, congress is involved in overall healthcare reform. and the numbers are on our side 80% of women experience childbirth. within that majority of women i would guess theres enough support to protect by law the normal, healthy birth care practices that the evidence supports and women want

Lamaze Healthy Birth Practices

The six Lamaze Healthy Birth Practices below are supported by
research studies that examine the benefits and risks of maternity care
practices. Therefore, they represent "evidence-based care," which is the gold
standard for maternity care worldwide. Evidence-based care means "using the best
research about the effects of specific procedures, drugs, tests, and treatments,
to help guide decision-making." Please note: The English versions
were revised in 2009.

Let Labor Begin on Its Own

Walk, Move Around, and Change Positions Throughout Labor

Bring a Loved One, Friend, or Doula for Continuous Support

Avoid Interventions That Are Not Medically Necessary

Avoid Giving Birth on the Back and Follow the Body’s Urges to Push

Keep Mother and Baby Together – It’s Best for Mother, Baby, and
Breastfeeding

Ten Steps of the Mother-Friendly Childbirth InitiativeFor
Mother-Friendly Hospitals, Birth Centers,* and Home Birth Services
To receive
CIMS designation as “mother-friendly,” a hospital, birth center, or home birth
service must carry out the above philosophical principles by fulfilling the Ten
Steps of Mother-Friendly Care.


A mother-friendly hospital, birth center, or home birth service:


Offers all birthing mothers:

Unrestricted access to the birth companions of her choice, including
fathers, partners, children, family members, and friends;

Unrestricted access to continuous emotional and physical support from a
skilled woman—for example, a doula,* or labor-support professional;

Access to professional midwifery care.


Provides accurate descriptive and statistical information to the public
about its practices and procedures for birth care, including measures of
interventions and outcomes.


Provides culturally competent care—that is, care that is sensitive and
responsive to the specific beliefs, values, and customs of the mother’s
ethnicity and religion.


Provides the birthing woman with the freedom to walk, move about, and
assume the positions of her choice during labor and birth (unless restriction is
specifically required to correct a complication), and discourages the use of the
lithotomy (flat on back with legs elevated) position.


Has clearly defined policies and procedures for:

collaborating and consulting throughout the perinatal period with other
maternity services, including

communicating with the original caregiver when transfer from one birth site
to another is necessary;

linking the mother and baby to appropriate community resources, including
prenatal and post-discharge follow-up and breastfeeding support.


Does not routinely employ practices and procedures that are unsupported by
scientific evidence, including but not limited to the following:
shaving;
enemas;
IVs (intravenous drip);
withholding nourishment or water;
early rupture of membranes*;
electronic fetal monitoring; other
interventions are limited as follows:


Has an induction* rate of 10% or less;†


Has an episiotomy* rate of 20% or less, with a goal of 5% or less;


Has a total cesarean rate of 10% or less in community hospitals, and 15% or
less in tertiary care (high-risk) hospitals;


Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal
of 75% or more.


Educates staff in non-drug methods of pain relief, and does not promote the
use of analgesic or anesthetic drugs not specifically required to correct a
complication.


Encourages all mothers and families, including those with sick or premature
newborns or infants with congenital problems, to touch, hold, breastfeed, and
care for their babies to the extent compatible with their conditions.


Discourages non-religious circumcision of the newborn.


Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital
Initiative” to promote successful breastfeeding:

Have a written breastfeeding policy that is routinely communicated to
all
health care staff;

Train all health care staff in skills necessary to
implement this policy;

Inform all pregnant women about the benefits and
management of
breastfeeding;

Help mothers initiate breastfeeding
within a half-hour of birth;

Show mothers how to breastfeed and how to
maintain lactation even if they
should be separated from their infants;

Give newborn infants no food or drink other than breast milk unless
medically indicated;

Practice rooming in: allow mothers and infants
to remain together 24 hours
a day;

Encourage breastfeeding on
demand;

Give no artificial teat or pacifiers (also called dummies or
soothers) to
breastfeeding infants;

Foster the establishment of
breastfeeding support groups and refer mothers
to them on discharge from
hospitals or clinics

† This criterion is presently under review.

choices in childbirth

so this is like a thursday post on friday.....

this topic has been on my mind lately. and this video from msnbc http://www.msnbc.msn.com/id/21134540/vp/32795933#32795933 brought it to the forefront for a blog post. i actually haven't watched the video b/c i don't have speakers on my computer right now but i did post a reply on the discussion (the question was basically what are your thought on the risks of homebirth) heres my reply

"Its always a risk/benefit analysis. There are risks and benefits to either scenerio and its a matter of choosing which risks are acceptable and which benefits are most important to you.

there are benfits to homebirth that show up in the research: fewer interventions, more skin-to-lskin, more rapid initiation of breastfeeding, greater satisfaction with the birth experience, one-to-one care for mom, etc

there are also risks. an emergent situation can arise that requires urgent action. sometimes a transfer to hospital care can be accomplished in time and sometimes time is of such essence that a transfer can't be accomplished in time. sometimes a woman will find labor to be more painful or more exhausting than anticipated and she wil want to tranfer for a non-emergent complication.

there are several kinds of midwives and the kind of training they have will vary but most midwives have training in ergency situations. most midwives can perform at least basic rescucitation on mom and or baby. many midwives carry oxygen, pitocin, suture equipment and other equipment to deal with emergencies. that would definately be a question to ask a midwife: "what kind of training do you have to manage an emergency?" "what are your transfer protocols?" etc

there are times when the benefits of a hospital birth will outweigh the benefits of a homebirth. if a woman goes into pre-term labor at say 32 weeks, or has pre-eclamsia, or an unmanaged health condition then a hospital birth may be the wisest choice. but there are very real rsks to hospital birth. some of these risks are the same risks anyone faces walking into a hospital : hospital aquired infection, medication errors, miscommunications between care providers during shift changes. some risks are specific to labor and delivery. the epidural delivers very good pain relief but it can also cause fever and a decrease in blood pressure. pitocin can jump start contractions but those contractions can be very intense and can even hyperstimulate the uterus leading to an emergency section. even some basic hospital procedures such as denying food and drink carry risks. you wouldn't run a marathon w/o adequate nourishment why expect to have a baby w/o eating and drinking?

the way transfers are managed is one area where improvement is sorely needed. a study was done recently that showed that there is so much fear on both sides that it is affecting the care women recieve when a transfer is needed. i think some kind of no-fault transfer policy needs to be implemented at a national level so obs can use their training when it is needed w/o fear of a lawsuit, so midwives can transfer women who need hospital services w/o fear of lawsuit....so everyone can share information freely and no one lets fear get in the way of care.

and as to the actual question, i've had 2 hospital births and one birth in a freestanding birth center. if i have another it will be a planned homebirth."


And this topic homebirth versus hospital gets to the heart of the matter. Your choices in childbirth boil down really to 2 things: your choice of healthcare provider and your choice of birthing place.

Many many women plan to just use whoever they've been using for well woman gyno care. You probably know and like your hcp. But this post from jen at vbac facts demonstrates how liking your hcp is not enough. http://vbacfacts.com/2009/08/26/an-ob-you-like-or-who-makes-you-comfortable-isnt-enough/

you pretty much have 3 choices in birth care: An OB, a family practice dr, or a midwife. any one of the 3 can be a good choice if they have a birth philosophy that works for you but in general obs will be the most interventive of the 3 and midwives the least interventive.

midwives work within the midwifery model of care. http://cfmidwifery.org/mmoc/define.aspx

The Midwives Model of Care

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

The Midwives Model of Care includes:

• Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
• Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
• Minimizing technological interventions
• Identifying and referring women who require obstetrical attention

The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.

Copyright (c) 1996-2008, Midwifery Task Force, Inc., All Rights Reserved

An OB on the other hand is a sugeon trained in the technocratic model of care. this is a long read but explains the technocratic model in great detail http://www.davis-floyd.com/USERIMAGES/File/TECHNOCRATIC%20MODEL%20OF%20BIRTH.pdf

basically in the technocratic model the birthing mother is seen as a machine destined to malfunction at some point.

Afamily practice dr who still attends births is hard to find but if found is oftn somewhere in between midwife and ob in mindset.

regardless of the letters behing your hcp's name you have got to be sure your birth philosophy meshes with theirs. Because if she usually cuts an episiotomy she'll probably cut one on you too. If he only "allows" a 12 hour labor before he starts a pit drip to "move it along" thats probably the care you'll get too.

And then you also have to be sure that the place you choose to give birth is willing and able to be supportive of your birth philosophy also. What are their usual procedures? If everybody who goes to hospital A has to do some time on the fetal monitor you probably will too unless your dr or midwife has okay'd you not doing it in advance. if they don't "allow" most of their mothers to labor in the tub they probably won't "let" you either.

a good place to start is with this list from the coalition for improving maternity services

Having a Baby?
Ten Questions to Ask
©2000 Coalition for Improving Maternity Services (CIMS).

1. Ask, “Who can be with me during labor and birth?”
Mother-friendly birth centers, hospitals, and home birth services will let a birthing mother decide whom she wants to have with her during the birth. This includes fathers, partners, children, other family members, or friends.
They will also let a birthing mother have with her a person who has special training in helping women cope with labor and birth. This person is called a doula or labor support person. She never leaves the birthing mother alone. She encourages her, comforts her, and helps her understand what’s happening to her.
They will have midwives as part of their staff so that a birthing mother can have a midwife with her if she wants to.
2. Ask, “What happens during a normal labor and birth in your setting?”
If they give mother-friendly care, they will tell you how they handle every part of the birthing process. For example, how often do they give the mother a drug to speed up the birth? Or do they let labor and birth usually happen on its own timing?
They will also tell you how often they do certain procedures. For example, they will have a record of the percentage of C-sections (Cesarean births) they do every year. If the number is too high, you’ll want to consider having your baby in another place or with another doctor or midwife.
Here are some numbers we recommend you ask about.
They should not use oxytocin (a drug) to start labor for more than 1 in 10 women (10%).
They should not do an episiotomy (ee-pee-zee-AH-tummy) on more than 1 in 5 women (20%). They should be trying to bring that number down. (An episiotomy is a cut in the opening to the vagina to make it larger for birth. It is not necessary most of the time.)
They should not do C-sections on more than 1 in 10 women (10%) if it’s a community hospital. The rate should be 15% or less in hospitals which care for many high-risk mothers and babies.
A C-section is a major operation in which a doctor cuts through the mother’s stomach into her womb and removes the baby through the opening. Mothers who have had a C-section can often have future babies normally. Look for a birth place in which 6 out of 10 women (60%) or more of the mothers who have had C-sections go on to have their other babies through the birth canal.
3. Ask, “How do you allow for differences in culture and beliefs?”
Mother-friendly birth centers, hospitals, and home birth services are sensitive to the mother’s culture. They know that mothers and families have differing beliefs, values, and customs.
For example, you may have a custom that only women may be with you during labor and birth. Or perhaps your beliefs include a religious ritual to be done after birth. There are many other examples that may be very important to you. If the place and the people are mother-friendly, they will support you in doing what you want to do. Before labor starts tell your doctor or midwife special things you want.
4. Ask, “Can I walk and move around during labor?
What position do you suggest for birth?”
In mother-friendly settings, you can walk around and move about as you choose during labor. You can choose the positions that are most comfortable and work best for you during labor and birth. (There may be a medical reason for you to be in a certain position.) Mother-friendly settings almost never put a woman flat on her back with her legs up in stirrups for the birth.
5. Ask, “How do you make sure everything goes smoothly when my nurse, doctor, midwife, or agency need to work with each other?”
Ask, “Can my doctor or midwife come with me if I have to be moved to another place during labor? Can you help me find people or agencies in my community who can help me before and after the baby is born?”
Mother-friendly places and people will have a specific plan for keeping in touch with the other people who are caring for you. They will talk to others who give you birth care. They will help you find people or agencies in your community to help you. For example, they may put you in touch with someone who can help you with breastfeeding.
6. Ask, “What things do you normally do to a woman
in labor?”
Experts say some methods of care during labor and birth are better and healthier for mothers and babies. Medical research shows us which methods of care are better and healthier. Mother-friendly settings only use methods that have been proven to be best by scientific evidence.
Sometimes birth centers, hospitals, and home birth services use methods that are not proven to be best for the mother or the baby. For example, research has shown it’s usually not helpful to break the bag of waters.
Here is a list of things we recommend you ask about. They do not help and may hurt healthy mothers and babies. They are not proven to be best for the mother or baby and are not mother-friendly.
They should not keep track of the baby’s heart rate all the time with a machine (called an electronic fetal monitor). Instead it is best to have your nurse or midwife listen to the baby's heart from time to time.
They should not break your bag of waters early in labor.
They should not use an IV (a needle put into your vein to give you fluids).
They should not tell you that you can't eat or drink during labor.
They should not shave you.
They should not give you an enema.
A birth center, hospital, or home birth service that does these things for most of the mothers is not mother-friendly. Remember, these should not be used without a special medical reason.
7. Ask, “How do you help mothers stay as comfortable as they can be? Besides drugs, how do you help mothers relieve the pain of labor?”
The people who care for you should know how to help you cope with labor. They should know about ways of dealing with your pain that don’t use drugs. They should suggest such things as changing your position, relaxing in a warm bath, having a massage and using music. These are called comfort measures.
Comfort measures help you handle your labor more easily and help you feel more in control. The people who care for you will not try to persuade you to use a drug for pain unless you need it to take care of a special medical problem. All drugs affect the baby.
8. Ask, “What if my baby is born early or has special problems?”
Mother-friendly places and people will encourage mothers and families to touch, hold, breastfeed, and care for their babies as much as they can. They will encourage this even if your baby is born early or has a medical problem at birth. (However, there may be a special medical reason you shouldn't hold and care for your baby.)
9. Ask, “Do you circumcise baby boys?”
Medical research does not show a need to circumcise baby boys. It is painful and risky. Mother-friendly birth places discourage circumcision unless it is for religious reasons.
10. Ask, “How do you help mothers who want to breastfeed?”
The World Health Organization made this list of ways birth services support breastfeeding.
They tell all pregnant mothers why and how to breastfeed.
They help you start breastfeeding within
1 hour after your baby is born.
They show you how to breastfeed. And they show you how to keep your milk coming in even if you have to be away from your baby for work or other reasons.
Newborns should have only breast milk. (However, there may be a medical reason they cannot have it right away.)
They encourage you and the baby to stay together all day and all night. This is called “rooming-in.”
They encourage you to feed your baby whenever he or she wants to nurse, rather than at certain times.
They should not give pacifiers (“dummies” or “soothers”) to breastfed babies.
They encourage you to join a group of mothers who breastfeed. They tell you how to contact a group near you.
They have a written policy on breastfeeding. All the employees know about and use the ideas in the policy.
They teach employees the skills they need to carry out these steps.

Would you like to give this information (and more)
to your doctor, midwife, or nurse?
This information taken from The Mother-Friendly Childbirth Initiative written for health care providers. You can get a copy of the Initiative for your doctor, midwife, or nurse by mail, e-mail, or on the Internet.
To Get a Copy by Mail
Write to:

Coalition for Improving Maternity Services (CIMS)
1500 Sunday Drive Suite 102
Raleigh, NC 27607
Tel 1: 888-282-CIMS
Tel 2: 919-863-9482
Fax: 919-787-4916
E-mail: info@motherfriendly.org
http://www.motherfriendly.org

Permission granted to freely reproduce in whole or in part along with complete attribution.
To Get Copies on the Internet
http://www.motherfriendly.org

please vivist their site. they have lots of useful info on there.

i feel like this is a long post so i'll stop for now but i think i'll continue on with this topic tuesday....

just posting links to articles today

apologies to my readers.... looks like links are not posting properly again

looks like the sue happy culture isn't a us only thing http://www.newsday.co.tt/news/0,106690.html midwives in spain are failing to renew their liscences due to a rise in negligency suits

heres a blog i came across today http://www.thehealthcareblog.com/ not specific to pregnancy/birth/postpartum but relevant nonetheless seems to give a good overview of the healthcare reform debate nd current healthcare policy and procedure

new drug, tafoxiparin for the prevention of prolonged labor during childbirth is in clinical trials http://www.reuters.com/article/pressRelease/idUS120679+04-Sep-2009+PRN20090904
sounds like its intended to be given prophylactically?

wish i could go to this birth film festival in orlando http://centralfloridagreenguide.com/2009/09/04/baby-international-film-festival-coming-oct-2nd-and-3rd/

this post http://womensphere.wordpress.com/2009/09/04/photos-of-childbirth-have-been-branded-pornography-in-zambia/ about a newspaper editor in zambia facing charges of pornagraphy for mailing a picture of a woman delivering a stillborn baby to a government oficial shows how deeply healthcare crisises affect birthing women all over the world. and how important it is to shed light on that. looks like the blog womensphere will be of interest in the future as well http://womensphere.wordpress.com/

and here are several links to articles about homebirth midwives in australia. you may be aware that homebirth advocates have had a rough time over there lately

http://www.abc.net.au/news/stories/2009/09/04/2677059.htm?section=justin
http://www.sbs.com.au/news/article/1083847/Government-U-turn-on-homebirth-laws
http://www.thechronicle.com.au/story/2009/09/05/city-mum-joins-homebirth-rally/
http://savehomebirth.com.au/news/

well looks like the little may wake up in a minute so i guess thats it for now. hopefully will get back to it later to post more.

eventually i would like to write some thoughtful original informative insightful post but ......

follow up friday

todays the day i follow up on various news stories and blog posts i've read over the week and this edition should be good cuz i just finished cleaning out my email inbox....

first up The Breastfeeding Promotion Act introduced by Representative Carolyn B. Maloney (NY) and Senator Jeff Merkley (OR) in the senate on June 11

heres a link to the actual text http://bit.ly/Hi944 or http://maloney.house.gov/documents/women/breastfeeding/061009%20Breastfeeding%20Promotion%20Act.pdf

(sorry to make you cut and paste but links are wonky for some reason)

The Breastfeeding Promotion Act (H.R. 2819, S. 1244) includes five provisions:

• Amends the Civil Rights Act of 1964 to protect breastfeeding women from being fired or discriminated against in the workplace.
• Provides tax incentives for businesses that establish private lactation areas in the workplace, or provide breastfeeding equipment or consultation services to their employees.
• Provides for a performance standard to ensure breast pumps are safe and effective.
• Allows breastfeeding equipment and consultation services to be tax deductible for families (amends Internal Revenue Code definition of "medical care").
• Protects the privacy of breastfeeding mothers by ensuring they have break time and a private place to pump (applies to employers with 50 or more employees, see text of legislation for details)

Heres a site that will look up your congresspeople. http://www.visi.com/juan/congress/ and heres a pre written letter to send with an auto everything if thats easier for you http://org2.democracyinaction.org/o/5162/t/6359/campaign.jsp?campaign_KEY=1697
Let them know how important this is!

#2 on my list is a new blog i found http://bfwlibrarymidwifery.wordpress.com/

haven't read it in detail yet but seems to focus on protocols for clinicians.....literature reviews, studies etc oh and its british.....

and here is a good post about the different types of midwives practicing in florida http://centralfloridagreenguide.com/2009/08/04/florida-midwifery/

ok well i'm posting for now but i'll prolly (maybe) edit to add more later

topical tuesday #1 - breastfeeding, galactagogues and regaln warning

(edited to add more info thursday september 3)

have i mentioned i changed my weekly plan a bit? i'm doing topics in childbirth education on tuesdays and thursdays now....

on to todays topic "breastfeeding, galactagogues and reglan warning"

many many new mamas think they have a low milk supply. in fact according to this study

http://bit.ly/i95oY

"The perception that their infant was not satisfied by breast milk alone was cited consistently as 1 of the top 3 reasons in the mothers' decision to stop breastfeeding regardless of weaning age (43.5%–55.6%)"

(most have a fine supply btw)

Now the best wy to asess milk supply is by observing weight gain and counting wet and poopy dipes.

the world health organization has new weight gain charts based on breastfeeding you can refer to. heres the one for girls http://www.who.int/nutrition/media_page/cht_wfa_girls_z_0_5.pdf and heres the one for boys http://www.who.int/nutrition/media_page/cht_wfa_boys_z_0_5.pdf

and heres a quick diaper counting link from kellymom http://www.kellymom.com/bf/supply/enough-milk.html (basically you want to see 6 or more wet dipes a day and at least 1 poopy dipe, though younger infants, less than a month old often have several little poops each day rather than 1 big one)

if your baby isn't gaining and isn't wetting and pooping it could be a supply issue. ( it could also be transfer issue - you could be making milk and s/he isn't taking it in ) in either case please see a healthcare provider to be sure baby is ok and see a lactation counselor or a lactation consultant to check for breastfeeding issues such as a bad latch.

if you determine a low supply is the culprit there are lots of ways to increase your supply but the simplest is just to nurse.

• if you can arrange to spend a day or several in bed skin to skin with your babe that will often do the trick.
• be sure to offer both sides before you call it quits on any one nursing session.
• even if you have a sleepy baby be sure you wake him or her up every 2-3 hours to nurse

if increasing the time you spend nursing your little one doesn't increase supply you can add a pumping session or several into your routine.

and there are foods, herbs and medications that can increase supply if necessary. heres another link from kellymom http://www.kellymom.com/herbal/milksupply/herbal_galactagogue.html that gives a good list of various galactagogues and the dosages and side effects

and that leads me to the warning portion of this post: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm149533.htm

Reglan or metoclopramide is a drug used to treat reflux and other gastric conditions but it also increases milk supply. it is not fda approved for use as a galactagogue but is often used as one.

from the fda release linked above:

"Current product labeling warns of the risk of tardive dyskinesia
with chronic metoclopramide treatment. The development of this condition is
directly related to the length of time a patient is taking metoclopramide and
the number of doses taken. Those at greatest risk include the elderly,
especially older women, and people who have been on the drug for a long
time.
Tardive dyskinesia is characterized by involuntary, repetitive
movements of the extremities, or lip smacking, grimacing, tongue protrusion,
rapid eye movements or blinking, puckering and pursing of the lips, or impaired
movement of the fingers. These symptoms are rarely reversible and there is no
known treatment. However, in some patients, symptoms may lessen or resolve after
metoclopramide treatment is stopped."