Anticipatory guidance in pregnancy

Anticipatory guidance in pregnancy

Accompanying client resource

What to Expect During & After Pregnancy 

Anticipatory guidance is information provided to clients about body and mood changes that can occur during pregnancy and postpartum. This information prepares clients for upcoming changes and can help them determine what changes are within the range of normal and when to seek medical care. Anticipatory guidance may decrease anxiety and create opportunities for conversations about mental health and postpartum planning.  

Knowledge needs may be different for transgender, Two-Spirit A term used within some Indigenous communities to reflect complex Indigenous understandings of gender and sexuality and the long history of sexual and gender diversity in Indigenous cultures. Two-Spirit encompasses sexual, gender, cultural and spiritual identity. It may refer to cross-gender, multi-gender or non-binary gender roles, non-heterosexual identities, and a range of cultural identities, roles and practices embodied by Two-Spirit peoples. Some people also use "2-Spirit" or "2S." (Source: Battered Women’s Support Services) , and non-binary Umbrella term referring to people whose gender does not fall within the binary gender system of woman/girl or man/boy. Some individuals identify as non-binary while others may use terms such as gender non-conforming, genderqueer, or agender. Non-binary people may or may not conform to societal expectations for their gender expression and gender role, and they may or may not seek gender-affirming medical or surgical care. (TTNB) clients based on their medical and surgical history and socio-ecological context. This document does not attempt to provide a comprehensive guide to anticipatory guidance for all clients but focuses on topics that have been highlighted in the literature and during interviews with TTNB community members and care providers [1].

For more information about socio-ecological context, see Gender-Affirming Approach to Infant Feeding.

Gender dysphoria Distress resulting from a difference between a person’s gender and their sex assigned at birth, associated gender role, and/or primary and secondary sex characteristics. (Source: WPATH) may occur for the first time, worsen, or return when trying to conceive, when pregnant, and in the postpartum period [9,10]. Physical and emotional changes contribute to internal dysphoria, while being misgendered in social situations or when accessing health care contributes to social (external) dysphoria [8,10]. Qualitative studies report that trans men are more likely to be misgendered because of chest growth rather than a visible pregnancy, as gender assumptions make it possible to hide a pregnant belly and pass as a "fat man" [4,5]. This led to some trans men choosing to isolate themselves at home rather than risk being misgendered when out of their home [2].  

For many TTNB people capable of becoming pregnant, taking testosterone is a key part of their gender affirming journey [2]. Stopping testosterone when pregnant or planning for pregnancy can lead to emotional and physical changes, including mood changes, return of monthly bleeding Menstrual bleeding or period. , chest tenderness and growth, and increased fat to the chest, abdomen, and hips [2–4]. These physical changes may cause or worsen feelings of gender dysphoria Distress resulting from a difference between a person’s gender and their sex assigned at birth, associated gender role, and/or primary and secondary sex characteristics. (Source: WPATH) [2].

While stopping testosterone may lead to unexpected emotions, emotional highs and lows are a part of pregnancy for almost all pregnant people. This does not reflect on gender or “appropriateness of pregnancy” [5].  

Pregnancy  

Growth of chest tissue is expected in pregnancy and may (or may not) contribute to feelings of gender incongruence A mismatch between a person's gender and the sex they were assigned at birth. or dysphoria [2]. After gender-affirming chest surgery, chest growth may still occur, depending on the type of surgery and amount of chest tissue remaining after the surgery [4,6].

Binding Wearing compression garments or using other methods to flatten the chest. during pregnancy will likely become increasingly uncomfortable and ineffective [2,4]; however, binding outside of pregnancy and lactation is associated with positive mental health outcomes [7]. Clients should be supported to continue binding if they want to and encouraged to monitor for increased pain, inflammation, respiratory concerns, or skin breakdown An umbrella term for rashes, blisters, cuts, scrapes and chafing. Can refer to anything that breaks down the barrier the skin provides. [7].  

For more information, see Binding During Pregnancy and Lactation.  

Postpartum

If TTNB people do not want to bodyfeed after pregnancy, they can suppress lactation pharmacologically or non-pharmacologically. If lactation is not suppressed medically, milk will come in on day 2-5 postpartum. In most cases, this will cause growth of chest tissue. This growth is unpredictable and, even if the client has had chest surgery, it can change the long-term appearance of the chest.  

For more information, see Lactation Suppression.

People who have had chest or breast reduction or construction may still be able to bodyfeed their infant but will likely need to supplement with donor milk or formula.  

For more information, see Bodyfeeding: History of Chest Surgery.  

Engorgement & Mastitis  

Clients who have had chest surgery can still experience engorgement and mastitis, even if they are unable to express any milk [4,8]. Signs of engorgement and mastitis (e.g., localized redness or heat, painful chest tissue, fever, and/or feeling unwell) should be reviewed with every client.    

For more information:

For an in-depth review of engorgement and mastitis, see the Academy of Breastfeeding Medicine’s Clinical Protocol #36: The Mastitis Spectrum.

Detailed client resource (uses gendered language) from the Academy of Breastfeeding Medicine: Mastitis in Breastfeeding.  

The accompanying resource, What to Expect During & After Pregnancy, provides guidance for managing discomfort from engorgement and mastitis. 

For many TTNB people, finding gender-affirming pregnancy and bodyfeeding clothing is difficult and may cause TTNB people to feel excluded and othered [4,6,9]. When bodyfeeding, gender-affirming clothing that is supportive, accessible, and leak proof may improve the feeding experience of TTNB people, and discussing this with clients can help them prepare for the realities of bodyfeeding. While binding Wearing compression garments or using other methods to flatten the chest. in the early postpartum period may decrease milk supply, a light binder with a zipper (in a larger size than their pre-pregnant or pregnant size) may be more comfortable than a nursing bra. 

Regardless of whether TTNB people choose to bodyfeed, the postpartum period can be exhausting and overwhelming. Hormonal, emotional, and physical changes, along with exhaustion, may worsen feelings of gender dysphoria Distress resulting from a difference between a person’s gender and their sex assigned at birth, associated gender role, and/or primary and secondary sex characteristics. (Source: WPATH) . Support systems, shown to decrease postpartum depression in cisgender Refers to people who are non-trans, i.e. whose gender matches their assigned sex at birth. women [11], may not be available to TTNB people due to family and cisnormative parenting groups, leading to feelings of exclusion and isolation [3,9,12].  

For those who are bodyfeeding, the chest growth they experience may increase dysphoria [4]. Navigating public spaces while bodyfeeding an infant requires TTNB people to consider personal safety, cisnormative assumptions, and privacy needs [4]. For those who are not bodyfeeding, suppressing lactation and, where applicable, restarting testosterone may help with the postpartum transition. However, many TTNB parents report difficulty navigating social expectations and assumptions, including finding their parenting names, being misgendered, and being asked intrusive personal questions when out with their child [4,9].  

Providers can normalize talking about mental health concerns by including a mental health check in alongside other routine assessments.  This may include asking about mood, energy levels, sleep health, work/home balance or functioning, relational concerns, and overall well-being [13].  

For more information, see Perinatal Mental Health.

Perinatal Services BC offers this simple handout on the basic steps of self-care in the postpartum period: NESTS for Well-Being.  

Where possible, discuss postpartum mental health with both the pregnant person and their support person/people. Normalize rapid emotional changes in the first two weeks postpartum (the ‘baby blues’) and discuss reasons to seek mental health support, including a persistent feeling of hopelessness, isolation, difficulty enjoying their baby, uncontrollable mood swings, or sleep disturbances (insomnia or hypersomnia) [14].  

  1. Trans Care BC Community Interviews. 2023.  
  2. Charter R, Ussher JM, Perz J, Robinson K. The transgender parent: Experiences and constructions of pregnancy and parenthood for transgender men in Australia. International Journal of Transgenderism. 2018;19: 64–77. doi:10.1080/15532739.2017.1399496
  3. Ellis SA, Wojnar DM, Pettinato M. Conception, pregnancy, and birth experiences of male and gender variant gestational parents: It’s how we could have a family. Journal of Midwifery & Women’s Health. 2015;60: 62–69. doi:10.1111/jmwh.12213
  4. MacDonald T, Noel-Weiss J, West D, Walks M, Biener M, Kibbe A, et al. Transmasculine Refers to trans people who were assigned female at birth and whose gender expression leans towards the masculine. individuals’ experiences with lactation, chestfeeding, and gender identity A person's deeply held, internal sense of themself as male, female, a blend of both or neither. (Source: GenderSpectrum.org) : A qualitative study. BMC Pregnancy & Childbirth. 2016;16: 1–17. doi:10.1186/s12884-016-0907-y
  5. Hoffkling A, Obedin-Maliver J, Sevelius J. From erasure to opportunity: A qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth. 2017;17: 332. doi:10.1186/s12884-017-1491-5
  6. van Amesfoort JE, van Rooij FB, Painter RC, Valkenburg-van den Berg AW, Kreukels BPC, Steensma TD, et al. The barriers and needs of transgender men in pregnancy and childbirth: A qualitative interview study. Midwifery. 2023;120: 1–11. doi:10.1016/j.midw.2023.103620
  7. Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding Wearing compression garments or using other methods to flatten the chest. among transgender adults: A community-engaged, cross-sectional study. Culture, Health & Sexuality. 2017;19: 64–75. doi:10.1080/13691058.2016.1191675
  8. Falck F, Frisén L, Dhejne C, Armuand G. Undergoing pregnancy and childbirth as trans masculine in Sweden: Experiencing and dealing with structural discrimination, gender norms and microaggressions in antenatal care, delivery and gender clinics. International Journal of Transgender Health. 2021;22: 42–53. doi:10.1080/26895269.2020.1845905
  9. Fischer OJ. Non-binary Umbrella term referring to people whose gender does not fall within the binary gender system of woman/girl or man/boy. Some individuals identify as non-binary while others may use terms such as gender non-conforming, genderqueer, or agender. Non-binary people may or may not conform to societal expectations for their gender expression and gender role, and they may or may not seek gender-affirming medical or surgical care. reproduction: Stories of conception, pregnancy, and birth. International Journal of Transgender Health. 2021;22: 77–88. doi:10.1080/26895269.2020.1838392
  10. Greenfield M, Darwin Z. Trans and non-binary pregnancy, traumatic birth, and perinatal mental health: A scoping review. Int J Transgend Health. 2021;22: 203–216. doi:10.1080/26895269.2020.1841057
  11. Lubker Cornish D, Roberts Dobie S. Social support in the “fourth trimester”: A qualitative analysis of women at 1 month and 3 months postpartum. J Perinat Educ. 2018;27: 233–242. doi:10.1891/1058-1243.27.4.233
  12. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstetrics & Gynecology. 2014;124: 1120–1127. doi:10.1097/AOG.0000000000000540
  13. Provincial Council for Maternal and Child Health. Perinatal mental health: Guidance for the identification and management of mental health in pregnant or postpartum individuals. 2021. Available: https://www.pcmch.on.ca/wp-content/uploads/PCMCH-Perinatal-Mental-Health-Guidance-Document_July2021.pdf
  14. BC Reproductive Mental Health Program, Perinatal Services BC. Best practice guidelines for mental health disorders in the perinatal period. 2014. Available: http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/MentalHealthDisordersGuideline.pdf
Current versionJanuary 14, 2025
AuthorsCaitlin BotkinNurse Educator, Trans Care BC; Registered Midwife (non-practicing) 
Rowan McNiven GladmanRegistered Midwife, IBCLC