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ICAN, VBAC Friendly Hospitals, Midwives, Childbirth Educators: Speaking with Elaine Diegman, CNM, Ph.D

April 30th, 2012 by avatar

We wrap up Cesarean Awareness Month and acknowledge the week of International Midwifery Day with a post about an initiative to  create a VBAC Friendly Hospital, led by midwives.

ln honor of Cesarean Awareness Month, Lakeisha Dennis, the Chapter Leader of International Cesarean Awareness Network (ICAN) of Greater Essex County, New Jersey, invited Elaine Diegman, CNM, Ph.D, to speak about Worst to First, a talk about how to modify New Jersey’s high cesarean rate. Professor Diegman is head of the University of Medicine and Dentistry of New Jersey’s (UMDNJ) School of Nursing’s Midwifery Program.

Nationwide, the cesarean section rate is about 33%; in other words, one in three women in the United States give birth by surgical cesarean section. The cesarean section rate has risen about 50% in 15 years. According to the World Health Organization, a cesarean section rate of about 5 – 10% is the target for overall optimal maternal – baby outcome.

The state of New Jersey has a cesarean section rate of about 39%. New Jersey consistently places in the top two states for the highest cesarean section rate, sharing this distinction at the moment with the state of Louisiana.

Despite the National Institute of Health’s recommendation about vaginal brith after cesarean (VBAC) being safe under certain circumstances, there is a ourtright ban on vaginal birth after cesarean (VBAC) in many hospitals across the nation and the birth educators and doulas at this meeting said they noticed some ob-gyn practices have a quiet bait and switch tactic in place around this issue.

Professor Diegman has a long and distinguished career. She started out by telling us she’s actually the oldest practicing midwife in New Jersey (and maybe in the American College of Nurse Midwives). She gave us some history about the profession of midwifery. She reminded us midwifery is mentioned in the Bible and all the past royal houses of Europe used midwives for their births. She added she attended so many births in her career, she stopped counting after 3000.

Professor Diegman wanted to talk to us about pro-active change regarding lowering the cesarean section rate. UMDNJK has spearheaded a new initiative at Newark Beth Israel Hospital. UMDNJ has worked to become an official Vaginal Birth After Cesarean (VBAC) Center, keeping with the guidelines developed by the National Institutes of Health and the New Jersey Hospital Association. Dr. Diegman and Mary Markowsky, CNM, who heads the midwifery area of Newark Beth Israel, were instrumental in helping the hospital gain this distinction.

The empowering role of the childbirth educator

Professor Diegman stressed it is crucial we educate women about the normalcy of birth. She is passionate about the midwifery model of birthing. She wants to spread the word about how pain in childbirth is not like pain in illness, and emphasizes women do have the ability to rise to the experience of childbirth.

She emphasized the crucial role of education in preserving a woman-baby-centered birth culture. Professor Diegman said healthcare providers don’t normalize birth for women and don’t introduce women to nonpharmacological techniques to manage their birth.

Women only learn these techniques in independent childbirth education classes. So, the role of the childbirth educator is crucial in helping women understand what birth really can be and in getting our women back. The childbirth educator has a unique role to educate and empower women.

Dr. Diegman said the media and our constant exposure to technology has eroded women’s confidence in their ability to give birth. She wants to bring our women back. When Oprah, a powerful media presence, comes out positively about epidurals, that hugely influences our society’s views of birth. Dr. Diegman went on to say Oprah’s not the only one; there’s a constant flow of negative media stereotypes about birth. In addition, she said our constant reliance on technology has eroded our confidence in our bodies. She said “We need to be warriors and get our women back!”

Sonora Davis, community doula with the Hudson Perinatal Consortium, says “….women don’t seem to be taking the time to acknowledge their pregnancy or bond with their babies in utero.” She said she’s noticed this leads to a lack of focus on the birth. The other doulas, childbirth educators and midwives in the room echoed this concern, saying the disconnect during pregnancy sets up a disconnect to the experience in the birth room.

Childbirth educators play a crucial role in helping women know what their options are for birth, showing them what normal physiological birth looks like, and helping them focus on their pregnancy and the miracle of becoming a mother.

It is indeed good news that there appears to be a small upswing in one corner of the world back to women-baby-centered birth. As childbirth educators we can help women learn their options for women-baby-centered birth.

We need to keep asking, as Beverly Chalmers did in her editorial in Birth (2002):

How Often Must We Ask for Sensitive Care Before We Get It? 

References

Chalmers, B. (2002).How often must we ask for sensitive care before we get it? Birth, 29(2), 79-82.

 I wish to acknowledge Jill Wodnick, MS, in helping collate the information in this article.

Cesarean Birth, Childbirth Education, Uncategorized, Vaginal Birth After Cesarean (VBAC) , ,

A Midwife’s Voice: Mindbody Care for Pregnancy and Birth

April 27th, 2012 by avatar

This is a guest post by Trish DeTura, RN, CNM, MS, MAMA President

Pregnancy is such an exciting time in a woman’s life filled with the great wonder of what is to be. However, it may also be a time of great stress as a woman’s body goes through a great metamorphosis. Some of the common discomforts of pregnancy are round ligament pain, indigestion, aching back and pelvic pressure, just to name a few.

Add to this list the mental/emotional challenges a woman experiences in pregnancy surrounding the uncertainty around motherhood, sadness and depression.

One wonders as a practitioner, what can I offer this woman that will benefit her and her unborn baby?

While attending the Art of Birthing Conference in the New York Academy of Medicine in 2000, I found a wonderful complementary technique.

Complementary techniques are popularly used by many women for the relief of aches and pains during pregnancy and birthing (Jones et al, 2012). Leanna Jones and her colleagues (2012) found complementary methods were most often offered and used in midwife-led births. Relaxation, acupressure/acupuncture, massage and immersion in water were found to provide pain relief and positive maternal outcome without invasive side effects. Also, regarding acupuncture/acupressure, a decrease in the use of forceps, ventouse and cesarean section was noted (Jones et al; 2012).

I learned about Maya Abdominal Massage from Rosita Arvigo and Ms. Hortense Robinson. Rosita is a naprapath, herbalist and teacher of Maya medicine. She who apprenticed with Don Elijio Pante, a traditional Maya healer, in Belize, Central America. Ms. Robinson is a midwife.

They shared how the Arvigo Technique of Maya Abdominal Therapy (ATMAT), restores the body to its natural balance by correcting the positions of organs that have shifted and restrict the flow of lymph, blood, nerve and qi energy. Thus, ATMAT promotes homeostasis.

As a result of ATMAT, the pregnant woman experiences an increase of arterial blood carrying oxygen, nutrients and minerals to the mother and her unborn along with removal of any waste via the venous system and lymph. In addition, the mom experiences a removal of any congestion or blockages enhancing better hormonal, nerve flow and flow of chi.

I thought this all made good physiologic and common sense. I was hooked! Onward to learning this technique to support women with all kinds of challenges then onward to learning the pregnancy aspect of this method.

This gentle, non-invasive approach of this abdominal massage begins at 20 weeks of gestation continuing up to when the woman delivers. ATMAT eases the common discomforts of pregnancy.

I find it to be a lovely complement to a midwifery practice, the mom gets to focus on her baby and her developing baby intimately, thus preparing her to open psychologically and physically to her pregnancy and birth.

Tiffany Field, Ph.D. at the Touch Research Institute in Miami, has collected extensive data on the profound healing effects of touch, which is what ATMAT is- healing and nurturing touch- for both the mother and her unborn.

In the Journal of Psychosomatic Obstetrics and Gynecology, Field (2010) published a study demonstrating that regular massage during pregnancy results in: decreased anxiety, improved mood, reduced back pain, improved sleep patterns, reduced stress hormone levels, fewer complications during labor and fewer complications for infants following birth.

Further, Field (2010) reports women who have received massage therapy experienced significantly less pain and their labors were on the average three hours shorter.

The data collected by the midwives providing ATMAT to their pregnant clients supports these findings. In addition to the shortening of labors, mothers who receive ATMAT bond with their unborn baby leading to less postpartum depression. This has been substantiated by Dr. Tiffany Field and her colleagues in a 2009 study revealing that postpartum depression was lessened as a result of prenatal massage.

It is my hope that one day the Arvigo Technique of Maya Abdominal Therapy will be recognized as an essential and vital aspect of maternity care. To learn more about this great modality please go to: www.Arvigotherapy.com

References:

Field, T. (2010). Pregnancy and labor massage therapy. Expert Review of Obstetrics and Gynecology, 5, 177-181.

Field, T., Diego, M., Hernandez-Reif, M., Deeds, O., & Figueiredo, B. (2009). Pregnancy massage reduces prematurity, low birthweight and postpartum depression. Infant Behavior & Development, 32, 454-460.

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP.Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

Trish DeTura, RN, CNM, MS specializes in the Arvigo Technique of Maya Abdominal Massage, a non-invasive and natural technique of restoring health to the reproductive organs. She is in private practice in Hoboken, NJ. Contact her at trishdetura@gmailcom

Cesarean Birth, Childbirth Education, Continuing Education, Do No Harm, Guest Posts, Midwifery, Pain Management, Uncategorized , , , , , , ,

Caring for Survivors of Sexual Abuse Throughout the Childbearing Journey

April 25th, 2012 by avatar

A guest post by Deborah Issokson, Psy.D.

Childbearing is a vulnerable process.

Regardless of our profession within the childbirth world, we are working to facilitate an experience that has a positive emotional outcome accompanied by a healthy psychological adjustment to motherhood. It is incumbent upon us to understand and be sensitive to all the ways in which childbearing can be both triggering and potentially healing for women with abuse histories.

It is crucial to remember that not all survivors will have the same experience of pregnancy, birth, postpartum and breastfeeding. And we cannot assume that all women experiencing difficulties with aspects of childbearing such as pelvic exams, touch, immodesty, language, and pain are abuse survivors.

For an abuse survivor, abuse memories may be triggered by the physical changes, social and psychological tasks, medical procedures, and rituals of childbearing.

For some, abuse memories and emotions will be familiar, expected; others may experience these memories as regressive in their healing. For still others, the memories and emotions will be unexpected and intrusive, signaling the first time they are coming forth.

Preserving the Mental Health of Sexual Abuse Survivors

From a mental health perspective, the task with an acknowledged sexual abuse survivor during childbearing is threefold: help her maintain her current level of functioning, help her contain the memories, and facilitate further healing using childbearing as a vehicle for growth.

If the woman is unaware of her abuse history, we may be in the position of suspecting it or listening to her share her own inklings based on the feelings, concerns, fears and distress that she is experiencing and we are observing.

However, the Pandora’s box of sexual abuse memories must be opened delicately. Ideally, pregnancy is a time of containment as a woman grows a baby inside her body, preparing psychologically and spiritually for motherhood. And while birth is a time of opening and transforming, it is also a time when we want to limit extraneous, stressful stimuli so that a woman can immerse in her transformation to motherhood.

Strategies for Childbirth Professionals

So what do we do, in our respective roles, to meet these goals, implement these tasks and stay mindful of pacing, timing and professional limitations and boundaries?

  • We can encourage a woman to review coping strategies she has previously employed.
  • We can encourage her to seek support from a therapist, partner, friends, a support network.
  • We can help her stay grounded by contextualizing her physical changes and discomforts, reviewing the real and appropriate changes happening in her body, reflecting on her health and resilience and helping her pace herself as she adjusts to the changes.
  • We can be instrumental in helping a woman explore her choices for place of birth, care providers, and birth intentions. Her choice of provider and the manner in which she makes her choices may be affected by her abuse history and by the gender of her abuser. She may choose a provider and a place of birth that could facilitate a healing experience for her. On the other hand, she may unconsciously recreate the dynamics she experienced with her abuser.

Women wonder about sharing their abuse story with everyone who cares for them, be it the medical provider, the educator, the doula or the breastfeeding counselor. While it isn’t necessary to tell the entire story, it can be helpful for certain providers to have a general sense of the history in order to be sensitized to the woman’s issues as they pertain to prenatal care, labor and delivery, postpartum care and breastfeeding assistance.

If a woman is working with a group practice or being taught by a revolving set of educators, she may not want to repeat her story for each provider. Rather, we can encourage her to share with one provider with whom she feels most comfortable, asking that a brief note be put in her chart to inform the others. We can also suggest she write a brief statement herself, highlighting what she most wants her providers to know about her story, her vulnerabilities and her coping strategies.

Emotional dynamics of birth and transition to parenting
For an abuse survivor, normal fears, anxieties and concerns about birth can take on additional psychic charge due to the physical and sexual nature of birth.

On one end of the continuum is the experience of giving birth as healing; on the other end is the feeling that birthing is tantamount to a recurrence of sexual abuse. In between are shades of gray.

Most births have healthy, uncomplicated physical outcomes; the emotional outcome is not so predictable. There is no telling how a woman will experience her birth and how she will make meaning of it. As a witness to her birth, we may perceive it as wonderful, empowering and successful, while the woman may have a completely different emotional experience and perception.

Furthermore, the emotional outcome is an unfolding process for the postpartum woman. The new mother spends part of her postpartum year reviewing and dissecting her birthing experience. It is not unusual for the survivor of abuse, years later, to have a new perspective on her experience. Sometimes it is a more healing perspective.

For an abuse survivor, the postpartum period can be a time of consolidation of past healing efforts as she enters a phase of parenting and protecting a new human being.

For other women, parenting can be the catalyst for new memories and flashbacks, new conflicts with extended family, and even regression in the healing process. Survivors of abuse are at high risk for experiencing postpartum depressive and anxiety disorders. These mental health issues require attention and treatment as soon as possible as they have a detrimental impact not only on the woman, but also on her baby and her entire family.

Empower by Giving Space to the Individual Woman
As providers of care, we are often witness to great courage, strength and healing as survivors of sexual abuse journey toward parenthood.

Empower your client to shape this childbearing experience for herself. Ideally, your work together can culminate in a positive emotional experience of pregnancy and birth, a healthy connection between mother and baby, and a sense of self-efficacy as a mother.

REFERENCES

Issokson, Deborah. 2004. Chapter 11, Effects of Childhood Abuse on Childbearing and Perinatal Health in Health Consequences of Abuse in the Family: A Clinical Guide for Evidence-Based Practice, K. Kendall- Tackett, editor. Washington D.C.: American Psychological Association.

Kendall-Tackett, K. 1998. Breastfeeding and the sexual abuse survivor. Journal of Human Lactation, 14(2), 125-130.

Simkin, Penny and Phyllis Klaus. 2004. When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women. Washington: Classic Day Publishing.

Sperlich, Mickey and Julia Seng. 2008. Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse. Oregon: Motherbaby Press.

Deborah Issokson, Psy.D, is a licensed psychologist in Massachusetts specializing in Perinatal Mental Health. She is a contributor to several editions of Our Bodies, Ourselves. She was a faculty member of the Boston University School of Public Health, lecturing on Maternal and Child Health (now closed). She  can be reached at info@reproheart.com. Visit her website at www.reproheart.com.

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Healthy Care Practices, informed Consent, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Research, Survivors of Sexual Abuse , , , , , , , , ,

Research Review: Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders

April 23rd, 2012 by avatar

A guest post by Sana Johnson-Quijada, MD

Autism is a syndrome, not a disease, with multiple genetic and non-genetic causes (Muhle, Trentacoste and Rapin; 2004). Current research has not been able to clearly define a definite cause of autism.

A recent study has added to our body of knowledge about autism. Krakowiak et al (2012) has published collaborative research showing a correlation between a mother’s health during pregnancy,  i.e. Maternal Metabolic Conditions, such as diabetes, hypertension and obesity, and neurodevelopmental disorders in children. The correlative evidence related to autism is listed below:

Etiology of Autism – Correlative Evidence

  • Maternal Metabolic Conditions (Krakowiak et al, 2011)
  • Toxins (oxidative stress) (Garecht and Austin, 2011)
  • Multiple interacting genetic factors (a specific gene has not been identified) (Muhle, Trentacoste and Rapin, 2004)
  • Sibling pairs (Greenberg, Hodge Sowinski and Nicoll, 2001)
  • Medications (Garecht and Austin, 2011)
  • Birth order (Turner, Pihur, and Chakravarti, 2011; Durkin et al, 2010)
  • Parental age (Turner, Pihur, and Chakravarti, 2011; Durkin et al, 2010)

Can the information from the study of Krakowiak et al (2012) help reduce the incidence of autism? Importantly, the information is correlative and does not demonstrate causality. The study, Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders, is simply done, makes sense, and is consistent with other studies that demonstrate that a healthy Mom helps produce a healthy fetus.

Let’s take a look at this specific study. In California, between 2003- 2010, Krakowiak et al (2012) enrolled 689 children (ages 2 – 5 years old) with a diagnosis of autism spectrum disorder or developmental delay, along with 315 children in a control group, in the CHARGE study (Children Autism Risks from Genetics and the Environment). The children were diagnosed by using standardized testing. The mothers were diagnosed by medical records and structured interviews.

The researchers found that all Maternal Metabolic Conditions, such as diabetes, hypertension and obesity, were more prevalent among the case mothers than the control mothers. The researchers note their findings are consistent with other studies linking maternal diabetes to impairments in their children.

Maternal diabetes, hypertension and obesity are associated with the maternal conditions of increased insulin resistance, poorly regulated glucose levels and chronic inflammation, which all adversely fetal development.

Prolonged exposure of the fetus to maternal elevated glucose levels can result in chronic fetal hyperinsulemia, which then results in increased fetal oxygen consumption and metabolism, which induces chronic intrauterine tissue hypoxia and possibly, downstream fetal iron deficiency. Both fetal tissue hypoxia and fetal iron deficiency can profoundly affect neurodevelopment in humans, such as aberrations in myelination, cortical connectivity and hippocampal neurons (Krakowiak et al, 2012).

Maternal chronic inflammation is associated with excess production of pro-inflammatory interleukin and cytokines in the mother. These substances cross the placenta and can adversely affect fetal development. Cytokine interleukin-6 has been associated with adverse development of the hippocampus and seizures in animal studies (Krakowiak et al, 2012). Other studies have found a correlation with inflammation and autism, including the studies on mercury fueling the oxidative stress found in autism (Garecht and Austin, 2011).

What do we know about inflammation? Inflammation triggers expression of cancer genes, depression genes, irritable bowel syndrome and so forth. Genes start talking and moving when they are pushed. Remember the research we have demonstrating familial inheritence in autism? Krakowiak et al (2012) believe inflammation may be a voice that is heard during pregnancy as well.

Does this study give us enough evidence to use when advising mothers to be healthy during pregnancy? The studies are not conclusive. But they make sense.

In participating with patients (clients) in their health care, life choices and treatments, ultimately, we all know, the patient (client) is accountable to him or herself. We present them with information and let them make their choices.

This study is consistent with life “sense,” and is empowering to all of us. We find in the idea of caring for our bodies and our children that we must do the friendly thing, starting with good self-care.

References:

Autistic children: diagnosis and clinical features. Rapin I. Pediatrics. 1991 May;87(5 Pt 2):751-60. Review.

Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders, Paula Krakowiak, Cheryl K. Walker, Andrew A. Bremer, Alice S. Baker,Sally Ozonoff, Robin L. Hansen, and Irva Hertz-Picciotto. Pediatrics peds.2011-2583; published ahead of print April 9, 2012,doi:10.1542/peds.2011-2583

The Genetics of Autism.Rebecca Muhle, Stephanie V. Trentacoste, and Isabelle Rapin. Pediatrics 2004; 113:5 e472-e486

Evidence of novel fine-scale structural variation at autism spectrum disorder candidate loci.Hedges DJ, Hamilton-Nelson KL, Sacharow SJ, Nations L, Beecham GW, Kozhekbaeva ZM, Butler BL, Cukier HN, Whitehead PL, Ma D, Jaworski JM, Nathanson L, Lee JM, Hauser SL, Oksenberg JR, Cuccaro ML, Haines JL, Gilbert JR, Pericak-Vance MA. Mol Autism. 2012 Apr 2;3(1):2.

The plausibility of a role for mercury in the etiology of autism: a cellular perspective.Garrecht M, Austin DW. Toxicol Environ Chem. 2011 May;93(5-6):1251-1273

Effect of Prenatal Valproic Acid Exposure on Cortical Morphology in Female Mice.Hara Y, Maeda Y, Kataoka S, Ago Y, Takuma K, Matsuda T. J Pharmacol Sci. 2012 Mar 22.

Quantifying and modeling birth order effects in autism. Turner T, Pihur V, Chakravarti A.PLoS One. 2011;6(10):e26418. Epub 2011 Oct 19.

Excess of twins among affected sibling pairs with autism: implications for the etiology of autism. Greenberg DA, Hodge SE, Sowinski J, Nicoll D. Am J Hum Genet. 2001 Nov;69(5):1062-7

Advanced Parental Age and the Risk of Autism Spectrum Disorder. Durkin, MS, Maenner, MJ, Newschaffer, LL, Cunniff, CM, Daniels, JL, Kirby, RS, Leavitt, L., Miller, L., Zahorondy, W., Schieve, LA. American Journal of Epidemiology. 2010, 168(11);1268-1276.

Sana Johnson-Quijada, MD, is a board certified psychiatrist who completed her psychiatry residency and fellowship in Primary Medicine between Loma Linda University and Harvard South Shore in 2002. She is in private practice in the areas of outpatient clinical, ECT, and serves as the Medical Director of the Loma Linda University Behavioral Medical Center Partial Hospital of Murrieta, California. Along with her husband, she parents her three children. She never gets tired of talking about becoming a friend to yourself. She’d love to hear from you via her website, Friend to Yourself.

Uncategorized

Part Two in a Series: Risk Factors and Types of Perinatal Mental Illness for Birth Professionals

April 20th, 2012 by avatar

Read Part One in this series . . .

Risk Factors for Perinatal Mental Illness (saaay what – so many??)

Etiology: Bio-psycho-social

Current research does not give us a crystal clear cause for perinatal mood disorders. It seems that a convergence of biological, psychological and social (biopsychosocial) factors play a role in the intensification of anxiety and mood disorders during the childbearing year.

In other words, it is likely that a mixture of past mental health issues, hormonal changes and stressors from your current situation create a vulnerability to a mood disorders in the childbearing year (Kleiman & Wenzel, 2011; Kleiman, 2009; PSI, 2009; Puryear, 2007; Nonacs, 2006; Kendall-Tackett, 2005).

Listed below are some of the commonly acknowledged risk factors. I tried to group them into bio/psycho/social categories, but as you can see, there is much overlap.

Biological / Psychological

  • A personal history of a mental illness in her lifetime, ie, depression anxiety, PTS/PTSD, OCD or bipolar disorder (may have been diagnosed & treated or was undiagnosed & untreated) (previous PPD history increases risk to 50 – 80 % risk of recurrent PPD, as compared to 10- 20% risk w/o a prior episode)
  • A familial history of depression or anxiety disorders, etc (undiagnosed/diagnosed)
  • Premenstrual syndrome/disorder. A woman with a heightened sensitivity to her hormonal cycle, may be more vulnerable to the hormonal changes of pregnancy & birth.
  • A heightened sensitivity to hormonal fluctuations of pregnancy and childbirth.
  • Going through a traumatic birth. Traumatic birth occurs on a continuum from disappointing care to painful natural birth to life rescue efforts during the birth (huge topic)
  • Her infant is born premature (both the birth and the NICU experiences can be traumatic)
  • A history of extensive infertility treatments, trauma from necessary medical procedures
  • A history of previous miscarriages (can accompany infertility tx or not)
  • Unresolved feelings about termination of an earlier pregnancy
  • Her infant is born with a disability.
  • Her infant is stillborn, or a history of previous stillbirth

Social / Psychological

  • Poverty is a big risk factor for the development of perinatal mental illness.
  • Lack of social support: geographical move, a non-supportive family structure (alcoholism, etc), or a major change in job (ie, from career to SAHM).
  • Unhealthy current family dynamics: Occurs on a continuum from feelings of disconnect, poor communication & relationship skills, different parenting styles, bullying, to domestic violence
  • Domestic Violence creates a complex history of trauma/PTS/PTSD
  • Personal history of sexual abuse or sexual assault creates a complex history of trauma/PTS/PTSD.
  • Past family dynamics: Unresolved issues from childhood regarding parenting and being parented interferes with the transition to parenthood (huge topic -can cause major anxiety and depression)
  • Major life stressors, such as an accident or death in the family.

Differential Types of Perinatal Mental Illness

An accurate diagnosis?

I’ve gotten feedback (thank you Lara!) that I need to acknowledge not all sadness and stress in new mothers should be considered pathological, ie, needing diagnosis and treatment. So I’d like to publicly say that being a mom, caring for a newborn, can be overwhelming and that sleep deprivation can be a big factor in destabilizing a person emotionally, and some support for a new mom such a hard job can go a long way. Debra Flashenberg, CD(DONA), LCCE, wrote an article for Lamaze about her friend’s personal experience with a perinatal mood disorder.

The thing about any mental illness is that it exists on a broad continuum from “adjustment” behavior to varying degrees of “abnormal” behavior, where the person becomes so disorganized in their daily living that it does warrant treatment, Where that line is, is not always obvious, and requires discernment and sensitivity to individual needs.

The clinical presentation of the diagnoses below often overlap and/or co-occur. Diagnosis is sometimes not simple, and may be confounded by a prior history of depression, anxiety, post-traumatic stress influenced by previous life experiences.

Simpler depression and anxiety can be diagnosed and treated in primary care. A psychiatric consult is necessary for more complex cases. Licensed mental health professionals can diagnose and treat a broad range of mental disorders. Optimal treatment is usually a combination of medication, therapy and social support, tailored to individual needs.

Not all of the following categories of perinatal mental illnesses are recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM). But, many practitioners in perinatal mental health, including authors of the references to this article, recognize these differential diagnoses in clinical practice.. There is currently an active discourse in creating these new diagnoses.

Rates of perinatal mood disorders occurrence:

  • 85% suffer baby blues
  • 15% suffer depression
  • 10% suffer postpartum anxiety
  • 3 – 5% postpartum OCD
  • .1% postpartum psychosis
  • 1 – 6 % postpartum (birth) trauma – PTSD

Alphabet soup: BB, PPD, PPA/PPOCD, PP, PTSD/CB

These categories may seem confusing, but, as a childbirth educator, you don’t have the burden of diagnosis, this is for educational purposes.

BB – Baby Blues. Not a mental illness. The baby blues self-resolve and are normal. Occurs in the first two weeks or so after birth, goes away by itself. Not a mild form of postpartum depression.

PPD – Postpartum Depression.

Symptoms: If weepiness, sleeplessness, low self-esteem, change in appetite, feelings of being abandoned, alone, anger (rage), listlessness continue past two – three weeks, may be indicative of PPD. May have thoughts of self-harm or of harming the baby. In general, women who are depressed after birth who actually attempt and commit suicide are those who have histories of previous psychiatric events or previous suicide attempts. But, whenever harming behaviors are mentioned, please take it seriously. Some specialists believe PPD can overlap BB and can occur anytime in the first year. If the sad feelings are dragging on past the two-three week delimiter, it is best to seek help, rather than continue to suffer painful debilitating symptoms while also caring for an infant.

PPA/PPOCD – Postpartum Anxiety/OCD – PPA/PPOCD.

Some research suggests that some women who develop PPA/PPOCD have a heightened sensitivity to hormonal levels, in particular oxytocin, and this sensitivity may over-stimulate natural maternal behaviors, thus increasing maternal behaviors to over-protectiveness (Driscoll and Sichel, 1999). Other researchers believe the pre-existence of perfectionistic/rigid thinking styles may predispose a woman to PPA / PPOCD (Kleiman & Wenzel, 2011).

Symptoms: A pervasive anxiety that expresses itself as over-concern for the baby, over concern about germs, cleanliness, sleep arrangements, parenting skills and the normal attachment process. The mom becomes hyper-vigilant. She may bring baby to the hospital or doctor over and over again. She may develop checking behaviors such as checking to see if the blankets around the baby are folded properly, checking to see if the baby is breathing over and over again. She may engage in checking and counting rituals (counting the ceiling tiles, right angles, etc), which help her feel safe & soothed. She ay have scary thoughts about harming the baby or herself may occur. As in PPD, these must be taken seriously.

PP – Postpartum Psychosis. Separate disorder from PPD/ PPA/PPOCD

Most significant risk factor for PP is previously (un)diagnosed bipolar disorder, a previous psychotic episode or a family history of schizophrenia. Healthcare provider screening and prevention is extremely relevant to PP. Women are most susceptible in the first thirty days after childbirth. Postpartum psychosis is a psychiatric emergency. Get help immediately.

Symptoms:

Not sleeping for a few nights in a row, delusions, speaking about nonsensical beings, thoughts about evil beings, death, intense fear, mumblings, robotic movements, acting as if she can hear words coming from somewhere else (command language), staring, flat affect, deflated speech, one word answers, catatonia, staring, paranoia. You cannot talk a person out of their psychotic delusions. Best to nod your head, say, “I understand” or “Must be hard” and GET HELP IMMEDIATELY. The person is very ill and needs help, not ridicule or fear.

Post-traumatic Stress Disorder (PTSD) Secondary to Childbirth -PSTD/CB.

Walker Karraa has written many articles about trauma and childbirth for Science and Sensibility. Like all emotional experiences, trauma is experienced on a continuum. There are two recognized diagnoses: post-traumatic stress (PTS) and post-traumatic stress disorder (PTSD), with PTSD having more long-term symptoms.

Symptoms of PTS are considered normal reactions to a traumatic event. PTS symptoms are the same as PTSD, but present to a lesser extent: dissociation, avoidance, numbing, flashbacks, hypervigilance, anxiety, depression. Normal response to trauma is considered a normal survival response, our mindbody’s way of integrating traumatizing events slowly, in small chunks. This way of ignoring things to get by, to a normal extent, is sometimes called “coping ugly.” PTS symptoms are self-limiting, and most people recover from it.

 Ayers (2004) reports 1/3 women in western world consider their birth to be traumatic and ten percent report severe symptom of traumatic stress. Dr Ayers (2004) says difficult birth experiences affects psychological health, but for majority it is self-resolved. 1% – 2% develop clinical post-traumatic stress symptoms which need treatment.

“Part Three” coming up is a guide to positive helping and suggested resources.

Do you believe you can be a positive influence regarding maternal mental health?

Do you believe it is important to be aware of perinatal mental illness?

Please share your views below. Love to hear from you!

References

Ayers, S. (2004). Delivery as a traumatic event: Prevalence, risk factors, and treatment for postnatal post-traumatic stress disorder. Clinical Obstetrics and Gynecology, 47(3), 552-567.

Driscoll, D. and Sichel, J. (1999). Women’s moods: What every woman must know about hormones, the brain, and emotional health. New York: HarperCollins

Kendall-Tackett, K. (2005). Depression in new mothers. New York: Haworth Press.

Kleiman, K. (2009). Therapy and the postpartum woman. New York: Routledge Press.

Nonacs, R. (2006). A deeper shade of blue. New York: Simon and Schuster.

Postpartum Support International (2009). Components of care. Seattle: PSI

Puryear, L. J. (2007). Understanding your moods when you’re expecting. New York: Houghton Mifflin Company.

Twomey, T.M. (2009). Understanding postpartum psychosis: A temporary madness. Westport, Ct.: Praeger Publishers.

Babies, Childbirth Education, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD , , , , ,