How to Soothe Common Pregnancy Discomforts: Heartburn

In this new series on Giving Birth with Confidence, we’re going to cover some of the most common discomforts that can happen during pregnancy and share tried-and-true ways to help soothe or eliminate them. Pregnancy can be an amazing time in a woman’s life, but it can also be challenging. The reality is that some women’s bodies accept and cope well with pregnancy and some don’t. In any case, having extra tools in your coping toolbox can go along way toward increasing your quality of life during the 4o-ish weeks of pregnancy.

Five Ways to Extinguish the Fire of Heartburn During Pregnancy

By Hillari Dowdle, freelance writer for FitPregnancy

It was heartburn that got me in the end. I could take the swelling, the back pain, the constant trips to the bathroom, the itchy skin, the fatigue, the sweating, the sleeplessness and even the psychological shock of seeing the scale tip 200 pounds. But the constant, searing pain of heartburn made the miracle of pregnancy seem more like a curse—by the middle of my third trimester, my mantra had changed from Please, let him be healthy! to Just get him OUT!

That fiery sensation known as heartburn happens when the lower esophageal sphincter (LES), a muscle responsible for keeping stomach contents in their place, begins to relax or leak. this allows stomach acids to flow upward into the esophagus, explains Suzanne Trupin, M.D., CEO of Women’s Health Practice of Champaign, Ill. Pregnant women are prime candidates for two reasons: First, the hormone relaxin—busy limbering up your joints and connective tissue for an easier birth—slows your digestion, meaning food stays in your stomach longer and triggers more acid production. Second, your growing baby exerts pressure on both the stomach and the LES, increasing the chance that acids will be pushed up into the esophagus.

So what’s an expectant mother to do? Follow these five tips to relieve the pain:

1. Eat less, more often
Overeating exacerbates heartburn, says rachel Brandeis, M.S., a registered dietitian in Atlanta who specializes in prenatal nutrition. “When you’re pregnant, there’s less room for your stomach to expand,” she explains. Maintaining a sensible diet will not only stave off heartburn in the short term, but throughout your pregnancy as well, because gaining more than the recommended weight puts more pressure on your abdomen, which can trigger the condition. Instead of three meals a day, aim for six mini-meals (See “Mini-Size Me” below) of no more than 1 1⁄2 cups of food each, Brandeis recommends. Smaller meals are easier for your body to digest.

2. Eliminate trigger foods
Identify the foods that intensify your heartburn and banish them from your diet. While there are no universally “banned” foods, common heartburn triggers include acidic foods, such as citrus fruits and tomatoes, greasy or fried foods, spicy foods, chocolate, coffee, carbonated beverages, and alcohol (which, as you well know, you should eliminate anyway!).

3. Focus on fluids
“Liquid-y foods are less likely to cause problems than solids, since they move through the stomach more quickly,” Brandeis says. Soups, smoothies, yogurt, milkshakes, protein shakes and puddings are good choices. Look for liquids that offer plenty of protein, such as milk and drinkable yogurt, and aim to make solids a little less so: “chew solid foods slowly and extremely well, until they’re almost liquefied,” Brandeis adds.

4. Sleep smart
To avoid nighttime heartburn, don’t eat anything for at least three hours before bedtime. Elevate the head of your bed by placing books under the legs, and if you’re not already sleeping on your left side, start now; stomach acids will have to travel uphill to reach the esophagus—no easy feat!

5. Time for Tums
It’s fine to find relief in a bottle of tums or rolaids or other calcium- containing antacids. However, “too much calcium can block iron absorption, so don’t take tums at the same time you take your prenatal vitamin,” Brandeis advises. By the time I gave birth, I estimate I’d ingested my own considerable body weight in tums. This overuse created calcium overload, which may have exacerbated my anemia. If you’re taking antacids 10 times a day (or more—as I was), talk to your doctor: she may want to check for ulcers or a hiatal hernia (where part of the stomach protrudes into the chest cavity), or prescribe medication.

Also, avoid antacids that list aluminum (such as aluminum hydroxide or aluminum carbonate) as an ingredient; it can cause constipation and can even be toxic in large doses. Remedies containing aspirin (such as alka-seltzer) should also be avoided during pregnancy; look for salicylate or acetylsalicylic acid in ingredients lists. You don’t want an antacid containing sodium bicarbonate (baking soda) or sodium citrate, either. Both are high in sodium, which causes water retention.

Mini-Size Me

Here’s a sample of what a day’s worth of small, healthful meals looks like:

1 cup of oatmeal with milk and 1 apple

1 cup of yogurt with fruit

1 ⁄2 peanut butter and jelly sandwich and 1 cup of vegetable soup

1 handful of whole-grain crackers and 1 ounce of your favorite hard cheese

2 ounces of chicken, 1 ⁄2 cup of mashed sweet potatoes and 1⁄2 cup of cottage cheese with fruit

Find eight more small snacks that are easy to make, packed with pregnancy nutrients and delicious at fitpregnancy.com/snackideas.

 

Did you experience heartburn during pregnancy? What helped you get rid of it? Share in the comments — women want to know!

 

How to Screen Yourself for Postpartum Depression

May is Mental Health Month. As childbirth education advocates, Lamaze believes that mental health during and after pregnancy is critical to the health and safety of moms and their babies. If you are experiencing depression, anxiety, psychosis, or any other mental health issues, contact your care provider and seek support and resources from Postpartum Progress and Postpartum Support International. You don’t have to suffer alone — and you don’t have to suffer. There is support and treatment available for mental health disorders. Also know that you are not alone — it has been found that 1 in 7 women will experience postpartum depression, though that rate is thought to be higher for all postpartum disorders.

So how do you know if you are experiencing a postpartum disorder? Many moms downplay or dismiss their feelings, chalking them up to “hormones,” but it’s important to take notice and check in with yourself. A postpartum disorder is more than just a “bad day,” and even if you feel as though you are coping, a postpartum disorder ultimately affects your quality of life. If you feel as though something is “off” or if your partner expresses concern about your state of well-being, you can take a free, quick, confidential, online screening quiz to determine whether you may be suffering from postpartum depression.

The Edinburgh Postnatal Depression Scale (EDPS) was developed in 1987 to help doctors determine whether a mother may be suffering from postpartum depression. The scale has since been validated, and evidence from a number of research studies has confirmed the tool to be both reliable and sensitive in detecting depression. The EPDS Score is designed to assist — not replace — clinical judgment. If you feel you may be at risk or suffering from post natal depression, please share the results with your care provider.

Pregnancy, Birth & Postpartum Resolutions

New Year’s resolutions may take on more meaning if you’re preparing for the birth of a child in 2013. This year, perhaps for the first time, “join the gym and lose 10 pounds” isn’t on the list. At the same time, many of the resolutions you make for a healthy pregnancy look a lot like those you would make for a healthy lifestyle, pregnant or not. For example:

  • eat fruit and vegetables daily
  • get 8 hours of sleep
  • exercise 30 minutes a day
  • carve out time for yourself
  • ask for help when you need it

For a healthy pregnancy, birth, and postpartum period, we’ve compiled a few significant resolutions for you to consider adding to your list this year.

 

Pregnancy

Listen to your body. If it’s telling you to slow down, do all that you can to make it happen. Cereal for dinner? Why not. Nap at 6 p.m.? Yep. On the other hand, if you’re feeling great, don’t let pregnancy slow you down — continue your exercise regimen, meet up with friends for dinner, enjoy life!

Learn about evidence-based maternity care. You can’t always count on your care provider to give you the best, most up-t0-date care. How will you know if you’re not receiving the best care? Learn how to navigate the maternity care system and how you can get the best care.

 

Labor & Birth

Plan for the best support. Who will attend your birth? Do they support your wishes? Will they provide positive energy? Think carefully about your birth support team. Look into hiring a doula. Share your birth plan with everyone well before labor begins.

Take labor one step at a time. Humans seem to be hardwired to think about what’s going to happen next. With labor, it helps to only think about what’s happening now. If you can take each contraction, each stage, each moment as it’s happening, you’ll be better able to put complete focus on the task at hand instead of worrying about what’s to come.

 

Postpartum

Speak up. It’s wonderful to have friends and family ooo and ahh at your new little joy. But a house full of visitors can be overwhelming during a time when you’re trying to understand a brand new world. Feel free to ask for some time and space alone with your baby. Post visiting hours on your front door or update your Facebook status to let friends know when you’re accepting visitors.

Know the signs of postpartum depression/disorders. Postpartum mood disorders (anxiety, depression, OCD, psychosis) affect hundreds of thousands of women every year. With knowledge of the warning signs and access to resources, women who suffer from postpartum mood disorders can and do recover.

Maternal Mental Health: Pre-Existing Risk Factors for PTSD and Childbirth

In light of the horrific and tragic events that took place at Sandy Hook Elementary School last Friday, Giving Birth with Confidence will be dedicating our posts this week to providing resources relating to mental health and wellness. Approximately 1.3 million women annually suffer from mental health disorders that occur during pregnancy and in the postpartum period. Perinatal and postpartum anxiety and mood disorders far outweigh the annual occurrence of several other major diseases combined. The key to finding help and treating mental health disorders is awareness; the more people who know how to spot warning signs and what to do to find help, the greater our possibility for better health.

 

 

This article is part of the Traumatic Birth Prevention & Resource Guide by PATTCh. Access the complete guide to learn more about traumatic birth and find resources for women and families.

By Heidi Koss, MA, LMHC

Health care providers aren’t exactly sure why some people get post-traumatic stress disorder (PTSD) when exposed to a traumatic event while others do not. Post-traumatic stress disorder can develop when you go through, see or learn about an event that causes intense fear, helplessness or horror. Any trauma, including birth trauma, lies in the eye of the beholder. What one may perceive as traumatic might not be traumatic to others.

As with most mental health problems, PTSD is probably caused by a complex mix of:

  • Your inherited mental health risks, such as an increased risk of anxiety and depression
  • Your life experiences, including the amount and severity of trauma you’ve gone through since early childhood. PTSD can result from a cumulative effect of multiple traumas over a lifetime.
  • The inherited aspects of your personality — often called your temperament
  • The way your brain regulates the chemicals and hormones your body releases in response to stress

General Risk factors for Post-Traumatic Stress Disorder
People of all ages can have post-traumatic stress disorder. However, some factors increase risk of developing PTSD after a traumatic event, including:

  • Being female — women may be at increased risk of PTSD because they are more likely to experience the kinds of trauma that can trigger the condition.
  • Experiencing intense or long-lasting trauma
  • Having experienced other trauma earlier in life
  • Having other mental health problems, such as anxiety or depression
  • Lacking a good support system of family and friends
  • Having first-degree relatives with mental health problems, including PTSD and depression
  • History of abuse (such as childhood abuse, sexual abuse, rape)
  • Combat exposure
  • Physical attack
  • Being threatened with a weapon
  • Car accident, plane or train crash
  • Life threatening experience (such as natural disaster, critical injury, medical crisis, attack, mugging)

These symptoms should alert you to possible PTSD:

  • Flashbacks of the event — vivid and sudden memories
  • Nightmares
  • Insomnia
  • Fears of recurrence
  • Emotional numbing
  • Panic attacks
  • Inability to recall important aspects of the event — psychogenic amnesia
  • Exaggerated startle response, hyper-arousal, always on guard
  • Hyper-vigilance, constantly looking around for trouble or stressors
  • Avoidance of reminders of the traumatic event
  • Intense psychological stress at exposure to events that resemble the traumatic event

How is PTSD different than other Pregnancy and Postpartum Mood Disorders?
Sometimes perinatal mood disorders overlap and it’s hard to tell where one ends and the other begins. PTSD is caused by an event in which you feel threatened, violated, and feel as if you could die. By the way our brain has processed the memory of the event, is causes heightened anxiety, hypervigilance, flashbacks, nightmares, etc. Therefore PTSD is an anxiety or stress reaction and it is different from other postpartum mood disorders such as depression and anxiety. However, other postpartum mood disorders can occur at the same time PTSD.

Resources
Recommended Books:

  • Postpartum Mood and Anxiety Disorders, A Clinician’s Guide, by Cheryl Tatano Beck and Jeanne Watson Driscoll
  • Beyond the Birth, A Family’s Guide to Postpartum Mood Disorders, by Juliana Nason, Patricia Spach and Anna Gruen. Published by Postpartum Support International of WA
  • When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, by Penny Simkin and Phyllis Klaus

Useful Organizations & Websites:

Heidi Koss, MA, LMHCA is a psychotherapist in private practice in Redmond, WA specializing in pregnancy and postpartum mood disorders (PPMD), birth trauma, and parent adjustment issues. She has been the Executive Director of Postpartum Support International of Washington (PSI of WA), WA State Coordinator for Postpartum Support International as well as co-founder of the Northwest Association for Postpartum Support (NAPS). She offers consultant services and PPMD trainings. Heidi has also been a postpartum doula and certified lactation educator. Heidi is the proud mother of two beautiful daughters.

 

 

 

PATTCh is a not-for-profit, multidisciplinary organization dedicated to the prevention and treatment of traumatic childbirth. Our mission is to develop cross-disciplinary relationships, research, and programs that:

  • prevent PTSD following childbirth through education, interdisciplinary collaboration, and multidisciplinary research;
  • educate perinatal care providers and paraprofessionals in the prevention and treatment of birth and reproduction related trauma;
  • encourage the development of culturally appropriate therapeutic approaches to post-traumatic stress symptoms following childbirth;
  • promote healthy birth practices for all women and families;
  • promote evidence-based research regarding PTSD secondary to childbirth;
  • increase global awareness of the prevalence, risk factors, and effects of PTSD secondary to childbirth; and
  • support collaboration and understanding among all stake-holders, including: researchers, policy makers, medical and mental health care providers, educators, community members, volunteers, women, and families.

 

Maternal Mental Health: Daily Support Service for Mothers Who Suffer from Postpartum Disorders

In light of the horrific and tragic events that took place at Sandy Hook Elementary School last Friday, Giving Birth with Confidence will be dedicating our posts this week to providing resources relating to mental health and wellness. Approximately 1.3 million women annually suffer from mental health disorders that occur during pregnancy and in the postpartum period. Perinatal and postpartum anxiety and mood disorders far outweigh the annual occurrence of several other major diseases combined. The key to finding help and treating mental health disorders is awareness; the more people who know how to spot warning signs and what to do to find help, the greater our possibility for better health.

Postpartum Progress (www.postpartumprogress.com), the most widely-read blog in the United States on postpartum depression, hosts a service to help pregnant and new mothers get through the difficulty of perinatal mood and anxiety disorders.

Daily Hope is the nation’s first support service featuring once-daily e-mails to mothers with postpartum depression, postpartum anxiety, postpartum OCD and antenatal depression or anxiety. This free service provides encouragement from survivors, the country’s top perinatal mental health specialists and authors of the leading books on perinatal mood and anxiety disorders and parenting.

Many of the nearly one million women who suffer each year do not have access to perinatal mental health specialists or PPD support groups where they live. “I hear from thousands of mothers across the country and around the world who say that having someone to lean on who deeply understands can contribute a great deal to their recovery process,” said Katherine Stone, founder of Postpartum Progress and survivor of postpartum OCD. “I felt Daily Hope would be a great way to use technology to offer mothers encouragement from the nation’s most trusted experts on their illnesses, regardless of where they live or what type of health insurance they have. The more support we can provide to women with postpartum depression, the better, because the quicker the recovery, the less likely the illness will have a long-term impact on mom and baby.”

Contributors to Daily Hope include, among many:

  • Karen Kleiman, MSW, author of “This Isn’t What I Expected: Overcoming Postpartum Depression”
  • Ann Dunnewold, PhD, author of “Life Will Never Be the Same: The Real Mom’s Postpartum Survival Guide” and “Even June Cleaver Would Forget the Juice Box”
  • Marlene Freeman, MD, MGH Center for Women’s Mental Health and Harvard University
  • Pamela Weigartz, author of “The Pregnancy & Postpartum Anxiety Workbook”
  • Susan Stone, LCSW, former president of Postpartum Support International
  • Janice Croze, co-founder of 5MinutesforMom.com and survivor of PPD
  • “Aunt Becky,” author of the blog Mommy Wants Vodka, founder of Band Back Together and survivor of antenatal depression
  • Adrienne Griffen, founder of Postpartum Support Virginia

To sign up (for free) and subscribe to Daily Hope, click here.

Postpartum Progress, founded in 2004, provides the most comprehensive, in-depth and accessible information available on perinatal mental illness for pregnant women and new mothers. Having already helped more than 350,000 women and healthcare providers, Postpartum Progress offers an unflinching look at getting through postpartum depression, postpartum anxiety, postpartum OCD, postpartum psychosis, and antenatal depression & anxiety. Postpartum Progress has been named one of the top 10 depression blogs on the web by Psych Central, the winner of Fit Pregnancy’s Best of the Web Awards in the Advice category, and was a runner-up in Parenting’s Must-Read Moms and Scholastic Parent & Child’s Best Parenting Blogs Awards. It has been featured on Babble, ParentDish, Café Mom, Health.com and many other parenting websites. Postpartum Progress was founded by Katherine Stone, who was named a WebMD Health Hero in 2008 and won the Bloganthropy Award in 2010 for her advocacy work for pregnant and new mothers with maternal mental illness.

Postpartum Progress the blog and Daily Hope are both offered by Postpartum Progress Inc., a non-profit organization dedicated to vastly improving the amount of services and support available to women with perinatal mood and anxiety disorders.

Maternal Mental Health: Anxiety Disorders in Pregnancy

In light of the horrific and tragic events that took place at Sandy Hook Elementary School last Friday, Giving Birth with Confidence will be dedicating our posts this week to providing resources relating to mental health and wellness. Approximately 1.3 million women annually suffer from mental health disorders that occur during pregnancy and in the postpartum period. Perinatal and postpartum anxiety and mood disorders far outweigh the annual occurrence of several other major diseases combined. The key to finding help and treating mental health disorders is awareness; the more people who know how to spot warning signs and what to do to find help, the greater our possibility for better health.

 

This World is Not Flat: Anxiety Disorders in Pregnancy

Imagine you are sitting in your care provider’s office, and next to the scary “universal pain chart” with the not-so-happy faces getting progressively more distressed and discolored, is this chart:

1 in 8 pregnant women will develop an illness that poses these risks:

  • preterm birth (the leading cause of infant mortality and disability in US)1,2,3
  • low birth weight4
  • low APGAR scores5
  • a more difficult labor and delivery with increase of PTSD symptoms related to birth6,7,8,9
  • increased chance of Postpartum Depression/Anxiety Disorders after birth10,11
  • newborn may have increased agitation12,13
  • jittery infants up to 6 months after delivery14
  • breastfeeding difficulties15
  • child may develop learning and attention disorders later in childhood16,17,18

Genetic Disorder? Pre-ecamplsia? STD?

Nope. Perinatal Anxiety Disorder.

Current estimates are that anywhere from 5% to nearly 25% of pregnant women (1 in 8 ) will have a mood or anxiety disorder.19,20,21 And for pregnant women with anxiety disorders, high levels of cortisol cross the placenta and have long-term effects noted long after birth.22

With my first pregnancy, I began developing symptoms of depression and anxiety shortly after my second trimester. I knew something was wrong, and had both physical and emotional symptoms that were getting progressively worse. At the time (10 years ago), my providers didn’t know to ask about depression and anxiety during pregnancy—and I did a darned good job covering it up. My illness went untreated, and I ended up suffering Post-Traumatic Stress Disorder (PTSD) in labor and developing severe postpartum depression and anxiety after the birth. I was three months postpartum before my illness got severe enough, and life threatening, to the point where any of us knew I needed immediate medical treatment.

Anxiety in pregnancy and birth is universal and normal. It is a normal reaction to a physically and emotionally stressful, life-altering event. Secondly, an anxiety disorder in pregnancy is a medical illness, not a character flaw or personality trait. Its etiology is currently traced to an interplay of hormonal, genetic, environmental and immunological systems of the body23,24 – not the half shot of espresso in your latte, your character, or your inability to relax in your [irritating] prenatal yoga class. Newer research is looking at the role of increased oxytocin around the time of birth in influencing the onset of Perinatal Anxiety Disorders (PAD).25 Bottom line: It is not your fault.

 

Symptoms of Anxiety Disorders
Anxiety in pregnancy is normal. But when anxiety in pregnancy is significant enough to cause physical, emotional, and cognitive distress — a perinatal anxiety disorder may be occurring and you need help.26

Pec Indman, EdD, MFT and co-author of the award winning book, Beyond the Blues: Understanding and Treating Prenatal and Postpartum Mood/Anxiety Disorders offered this in a recent interview for this post:

While it’s normal to have some worries during pregnancy (for example, “Will my baby be healthy? or, “ Will I be a good mom”?)–women with anxiety find the worry gets in the way of enjoying the pregnancy and other aspects of life. Women with anxiety may also have appetite changes (often difficulty eating), and find that the worry makes it difficult to fall asleep. Some women experience panic episodes during pregnancy. These are times of extreme anxiety where there may be hot or cold feelings, difficulty breathing or a smothering sensation, numbness or tingling in the fingers or around the mouth, a racing heart, and a feeling of loss of control.

There are several types of anxiety disorders that occur in pregnancy and postpartum, including Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Panic Disorder, and PTSD. You can learn more about each type at www.postpartum.net under “Get the Facts.” But generally, symptoms27 of an anxiety disorder include:

  • Excessive, ongoing worry that impacts your day to day activities
  • Thoughts of worry regarding the future, or catastrophic events occurring
  • Insomnia
  • Poor appetite
  • Physical restlessness, inability to sit still
  • Dizziness, hot flashes, nausea
  • Panic attacks

 

Risk Factors
Research shows that there are some risk factors that may predispose some of us to anxiety disorders in pregnancy, and can be discussed with your care provider, partner, family or trained professional. Risk factors28,29 include:

  • Family history of anxiety disorders
  • Personal history of depression or anxiety
  • Thyroid imbalance

 

What do you do if you have symptoms or risk factors for an anxiety disorder in pregnancy?

1. Get help. Talk to a care provider. If you can’t talk yourself, find someone you trust to do so with you. The risks are too great. Pec Indman, EdD, MFT, shares:
If a woman is struggling during pregnancy it is essential to get help. Talk to a trained (many providers have not been trained in this area) and understanding professional. There are lots of kinds of effective treatments including counseling (in particular Cognitive-Behavioral Therapy and Interpersonal Therapy), social support, exercise, Omega-3 fatty acids, acupuncture, and medication.

Regarding women currently on medication, Pec continues:
Women who are on medication for depression, bipolar disorder, or anxiety, should consult with a prenatal (or perinatal) mental health expert before stopping medication. We know that over 50% of women who stop their medication before, or when they are find out they are pregnant, become ill again. Many medications can be taken during pregnancy and will help prevent a relapse.30

2. Ask your care providers (OB/GYN, Midwife, Nurse Practitioner, Family Practitioner) if they are trained in depression and anxiety in pregnancy. One tip I give women is to phrase it this way: “If I develop depression or anxiety during pregnancy or after, how will you be able to help me?” or “How do you help women who develop anxiety or depression in pregnancy?” If it is too difficult to do that, ask a trusted friend, partner, or family member to go with you to your next appointment and help you approach your care provider. Write a list of questions and concerns before you go. Calling ahead to let the front office know you need extra time in your appointment is also a good idea.

What if? If your only option is a care provider who is not trained in this area, go to Postpartum Support International (PSI) for excellent resources to take with you to your appointment, or to find local support systems, or call the warm-line for volunteer support on getting help in your area (1-800-944-4773). If making that call or going online is anxiety producing, ask a trusted friend, partner, or family member to go online for you or with you, to PSI and get the information you need.

3. GET A TRAINED DOULA!!! Birth and postpartum doulas can help you get through birth and postpartum adjustment. I strongly suggest you hire a doula who has training in this area (birth doulas are not required to know this information and postpartum doulas often receive little and/or outdated training on anxiety and depression disorders in pregnancy). Some good questions when interviewing doulas are:

  • What training do you have in anxiety and depression disorders in pregnancy?
  • If I get depressed or anxious, how will you know and how will you help?
  • What local resources do you give to clients?
  • How do you feel about anti-depressant medication during pregnancy and breastfeeding? Any doula who is completely “anti-medication” for any medical illness needs to turn in their birth ball and get with the program (it’s a blog, I can say things like that!). They do not have the skills to help you. Go to PSI and ask therapists in your area for referrals to doulas with experience.

 

Nothing Flat About this World of Anxiety Disorders
Pec Indman notes, “Healthcare professionals used to think pregnant women didn’t experience depression or anxiety. We also used to think the world was flat! Thinking has changed about a lot of things.”

Just as thinking and care regarding birth has changed, health care providers are starting to get it regarding mood and anxiety disorders in pregnancy. But much like our births, women have to raise our voices to raise awareness, and in turn get the care we so desperately deserve and need, for our brains and our reproductive systems.

With my second pregnancy, I knew before I peed on the stick — based on my first pregnancy — I had significant risks for depression and anxiety, that it was a physical illness, and that the risks to me and my baby were real and needed to be avoided. I was extremely fortunate to have the financial access to good, trained providers — they are forever in my heart. And I went through a mine field of providers who didn’t know current research and made me feel like a bad mother until I found the ones who “got it.” I firmly believe that when given the right information regarding our bodies, and particularly our pregnant bodies, we do a damn good job to learn more, discuss with those who could help us with treatment, and make the best informed choices for our lives. Once we remind ourselves and our care providers that our brain and uterus inhabit the same body and need the same kind of care, we will be part of the move to see that the world is not flat.
.

A special thanks to Pec Indman, EdD, MFT for her contribution to this article, humor, and support.

Pec Indman EdD, MFT, is a mom with over 20 years experience as a perinatal mental health psychotherapist and educator. She is the chair of education and training for Postpartum Support International, and co-author of the award-winning book, Beyond the Blues. An updated edition will be available the end of Oct. 2010. Beyond the Blues, Understanding and Treating Prenatal and Postpartum Depression & Anxiety.

 

References

 

  1. Perkin, M.R., Bland J.M. et al. 1993. The effect of anxiety and depression during pregnancy on obstetrical complications. BrJournal of Obstet Gynaecol 100:629-34.
  2. Wadwa, P.D., Sandman, C.A. et al. 1993. The association between prenatal stress and infant birth weight and gestational age at birth: a prospective investigation. Am J Obstet Gynecol 169:858-64.
  3. Orr, S. T., J. P. Reiter, D. G. Blazer, and S. A. James. 2007. Maternal prenatal pregnancy-related anxiety and spontaneous preterm birth in Baltimore, Maryland. Psychosomatic Medicine 69 (6):566-70.
  4. Ibid.
  5. Ibid.
  6. Beck, C. T., 2004a. Birth trauma: In the eye of the beholder. Nursing Research 53, 28-35.
  7. Beck, C. T., 2004b. Post-traumatic stress disorder due to childbirth: The aftermath. Nursing Research 53, 216-224.
  8. Keogh, E., S. Ayers, and H. Francis. 2002. Does anxiety sensitivity predict post-traumatic stress symptoms following childbirth? A preliminary report. Cognitive Behavioral Therapy 31 (4): 145-55.
  9. Kelly, R. H., J. Russo, and W. Katon. 2001. Somatic complaints among pregnant women cared for in obstetrics: Normal pregnancy or depressive and anxiety symptoms amplification revisited? General Hospital Psychiatry 23 (3):107-113.
  10. Lee A.M., Lam S.K. et al. 2007. Prevalence, course and risk factors for antenatal anxiety and depression. Obstet Gynecol 110:1102-1112.
  11. Rambelli, C., Montagnani, M.S. et al. 2010. Panic disorder as a risk factor for post-partum depression: results from the perinatal depression-research and screening unit study. Journal of Affect Disord,122(1-2):139-143.
  12. Coplan, R. J., K. O”Neil, and K. A. Arbeau. 2005. Maternal anxiety during and after pregnancy and infant temperament at three months of age. Journal of Prenatal and Perinatal Psychology and Health 19 (3):199-215.
  13. Tagle, N., Neal, C., Glover, V. 2007. Antenatal maternal stress and long term effects on child neurodevelopment: How and why? Journal of Child Psychology and Psychiatry, 48, 245-261.
  14. Ibid.
  15. Britton, J.R. 2007. Postpartum anxiety and breastfeeding. Journal of Reproductive Medicine, 52:689-695.
  16. Weinberg, M. Tronic, E.Z. 1998. The impact of maternal illness on infant development. J Clinc. Psychiatry 59(suppl 2):53-61
  17. O’Connor, T. G., J. Heron, and V. Glover. 2002. Antenatal anxiety predicts child behavioral/emotional problems independently of postnatal depression. Journal of the American Academy of Child and Adolescent Psychiatry 41 (12): 1470-77.
  18. Ibid.
  19. Onunaku, N. 2005. Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.
  20. Knitzer, J., Theberge, S., Johnson, K. 2008. Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Five Issue Brief 2.
  21. Gaynes B., Gavin, N., Melter-Brody, S., Lhor, K., Swinson, T., Gartlehner, G., et al. 2005. Perinatal depression prevalence, screening accuracy, and screening outcomes: Summary, evidence report and technology assessment, No 119. AHRQ Publication No. 05-E006-1.
  22. Ibid.
  23. Altemus, M. 2001. Obsessive-compulsive disorder during pregnancy and postpartum. In: Yonkers, K., Little., B. (eds) Management of psychiatric disorder in pregnancy. Oxford University Press, NY, pp 149-163.
  24. Stein, D.J., Hollander, E., Simeon, D., et al. 1993. Pregnancy and obsessive-compulsive disorder. Am J Psychiatry 150:1131-1132.
  25. Bartz, J.A., Hollander, E. 2008. Oxytocin and experimental therapeutics in autism spectrum disorders. Progressive Brain Research, 170:451-462.
  26. American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders (4th ed, text revision). Author, Washington, DC.
  27. Ibid.
  28. Lee A.M., Lam S.K. et al. 2007. Prevalence, course and risk factors for antenatal anxiety and depression. Obstet Gynecol 110:1102-1112.
  29. Ibid.
  30. Cohen, L.S., Altshuler, L.L. 2006. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA, 295:499-507

What is Evidence Based Birth and Why Should I Care?

By Rebecca Dekker, PhD, RN, APRN from www.evidencebasedbirth.com

 

Have you ever been told that you have to do things a certain way when you are giving birth? That your care provider may or may not allow you to do something?

As a nursing professor, I teach my students to always ask the question, “Why? Why do we do things a certain way? Is there any evidence to back this up?”

So today I am going to talk with you about how it’s okay—and it’s even best—if you ask “What’s the evidence for that?” when you are told you need to do things a certain way during pregnancy and birth.

When I got pregnant for the first time, even though I was a nurse, I really didn’t know that much about labor and delivery. I read a few baby books, took the brief hospital class, and looked through my old OB textbook a couple of times. I thought that was all I needed to know—because my care providers would guide me through labor and delivery, and they knew what was best, right?

I ended up having a pretty typical labor and delivery in the hospital—a vaginal birth of a 6 pound 8 ounce little girl– along with IV fluids, continuous monitoring, strict bed rest, nothing to eat or drink for 24 hours, Pitocin and an un-wanted epidural for “failure to progress,” vacuum extraction, and finally—immediate separation from my healthy baby after birth so that she could be observed in the nursery for several hours.

A few years later, when I became pregnant again, I started thinking about everything that I had experienced in the hospital. By this time, I had finished my research doctorate and I was in a full-time nurse faculty position, teaching nursing students and doing research. As a teacher, I was talking every day with my students about evidence-based practice. Meanwhile, as a researcher, I was discovering new evidence for how to best take care of people with heart disease.

Then one day, I started to get curious. I had always had a gut feeling that there was something wrong about my first birth. I was a completely healthy, low-risk pregnant woman who was in great physical condition. I was as healthy and strong at 9 months pregnant as I am right now. So why did I get the feeling that something was wrong about the care I received? Was my care really based on best evidence?

For those of you who don’t know, evidence based care means that your healthcare is based on the most up-to-date medical evidence about what works best. Evidence-based care also means that you are informed accurately about risks and benefits of different options, so that you can make the best informed medical choices for your unique situation.

Using the resources at my university, I began to read the medical evidence for the care I received at my first birth. Imagine my surprise when I learned that much of the care that I received has been shown by medical evidence to be harmful to healthy pregnant women and their babies!

Amazed by the evidence I was uncovering, I googled “evidence-based care during labor and delivery.” I was stunned to find that nobody else was really blogging about this the way I thought it could be done. The evidence exists out there—but in order to read the evidence you need an expensive subscription and you need to have research skills in order to decipher the evidence. I happened to have both the subscription and the skills. I thought to myself, “Wouldn’t it be great if I could blog about the evidence about birth options so that pregnant women all over the world can access and understand this information?”

And so www.EvidenceBasedBirth.com was born!

At Evidence Based Birth, my main goal is to write articles that review the highest quality medical evidence for certain birth practices. For examples of evidence-based articles, click here. For your sake, I always have at least two experts review my articles, and I try to write the articles in as non-biased a way as possible. I don’t want to insert my personal opinions into these articles. Instead, I would like for the evidence to speak for itself, and then let you and your care provider decide how you want to use that evidence for your unique situation.

I realize that educating people about the evidence is not enough. Real-life stories can give people the courage to put evidence into motion. So I publish testimonials, written by women and care providers, that promote the use of evidence-based practice. For examples of testimonials, click here.

Another resource for you at Evidence Based Birth are printable practice bulletins. These are 1-2 page, printable versions of my articles that are written in the language of healthcare providers. You can print these off and use them to start discussions with your care provider about evidence based care. To see a list of available printable practice bulletins, click here.

 

Why should I care about whether or not my birth is evidence-based?

Nursing students are in a unique position to observe what is going on in the maternity care system with a fresh, unbiased view. I asked a nursing student who is currently in her OB clinical rotation to share her impression about why you should care about evidence-based birth:

Kara Lester, a BSN nursing student, writes:

“As a nursing student currently in my OB rotation, I have met many pregnant mothers throughout the semester. Some are well-educated, while others have more limited knowledge about pregnancy. It is so important for women to be active participants in their care because it gives them autonomy within the healthcare setting. Women who are aware of the evidence and options available will have more confidence when it comes to voicing their thoughts and feelings to healthcare providers.

“Also as healthcare providers, we need to empower women to get more involved in their care by giving them the facts and letting them decide what option is best for their situation. During one of my clinical rotations, I sat through a birthing class with a first-time pregnant couple and saw firsthand that as their knowledge grew, so did their confidence. As the couple became more engaged, they started to feel more comfortable in their decisions. It was really neat to see their transformation from being quiet and anxious to calm and confident. Witnessing this reminded me that as an active participant you really can have an influence on the care you receive—and ultimately the outcome of your stay.”

 

What can I do next?

You have already taken a great first step by learning what evidence-based care means. However, here’s a little secret I’m going to tell you. Even though we have evidence for many treatment options, this evidence is not always used in practice. Sometimes your care providers might not know about the evidence, or they might choose to ignore the evidence. Why? We don’t know exactly why, but there are many possible reasons. It may be that some care providers are too busy and do not have time to keep up with the most up-to-date research. Or maybe they can’t access the evidence. Or maybe they just prefer to do things the way they have always done them.

So here is my homework assignment for you: Ask your care provider about the evidence. Whenever a treatment option is suggested, ask, “What’s the evidence for that? What are the risks? What are the benefits? Are there any other options that I should consider?”

Ultimately, I believe that the power to move towards evidence-based care is in your hands—the hands of pregnant women and their families. This past Labor Day, nearly 10,000 women in the U.S. rallied on the streets to raise awareness for the need for evidence-based maternity care. In 2013, we expect those numbers to double. I encourage you to educate yourself about evidence-based care and then get involved at the local or national level with ImprovingBirth.org, an organization dedicated to promoting evidence-based maternity care in the U.S. Who knows? Maybe, if enough women stand up to demand the best care—evidence-based care–we can make birth safer and better for us and our babies on a national scale.

Thoughts for discussion: Why do you think evidence-based care is important? Does knowing the evidence make you feel more confident in your choices?

 

Rebecca Dekker is an Assistant Professor of Nursing and teaches pathopharmacology to undergraduate nursing students. She recently received the Marie Cowan Promising Young Investigator Award from the American Heart Association, and she is principal investigator on a research grant from the National Institutes of Health. In 2012, Rebecca founded EvidenceBasedBirth.com and joined the executive board of ImprovingBirth.org—a non-profit organization dedicated to promoting evidence-based care for women and babies.

 

You can follow Rebecca’s articles on the Evidence Based Birth Facebook page

Maternity Care Tips from the Trenches

As expectant parents, you are faced with so many important decisions. It’s comforting to know and hear from others who have been in your shoes tell their personal childbirth stories. As part of Lamaze Push for Your Baby campaign, we have created a video of personal stories from parents who share what they learned along the way and ways you can push for the best care!

 

 

Reading Beyond the Headlines: A Closer Look at the Study on Antidepressants During Pregnancy

A recent study regarding the use of antidepressants has been gaining a lot of media attention. The actual study, The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has been described by media with a fair amount of fear-based headlines. Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRIs), is an important topic of research,  as care providers from many fields address the prevalence and negative effects of depression and other mood disorders in pregnancy.

 

Understandably, pregnant women and their families may be greatly alarmed by these dramatic press releases, and in some cases may consider suddenly discontinuing their medication, without realizing the significant risks that accompany suddenly stopping medication. What do the experts say?

 

I asked the study’s lead researcher, Alice Domar, MD what advice she would offer a pregnant woman who is currently on one of the SSRI medications listed in the study to do, and she kindly offered this response:

 

I would never recommend the sudden discontinuation of an SSRI during pregnancy. There are significant side effects associated with the abrupt cessation of antidepressants and we don’t know the impact on the developing fetus. The three main points we were trying to make with the paper were: 1) there are risks associated with taking SSRIs during pregnancy, 2) there are no clear benefits, and 3) each patient needs to have a discussion with her physician about her individual risk/benefit ratio.  There is a huge difference between a woman who is suicidal, who in all likelihood should remain on medication, versus women with mild or moderate symptoms who would benefit from a different approach, such as cognitive behavioral therapy, or physical exercise, both of which are very effective in the treatment of depressive symptoms.” –Alice Domar, MD (personal email communication, 11/2/12)

 

Another of the study’s researchers, Dr. Adam Urato, offered this follow-up:

“Your question is a good one (What would you advise a pregnant woman who is currently on one of the SSRI medications listed in the study to do?) and it is one I deal with several times each week as an Maternal-Fetal Medicine specialist.  I agree with Dr. Domar’s comments.  Sudden discontinuation of the SSRIs is not recommended.  They should be tapered for those who plan to discontinue them. The patient and their pregnancy health care provider (and their mental health provider) need to be aware of the scientific evidence regarding these drugs.  That evidence shows significant risk of pregnancy complications (like miscarriage and preterm birth) and no evidence of benefit for moms and babies.  In non-pregnant populations, alternatives like cognitive behavioral therapy and exercise appear to be as effective as the SSRI antidepressants and without the side effects and pregnancy risks.” (Personal email communication, 11/2/12)

 

Reaching out to experts in the field provided roundtable perspective. Christina Chambers, MPH, PhD, California Teratogen Information Specialist (CTIS) and director of the Pregnancy Health Information Line, had these thoughts:

“I agree with the authors’ comments. Caution is warranted, treatment makes sense when benefits are clear, and women with less severe illness might consider alternative approaches if they work, abrupt discontinuation without doctor’s advice is not a good idea, and care needs to be taken to address the issue of complications for mother and baby of untreated or poorly treated maternal depression. If a woman has questions, she should consult her doctor. She can also call the Organization of Teratology Information Specialists (OTIS) at 866-626-6847 to speak to an expert in this field.” (Personal email communication, 11/2/12)

 

Lucy Puryear, MD, immediate past president of Postpartum Support International (PSI) and Medical Director of The Women’s Place: Center for Reproductive Psychiatry offered:

“For women with mild to moderate depression psychotherapy and alternative treatments are absolutely the first choice. But for women with moderate to severe depression that is impairing functioning, antidepressants must be an option. Antidepressants do work in this population and save lives. Our challenge is to continue to look for the safest and most effective treatments for women during this vulnerable period.” (Personal email communication, 11/2/12)

 

PSI’s Executive Director Wendy N. Davis, PhD, agreed,

“We are most concerned that women will be unduly frightened by articles that discuss risks of antidepressants but do not discuss positive experiences or research studies that show little statistical relationship between SSRI use and pregnancy outcome. We want to connect women with reliable resources and experts in perinatal psychiatry so they can make thoughtful decisions about treatment options for depression and anxiety during pregnancy.”

 

A word about the science….

One of the pre-eminent researchers in the field, Adrienne Einarson of The Motherisk Program, shared some important criticisms of this study:

Here are my main problems with this publication:

1) It is said to be a review on treatment for infertility patients, however, one-third of the paper is about the lack of efficacy of antidepressants in general.
2) To say there is no evidence for effectiveness in pregnancy is true, but that is simply because there are no RCTs (randomized control studies), not because this has been proven.
3) All of the studies that were picked were ones that found negative effects, with no mention of how marginal the statistical significance really was.
4) The paragraph that is the most concerning is the one starting with “There is compelling evidence that SSRI use prior to and during pregnancy can pose significant risks to the pregnancy and to the short- and long-term health of the baby…” Of course there is compelling evidence when you choose your studies to fit your hypothesis.

This was a biased review, not a systematic one as reviews should be. In fact, there was not a single study referenced in this paper that did not find any harmful effects when there are many that have been published. (Personal email communication, 11/4/12)

 

When I was pregnant with my daughter, I had a sinus infection. I went to a general practitioner for treatment and shared that I was on an SSRI. You would have thought I told her I was shooting heroine every hour on the hour while tossing back jello shots and chain smoking! If I hadn’t had the science from my research treatment team at the UCLA Women’s Life Center, I could have easily been scared into stopping my medication. Instead I pulled out a collection of evidence-based research I carried in my purse and left it with her.

 

Unfortunately, for a woman who is pregnant and has depression, trying to decipher headlines and the seemingly constant stream of warnings might be overwhelming. Not to mention the stigma that accompanies depression and motherhood. Most don’t realize that to be that mom means you have to be constantly armed with proof that you are not harming your child. This is where having Adrienne Einarson’s insights can help you navigate the science, and advocate for your health and well-being.

 

Take Home Message:

If you are currently pregnant and taking an SSRI, do not abruptly stop taking your medication until you talk health care provider about risks and benefits for your individual care. If you feel you may be experiencing depression or anxiety and are pregnant, you deserve help with your symptoms. Not getting help has been proven to have negative effects on a developing fetus and increases the risk of pre-term birth, lower birth weight, and postpartum depression. Discuss your symptoms with your care provider immediately. I highly recommend using the resources available at OTIS (866) 626-6847 to address your concerns and questions.

 

____________________

Walker would like to thank Alice Domar MD; Adam Urato, MD; Christina Chamber, PhD, MPH; Lucy Puryear, MD; Wendy Davis, PhD; and Adrienne Einarson for their contributions.

 

Reference

Domar, A. D., Moragianni, V. A., Ryley, D.A., & Urato, A.C. (2012). The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, Vol.0(0) pp. 1–12 doi:10.1093/humrep/des383

 

Other Resources:

Department of Health and Human Services: Depression During and After Pregnancy: A Resource for Women, Their Families, & Friends

In the News: Asthma Medication During Pregnancy

According to a new study from the Netherlands reported by Reuters Health, more than one-third of pregnant women on asthma medications stop taking them during the first few months of pregnancy. These findings are alarming because asthma, when untreated and uncontrolled, can have negative affects on a developing fetus. Last year, we provided a blog post discussing the importance of keeping asthma controlled during pregnancy:

“It is important for pregnant women to remember that they are their babies’only source of oxygen. If a mom’s asthma is not controlled, both she and her baby are getting less oxygen. Although babies do not take their first breath until they are born, in utero they receive all their oxygen from the placenta (the blood connection between mom and baby). …untreated asthma is considered to be riskier than asthma controlled with medications in pregnancy.”

Regarding the safety of asthma medication, Reuters reports:

“Both the Global Initiative for Asthma (GINA) and the U.S. National Asthma Education and Prevention Program recommend that women continue taking asthma medications throughout pregnancy, because the risks of exacerbated asthma are greater than the risks of the medication.”

Further, GINA advises “there is not much evidence showing that asthma medications are harmful to the fetus.” In the article on our blog, OTIS teratogen information specialist Nadia Mohamedi talks about the low risks from certain asthma medications:

“The majority of women can control their asthma by taking an inhaled medication like albuterol or an inhaled corticosteroid. Inhaled medications act directly on the air passageways to decrease inflammation and open them up for breath. Because inhaled medications are not meant to be absorbed and distributed throughout the body like a pill you swallow is, very little of inhaled medications are absorbed into your blood and able to go to your developing baby. Thus, inhaled medications are usually considered to be of a low risk to the baby.”

Have you/are you experiencing pregnancy with asthma? Chime in — let us know your thoughts on the study and how your experience has been.