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Perineal Massage to Reduce Tearing: A Look at the Evidence

January 9, 2013 By Cara Terreri 4 Comments

Tearing during childbirth is common. Tears in the perineum can cause post-partum pain, but they usually don’t cause any severe or long-term complications. Natural tearing has been shown to have better outcomes as opposed to performing an episiotomy. And yet, tearing in childbirth is listed as one of women’s biggest fears. Several childbirth books recommend that women perform perineal massage in the weeks leading up to birth as a way to stretch the perineal tissues and reduce the chance of tearing. Today, Rebecca Dekker of Evidence Based Birth, takes a look at the research on perineal massage during pregnancy and provides information on its effectiveness.

 

By Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth

 

What is perineal massage?

It is thought that massaging the perineum during pregnancy can increase muscle and tissue elasticity and make it easier for a mother to avoid tearing during a vaginal birth. Typically, women are taught to spend about 10 minutes per day doing perineal massage, starting at about 34-35 weeks of pregnancy. Women are taught to insert 1-2 lubricated fingers about 2 inches into the vagina and apply pressure, first downward for 2 minutes, and then sideways for 2 minutes. The massage can be done by the woman or her partner, and sweet almond oil is sometimes used for lubrication (Labrecque, Eason et al. 1999).

 

What is the evidence for perineal massage?

In 2006, Beckmann and Garrett combined the results from four randomized, controlled trials that enrolled 2,497 pregnant women. Three of these studies involved only women without a previous vaginal birth (mostly first-time moms). One study enrolled women with and without a previous vaginal birth. All four of the studies were of very good quality.

 

Beckmann and Garrett found that women who were randomly assigned to do perineal massage had a 10% decrease in the risk of tears that required stitches (aka “perineal trauma”), and a 16% decrease in the risk of episiotomy—but these findings were only true for first-time moms.

 

It is important for you to understand that this is a 10% reduction in relative risk, and relative risk is different than absolute risk. Let me give you an example. Say you are a first-time mom, and let’s pretend your absolute risk of perineal trauma is 50%. A 10% decrease in relative risk means that your absolute risk decreases by 5% (because .5 X .1 = .05). So for you, doing perineal massage reduces your absolute risk of perineal trauma from 50% to 45%.

 

*As a side note, all of the numbers I am reporting below are changes in relative risk.

 

Importantly, for second-time moms who had already had a vaginal birth, prenatal perineal massage did not reduce the risk of perineal trauma (any tearing requiring stitches). However, second-time moms who massaged did report a 32% decrease in the risk of ongoing perineal pain at 3 months post-partum.

 

Surprisingly, Beckmann and Garrett found that the more frequently women used perineal massage, the less likely they were to see any benefits. Women who massaged an average of 1.5 times per week had a 17% reduced risk of perineal trauma and a 17% reduced risk of episiotomy. Women who massaged between 1.5-3.4 times per week had an 8% reduced risk of perineal trauma.

 

Interestingly, women who massaged > 3.5 times per week experienced NO benefits and had a longer pushing phase of labor by an average of 10 minutes. So basically the finding was: the less frequent the massage, the better off the outcomes. However, this finding was unexpected, and the researchers had a hard time explaining it. I think we should interpret this result with caution, because in the largest clinical trial on perineal massage (included in Beckmann and Garrett’s review), Labrecque et al. (1999) found that the more often women did the massage, the more likely they were to avoid any tears.

 

Other results: 

There were no differences between women who did prenatal perineal massage and those who did not with regard to:

  • First degree tears
  • Second degree tears
  • Third or fourth degree trauma
  • Use of forceps or vacuum during delivery
  • Sexual satisfaction 3 months post-partum
  • Pain with sexual intercourse 3 months post-partum
  • Uncontrolled loss of urine or bowel movements 3 months postpartum

 

Wait, I’m confused. You say that there was a significant decrease in perineal trauma requiring suturing. But there was no difference in 1st, 2nd, 3rd, or 4th degree tears. How can this be?

It’s important for you to understand that perineal trauma is an “umbrella” category that means all types of trauma requiring stitches, including episiotomies. Perineal massage during pregnancy decreased the overall risk of perineal trauma (the umbrella outcome), but the effect was too weak to see any difference with each of the individual outcomes (first degree, second degree, etc.). Also, the researchers think that the overall decrease in perineal trauma may have been due to the decreased episiotomy rate in the perineal massage group.

Why would perineal massage during pregnancy reduce the rate of episiotomies, but not tears?

The researchers guess that the women who were trained in perineal massage were highly motivated to birth with an intact perineum, so maybe they were more likely to refuse an episiotomy. Fewer episiotomies would then mean fewer incidents of trauma requiring stitches.

So what can we learn from the evidence?

During pregnancy, massage of the perineum can reduce the risk of tearing requiring stitches, but this benefit is only seen in moms giving birth vaginally for the first time. It is thought that most of the decreased risk of perineal trauma was due to a decrease in the episiotomy rate. In the largest study included in this review (Labrecque et al., 1999), there was an overall episiotomy rate of 38%. In the U.S., 25% of women have an episiotomy during a vaginal birth (Declercq, Sakala et al. 2007), and rates are even lower for some providers.  It is possible that these research findings might not apply to birth settings where episiotomies are extremely rare.

 

Second time moms who use perineal massage will not see any decrease in their risk of tearing, but they may reduce their risk of ongoing perineal pain at 3 months postpartum.

 

So in summary, for first-time moms only:

Perineal massage during pregnancy

↓

Decreased risk of episiotomy

↓

Decreased risk of trauma requiring stitches

If women choose to use perineal massage during pregnancy, there is no consensus on the amount of massage needed to reduce the risk of tearing.

 

Have you learned about perineal massage? Have you tried it or do you plan to? If you have already had a baby, do you feel it helped you?

 

References

Aasheim, V., A. B. Nilsen, et al. (2011). “Perineal techniques during the second stage of labour for reducing perineal trauma.” Cochrane Database Syst Rev(12): CD006672.

Beckmann, M. M. and A. J. Garrett (2006). “Antenatal perineal massage for reducing perineal trauma.” Cochrane Database Syst Rev(1): CD005123.

Byrd, L. M., J. Hobbiss, et al. (2005). “Is it possible to predict or prevent third degree tears?”Colorectal Dis 7(4): 311-318.

Christianson, L. M., V. E. Bovbjerg, et al. (2003). “Risk factors for perineal injury during delivery.” Am J Obstet Gynecol 189(1): 255-260.

Dahlen, H. G., C. S. Homer, et al. (2007). “Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial.” Birth 34(4): 282-290.

Declercq, E. R., C. Sakala, et al. (2007). “Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences: Conducted January-February 2006 for Childbirth Connection by Harris Interactive(R) in partnership with Lamaze International.” J Perinat Educ 16(4): 9-14.

Groutz, A., J. Hasson, et al. (2011). “Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium.” Am J Obstet Gynecol 204(4): 347 e341-344.

Hirayama, F., A. Koyanagi, et al. (2012). “Prevalence and risk factors for third- and fourth-degree perineal lacerations during vaginal delivery: a multi-country study.” BJOG 119(3): 340-347.

Labrecque, M., E. Eason, et al. (1999). “Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy.” Am J Obstet Gynecol 180(3 Pt 1): 593-600.

Soong, B. and M. Barnes (2005). “Maternal position at midwife-attended birth and perineal trauma: is there an association?” Birth

32(3): 164-169.

 

 

About Rebecca Dekker
Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style.

 

Filed Under Birth, Featured Story, Pregnancy Tagged With perineal massage

Pregnancy, Birth & Postpartum Resolutions

December 31, 2012 By Cara Terreri Leave a Comment

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.

Filed Under Birth, Featured Story, Health and well-being, Parenting, Post-partum depression, Postpartum, Postpartum Mood Disorder, Postpartum support, Pregnancy

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

December 21, 2012 By admin 1 Comment

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.

 

Filed Under Depression in Pregnancy, Featured Story, Health and well-being, Parenting, Post-partum depression, Postpartum, Postpartum Mood Disorder, Postpartum support, Pregnancy, Traumatic Birth Prevention & Resource Guide

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

December 19, 2012 By admin Leave a Comment

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.

Filed Under Depression in Pregnancy, Featured Story, Health and well-being, Postpartum, Postpartum Mood Disorder, Postpartum support, Pregnancy

Maternal Mental Health: Anxiety Disorders in Pregnancy

December 17, 2012 By Walker Karraa, MFA, MA, CD(DONA) Leave a Comment

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
Filed Under Depression in Pregnancy, Featured Story, Health and well-being, Postpartum, Postpartum Mood Disorder, Postpartum support, Pregnancy Tagged With Perinatal Mood/Anxiety Disorders, postpartum disorders

What is Evidence Based Birth and Why Should I Care?

December 3, 2012 By admin 7 Comments

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. 

Filed Under Birth, Featured Story, Health and well-being, Pregnancy Tagged With evidence-based care

Maternity Care Tips from the Trenches

November 30, 2012 By Cara Terreri Leave a Comment

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!

 

 

Filed Under Birth, Featured Story, Health and well-being, Pregnancy

Bonding with Baby Now

November 28, 2012 By admin Leave a Comment

By Phyllis Klaus, MFT, CSW

As with pregnancy, bonding with baby develops over time. It, too, is a process that, with your care and attention, will deepen and progress with each passing day. Do you remember when you learned you were pregnant? Surely it was a deeply emotional moment. A second before, you were responsible for yourself and a second after you were forever linked to a new being growing inside you. The bond you feel with your baby isn’t as instantaneous; it will grow slowly yet steadily over these months of pregnancy until the day you meet your child and begin life as a family.

“Bonding” refers to the feelings of love and empathy that parents develop for their children. During pregnancy, sometimes that love is manifested in the form of dreams and fears about your baby and future as a mother. Positive, loving dreams can help you connect with your little one, but fearful ones can diminish your confidence about your baby’s health or your own capabilities. Let your health-care provider worry about your baby’s health. Then give yourself space to deal with your other fears in a way that works for you. Write in a journal or draw pictures of what’s going through your head. Share your concerns with your partner, as well as with your girlfriends, pregnant or not. Expressing your thoughts will help you deal with them and accept your child into your life.

Another way to begin bonding with baby is to send him loving messages. During a quite moment, put your hands on your abdomen and send happy thoughts and energy to the baby: how excited you are to meet him, what you plan to do when he arrives, how you can’t wait to have him as part of your family. Many women say this activity makes them less anxious and worried about their pregnancy.

The Power Of Your Partner

Your partner is a major factor in how you feel about your baby. If your partner is excited about your pregnancy, watches over you, protects you and takes care of you, you will likely feel closer to your child. But if your partner is unhappy or hesitant, then you may have doubts and worries too.

Your partner may be nervous about being a dad because he’s unhappy with how he was parented or his own childhood. That’s why now is a good time to talk to him about how each of you grew up, both the good and the bad. Discuss what kind of relationship you had with your parents. You don’t just have to start a conversation out of the blue; wait until a situation presents itself. Your friends might tell you they don’t have a set bedtime for their toddler, or you may see a couple in the supermarket letting their child select a sugary cereal. Use these incidents as starting points for conversations; discuss how your parents handled such issues and what you would do with your own child. By talking about your upbringing, you can establish a unified front on how you will raise your kids and address any fears that your partner may have about being a parent.

You should also discuss your feelings about the baby, how he has and will alter your life. When you and your partner can talk freely about the many changes that a baby will bring to your relationship, finances and lifestyle, you can continue to support each other and see the baby as enhancing your life instead of disrupting it.

If your partner feels removed from your pregnancy, help him with this simple exercise. Have him put his hand on your abdomen, and when he feels movement or when you tell him you sense the baby, have him say, “Hello, baby.” If he does this a few times a day for a week or two, he’ll feel more connected to both of you. Pretty soon, the baby may even kick his hand at the sound of your partner’s voice.

Your child was conceived out of deep love. That’s why bonding with baby doesn’t have to wait until she’s born: It really starts the moment that you find out you are pregnant, and it continues throughout your pregnancy. Not only is it a way for you to get closer to your child, it will also help you grow closer to your partner. And becoming an even more solid couple will help prepare you for your newly bestowed title: parents.

Filed Under Dads, Featured Story, Newborn, Parenting, Pregnancy Tagged With bonding

Feasting for Two

November 21, 2012 By Cara Terreri Leave a Comment

Around the United States, millions of people will be getting together tomorrow to enjoy the time-honored Thanksgiving tradition of gathering with friends and family, giving thanks — and eating. A lot. When you’re pregnant, the family holiday get-together takes on a whole new dimension. Below are a few tips to help you remain happy, healthy, and sane among family and friends.

 

Drink up – Well, not those kinds of drinks. It’s easy to get caught up in conversation, cooking, and general merry-making when among friends and family during the holidays. As others refill their glass with bubbly, fill yours with water to stay hydrated.

Smile & nod – A growing bump and a family gathering prompts lots of advice, suggestions, and birthing war stories. With unwanted advice, many women find it easier to just smile and nod. Or, reply with, “My doctor/midwife has advised us to ______” Hard to argue with medical advice. If people feel the need to share their negative/scary birth story, say, “Shhh! No bad birth stories — the baby can hear you!”

Have seconds – And thirds, and fourths. If you’re in your third trimester, eating a large meal in one sitting may push you past your comfort level. Instead, eat small portions of your holiday meal throughout the afternoon and evening.

BYO crackers – If you’re in your first trimester and experiencing nausea, consider bringing your own side dish to dinner — crackers. No one will care that you can’t partake in Grandma’s favorite casserole or pumpkin pie — more for them!

Hands off – Some women love for others to fuss over and touch their belly while pregnant. Other women hate it. If you fall into the latter category, come up with a game plan to politely (or bluntly — whatever your style) let people know that you’re not comfortable with their touching. Perhaps a special t-shirt?

Take a break – The holidays are the perfect time to “pull the pregnancy card.” Feel free to retreat, take a seat, put your feet up — growing new life is hard work!

Filed Under Featured Story, Pregnancy Tagged With holidays

Exposures During Pregnancy – Questions from Adoptive Parents

November 14, 2012 By admin Leave a Comment

By Lori Wolfe, MS, Director of the Texas Teratogen Information Service Pregnancy Riskline

 

November is National Adoption Month and during this time, I’m always reminded of the vast numbers of children without permanent homes for the holidays, as well as the barriers keeping many people from taking the leap of faith to welcoming a child into their families.

I am particularly reminded of a call I recently received from an anxious couple, Nick and Shae Boyd. They were in the process of adoption, opting to adopt domestically. They were lucky enough to be contacted by their adoption agency regarding a possible match! As a genetic counselor who works for a pregnancy riskline, I frequently talk with couples in all phases of the adoption process. Often these couples only have a day or so to make up their minds if they wish to be considered for a particular baby. Needless to say, they are happy, anxious and in a hurry for the information, all at the same time!

In this case, the baby girl was due in two weeks. The birth mother reported using methamphetamines a few times in the first trimester, and smoked half a pack of cigarettes per day throughout the pregnancy, but had reduced this amount recently. The birth daddy was reported to drink alcohol on weekends and did have some cocaine use. The Boyd’s were very worried and concerned about the possible risks to the baby girl from all of these exposures and were unsure about this possible match. What should they do? What if the baby had increased risks for birth defects and learning problems? If they said “no” to this match, would they get another chance?

I quickly told them they had called the right place. Anytime you have questions about exposures during pregnancy, it is best to ask a trained teratogen specialist as we answer questions like this every day. They had reached me through OTIS, the national Organization of Teratology Information Specialists, and had called our toll-free 866-626-6847 number.

I explained that the use of street drugs always sounds scary, but we need to look at which birth parent used the drug, when in the pregnancy the exposure occurred, and how much and often was the drug was used. When the birth dads are using drugs, our concern is really only at the time of conception. With exposures to the birth dads, we know that the number and quality of the sperm they produce can be reduced and/or damaged. This can lead to fertility issues. But in the case of a successful pregnancy, the studies have not shown any increased risk for birth defects and learning problems in the babies that are born. So Nick and Shae do not need to worry about any possible increased risks from the birth dad’s exposures.

Now what the birth mom uses throughout her pregnancy is a different story, as the pregnant woman shares a blood supply with the baby. So what the mom takes into her body, for the most part, does get to the baby to some degree. I explained that unfortunately the recreational use of methamphetamines these days is pretty common. The good news in this case is that the birth mom only used the drug a few times in the first trimester, and has not reported any drug use since that time. Even though a few studies have shown that the heavy use of methamphetamines during the first trimester may have a small increased risk for a birth defect over the population back ground risk of 3 to 5 per 100 births, in this case there would not be a known risk due to the limited exposure. I also explained that there would not be a known increased risk for learning or behavior problems, or for withdrawal at birth, with only a few exposures in the first trimester. In cases of more heavy and/or prolonged use of methamphetamines, the risks can be higher.

As Shae and Nick breathed a sigh of relief, I went on to explain that smoking a one half of a pack of cigarettes per day is most likely not going to increase the background risk for birth defects either. Studies have shown that heavier smoking, more like one pack per day, does have a small one percent increased risk for oral clefting in the baby. The other risks that we often talk about with cigarette smoking, including an increased risk for a smaller baby who is born early, and an increased risk for asthma and allergies, are probably not significantly increased with exposure to 10 or fewer cigarettes per day, but could be there. Nick asked about SIDS and we talked about how this is more often seen when the babies go home to smoking households.

The Boyd’s told me they were very relieved! When their case worker had told them about this baby girl, there were very excited but really worried about the drug exposures. After talking with me, the Boyd’s did give their case worker the green light to submit their profile to the birth mom! If that little girl lands in the arms of such a caring and thoughtful couple, I know the phrase “home for the holidays” will have much greater meaning for them this year.

If you have any questions at all surrounding the adoption process and the risks to the baby of exposures during the pregnancy, please call OTIS’s specialists toll-free at (866) 626-OTIS (6847).  Good luck in your adoption journey!

 

Lori Wolfe, MS, is a board-certified genetic counselor and the past president of OTIS. She is also the director of OTIS’ Texas affiliate, the Texas Teratogen Information Service (TTIS), which she founded in 1991. Learn more about the TTIS by visiting http://www.ttis.unt.edu/. OTIS is a North American non-profit dedicated to providing accurate evidence-based information about exposures during pregnancy and breastfeeding.

Filed Under Adoption, Exposures During Pregnancy, Featured Story, Pregnancy Tagged With adoption, drug use during pregnancy
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