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Doula Support
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Weekend 3
ICA PEDIATRICS DIPLOMATE
Sharon Vallone, DC, FICCP
Jennifer Murphy DC DICCP
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Doula Support
• A doula makes sure the needs of the laboring
woman's partner are met, allowing the partner to
focus energy into becoming an effective, positive
part of the birth process. A doula can create an
atmosphere between partners that facilitates
wonderful labor memories, adding to the superb
care midwives provide by remaining close by
while your midwife performs clinical tasks.
• Advocating your choices during birth.
• Your doula will be available after your baby is
born to help you with breastfeeding, postpartum
care, and basic infant care.
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•
Also, compared to national data, fewer doula mothers
used epidural anesthesia and more initiated
breastfeeding. The Robert Wood Johnson Foundation
(RWJF) supported the project with a $327,196 grant
awarded through its Local Initiative Funding Partners
Program (LIFP), a national matching-grant program that
seeks to stimulate innovative, community-based
projects to improve the health and health care of
underserved and vulnerable populations. Following the
RWJF grant, Chicago Health Connection secured
funding from other sources to replicate the project. As
of December 2003, doula programs based on the
Chicago model were under way in Atlanta, Albuquerque
and Minneapolis as well as eight additional Illinois sites.
• http://www.rwjf.org/portfolios/resources/grantsreport.jsp?filename=
029806.htm&iaid=144
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• She does not perform clinical activities; she is purely
a labor educator during pregnancy and emotional
support during childbirth.She stays with the family
during labor and birth and her sole purpose is to
provide support and encouragement, and to make
sure all the laboring woman's physical and emotional
needs are met.
• Doulas work at hospital and home births. In hospitals,
since there is normally no one on the payroll who
stays with a woman throughout her entire labor and
birth, doulas provide this service. Doulas are also
known for their ability to advocate for a laboring
woman's wishes at a hospital. At a homebirth doulas
take on more of a labor-support role and less of an
advocate role.
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• Chicago Health Connection, a health education and
advocacy organization, developed and implemented a
four-year pilot project that used nonmedical birth
assistants known as doulas to help low-income single
teen mothers in high-risk Chicago neighborhoods. The
doulas, who were recruited from the community and
trained by project staff, provided information and
emotional and physical support to the mothers from the
last months of pregnancy through the first weeks
postpartum and generally were present during labor and
delivery. A researcher tracked outcome data for 259
women served by the project's three pilot sites in
Chicago. Only 8.1 percent of the mothers with a doula
present at birth had a cesarean section compared to
12.9 percent for Chicago teen mothers as a whole, the
researcher found.
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•Most doulas are certified by a doula
organization, like Doulas of North
America (DONA) or Association of
Labor Assistance & Childbirth
Educators (ALACE). They have gone
through extensive training to learn
everything there is to know about
labor support and they have to be
recertified every so many years.
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What training have you had? (If she is certified, you may want to check with the
certifying organization for
performance references).
What is your philosophy about childbirth and supporting women and their partners
during labor?
When do you try to join women in labor?
May we meet with you to discuss our birth plans and the role you will play in
supporting me (us) through childbirth?
May we call you with questions or concerns before and after the birth?
Will you meet with me (us) after the birth to review the labor and answer questions?
Do you work with one or more backup doulas for times when you are not available?
May we meet her/them?
What is your fee, what does it include, when is it due and what are you refund
policies?
Can you provide references? (Be sure to check the references)
OTHER RESEARCH REFERENCES
• Berry, LM, "Realistic expectations of the labor
coach." Journal of Obstetric, Gynecologic and
Neonatal Nursing, Sept./Oct.: 354-55, 1988.
• Bertsch, TD, Nagashima-Whalen, L, Dykeman, S.
Kennel, JH, McGrath, S., "Labor Support by firsttime fathers: direct observations with comparisons
to experienced doulas." Journal of Psychosomatics
in Obstetrics and Gynaecology, 11:251-260, 1990.
• Cogan R, Spinnato JA. "Social support during
premature labor: effects on labor and the newborn,
"Journal of Psychosomatics in Obstetrics and
Gynaecology, 8:209-216,1988.
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OTHER RESEARCH REFERENCES
OTHER RESEARCH REFERENCES
• Gordon NP, Walton D, McAdam E, Derman J,
Gallitero G, Garrett L. "Effects of providing hospitalbased doulas in health maintenance organization
hospitals." Obstetrics & Gynecology, 93(3):422426, 1999.
• Hodnett ED. "Support from caregivers during
childbirth." (Cochrane Review) In the Cochrane
Library, Issue 2. Oxford Update Software, 1998.
Updated quarterly.
• Hodnett ED, Osborn RW. "A randomised trial of the
effects of monitrice support during labor: mothers'
views two to four weeks postpartum," Birth,
16:177-183,1989.
• Hodnett ED, Osborn RW. "Effects of continuous
intrapartum professional support on childbirth
outcomes," Research in Nursing Health, 12(5):289297,1989.
• Hofmeyr GJ, Nikodem VC, Wolman WL, Chalmers
BE, Kramer T. "Companionship to modify the
clinical birth environment: effects on progress and
perceptions of labour, and breastfeeding," British
Journal of Obstetrics and Gynaecology, 98:756764, 1991.
• Hommel F. "Natural childbirth: nurses in private
practice as monitrices," American Journal of
Nursing, 69:1446-50, 1969.
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OTHER RESEARCH REFERENCES
OTHER RESEARCH REFERENCES
• Kennell JH, Klaus MH, McGrath SK, Robertson S,
Hinkley C. "Continuous emotional support during
labor in a US hospital: a randomized controlled
trial," Journal of American Medical Association, 265
(17): 2197-2201, 1991.
• Kennell JH, McGrath SK "Labor support by a doula
for middle-income couples; the effect on cesarean
rates," Pediatric Res, 32:12A, 1993.
• Kennell J H. "The effects of continuous emotional
support for couples during labor," Presentation at
the first international conference of Doulas of
North America, Seattle, WA, July 22, 1994.
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• Klaus MH, Kennell JH, Robertson SS, Sosa R. "Effects of
social support during parturition on maternal and infant
morbidity," British Medical Journal, 293 (6547): 585-587,
1986.
• Landry SH, McGrath SK, Kennell JH, Martin S, Steelman L,
"The effects of doula support during labor on mother-infant
interaction at 2 months," Pediatric Res, 43(4):Part 11, 13
A, 1998.
• Langer A, Campero L, Garcia C, Reynoso S. "Effects of
Psychosocial support during labour and childbirth on
breast feeding, medical interventions, and mothers' wellbeing in a Mexican Public hospital: a randomised clinical
trial." British Journal of Obstetrics and Gynaecology,
105:1056-1063, 1998.
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OTHER RESEARCH REFERENCES
• Martin S, Landry S, Steelman L, Kennell JH, McGrath S. "The
effect of doula support during labor on mother-infant
interaction at 2 months," Infant Behavior Development,
21:556, 1998.
• McGrath SK, Kennell JH, "Induction of labor and doula
support," Pediatric Res, 43(4):Part II, 14A, 1998.
• Sosa R, Kennell JH, Klaus MH, Robertson S, Urrutia J. "The
effect of a supportive companion on perinatal problems,
length of labor, and mother-infant interaction," The
New England Journal of Medicine, 303 (11): 597-600, 1980.
• Wolman WL, Chalmers B, Hofmeyr J. Nikodem VC.
"Postpartum depression and companionship in the clinical
birth environment: a randomized, controlled study,' American
Journal of Obstetrics and Gynecology, 168:1388-1393, 1993.
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Adjust During Labor?
Dig Deep in Technique
• Optimum nerve supply
– Cervix to dilate
– Uterus to contact rhythmically and forcefully
– Controls the hormones necessary to initiate
and continue the labors process
• Alignment of the pelvis ensures the
maximum amount of room for the baby to
exit.
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• Cranial Adjustments
• Seated cervicals
– Upper cervical work
very dynamic in
regulating or restarting
contractions
– Protect your wrists
• Toggle
• Activator technique
• Logan basic performed
while patient on all fours
• Standing or seated
thoracic adjustments
• Sacral work—Buckling
• Anteriority
• Drop work
– Toggle board
• Flexion/Distraction
– Side lying
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Adjusting the laboring patient
• Work with the mother and her contractions
– Cannot get good motion fighting the contraction
– Use contraction to your advantage
Education of Labor
• Don’t dehydrate
– Causes baby heart rate to drop
• Work in multiple positions
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Hard to work in hospital areas with monitoring equipment
Better for mom to move around
Water birth is very helpful
Leaning on physioball or wall while decompressing L5/S1
• Educate dad or coach in massage techniques or
sacral distraction if you can’t be there
• Have coaches to assist
– One for baby, one for mom
• Stretches are very helpful
• St. John’s Wort oil
– Discuss pressure
– Teach to protect from injury
– Helps with pain in labor when rubbed on back
or abdomen
• Therapy ball can assist with labor and self adjusting
– Ligaments are loose
– Gravity to assist PostPartumValloneMurphyDICCP
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Other Care
• Sciatica
• Carpal Tunnel
– Opposite uterine
ligament
• Cranio-sacral work
– Unwinding abdomen
– Unwinding cranials
• Foot work
– Myofascial release
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• Allergy
– Apple cider vinegar
– Concentrated cranberry
juice
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• Muscle cramping
– Myofascial release
– BioFreeze
– Acupressure/NIMMO
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Indications of Complications
Umbilical Cord Prolapse
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Temp of 100.4 or higher
Chills
Nausea/vomiting
Moderate to strong abdominal
or back pain
Increased pain, swelling,
redness, or drainage from
episiotomy or C-section
incision
Bleeding through more than
one pad per hour
Blood clots the size of a plum
Extreme paleness
Rapid, racing pulse
• Foul smelling vaginal
discharge
• Chest pain
• Increasing tenderness in the
lower abdomen
• Red, warm to touch, painful
breasts
• Burning on urination or blood
in urine
• Severe HA in forehead and
behind eyes (extreme pain
while sitting or standing)
• Feeling depressed over 3 days
• Severe weakness
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Occurs when the cord slips into the vagina after the membranes have
ruptured, before the baby descends into the birth canal.
Affects about 1 in 300 births.
The baby can then put pressure on the cord as it passes through the
cervix and vagina during labor and delivery, reducing or cutting off his
oxygen supply. Can result in stillbirth unless the baby is delivered
promptly--cesarean section. Babies who are delivered promptly are
usually unharmed.
The risk is increased if the baby is in a breech (foot-first) position or if
baby is premature. In these cases, the baby’s presenting part (the foot
or a smaller than-normal head) does not fill the pelvis and allows the
cord to slip.
More common
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The umbilical cord is too long
Too much amniotic fluid
When membranes are ruptured artificially to start/speed up labor.
Vaginal twin deliveries (second twin most commonly affected)
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• If a pregnant woman’s membranes rupture outside of the
hospital, and she feels something in her vagina, she
should have someone take her to the hospital
immediately or call 911.
• A health care provider may suspect that a woman in
labor in the hospital has umbilical cord prolapse if her
unborn baby develops heart rate abnormalities after the
membranes have ruptured. The provider can confirm
that the cord has prolapsed by doing a pelvic
examination.
• Emergency situation, and the provider will take steps to
relieve pressure on the umbilical cord by lifting the
presenting fetal part away from the cord while preparing
the woman for prompt cesarean delivery. Occasionally, if
a woman’s cervix is fully dilated, she may be able to
deliver vaginally.
• May occur late in pregnancy (>30 weeks) or in labor
• As a result of tetanic contraction of the uterus during
labor, the uterus may rupture
• Most frequently seen if there is an excessive infusion
rate of oxytocin resulting in hyperstimulation of the
uterine muscle
• Spontaneously occurs in1 in 1,900 deliveries
• May occur as a result of blunt trauma to the abdomen in
a motor vehicle accident
• A predisposing factor may be a uterine scar from
previous C section or removal of a fibroid tumor.
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Amniotic Fluid Embolism
Acute Inversion/Prolapse
• 1/8000-80,000 pregnancies, but 10-80% fatal
• Amniotic fluid entering the maternal circulation
– Rent through the amnion and chorion
– Open maternal veins
– Pressure gradient sufficient to force the fluid into the venous circulation
• Woman in vigorous labor develops
– Severe dyspnea
– Hypoxemia
– Cardiac collapse
• Woman either dies immediately or serious hemorrhage with severe
coagulation defects
• If woman survives, therapy is very unsuccessful
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Ruptured Uterus
Resusitation
Oxygenation
Mechanical ventilation
Blood replacement
Fibrinogen, heparin, fibrinolytic agents, and antifibrinolytic agents
• “turning inside out” of the uterus in the third stage of
labor. Consequence of strong traction on the umbilical
cord that is attached to the placenta implanted in the
fundus of the uterus.
• Circulatory collapse and shock may follow
• 1 in 20,000 pregnancies
• Contributing factors
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Errors in maneuvers during delivery
Tough cord that doesn’t break away from the placenta
Fundal pressure
Relaxed uterus and cervix
• Treatment may be manual replacement or surgery
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Vaginal Prolapse
Uterine Prolapse
• Portion of the body of the uterus may protrude from
the vulva during early months of pregnancy
– 1st degree—Cervix remains in vagina
– 2nd degree—Cervix is at or near introitus
– 3rd degree—Most of uterus outside the vagina
• Hard to conceive if full prolapse
• Caused by weakness in pelvic floor including ms,
ligaments and fascia
• Must be fixed in early pregnancy
– Uterus replaced and held into position
– If pelvic floor weak, then bed rest
– If the cervix persists outside the vulva and can’t be replaced—must
terminate pregnancy
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• Vagina is stretched so that when its front wall bulges
(cystocele) or its back wall bulges (rectocele) during
straining.
• Upper posterior vaginal wall prolapse is nearly
always associated with herniation of the pouch of
Douglas, and, because this is likely to contain loops
of bowel (enterocele).
• Causes
– Aging and the birthing process can be associated with the
development of vaginal prolapse.
• Treatment
– Pessary in vagina
– Surgery
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Pyelonephritis
• One of the most common medical complications of
pregnancy and may occur postpartum (most frequently
right sided)
• Result of bacteria ascending from the bladder through the
blood vessels and lymphatics.
• S/S can be rather abrupt
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Bladder irritation
Hematuria
Fever, chills and aching pain in lumbar region
Anorexia, nausea, and vomiting
• Asymptomatic bacteriuria
– Actively multiplying bacteria within the urinary tract w/o symptoms of a
urinary infxn
– Typically present at the time of the first prenatal visit
– 25% will develop into acute symptomatic
Puerperal Sepsis (Infxn)
• Patients with a puerperal genital tract infection are
susceptible to the development of septic shock,
pelvic thrombophlebitis and pelvic abcess
• Patients with retained placental components
(placenta accreta) are subject to infection and
morbidity
• Following vaginal delivery, approximately 6-7% of
women demonstrate febrile morbidity
• Following C section, this number doubles
• Antepartum factors
– Anemia-Iron deficiency
– Poor nutrition
– Sexual intercourse-membrane rupture
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Puerperal sepsis
• S/S
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Fever
Uterine tenderness (day 2 or 3 postpartum)
Chills
Headache
Malaise
Anorexia
Pallor, tachycardia and leukocytosis
• The uterus is soft, large and tender
• Lochia may be diminished or profuse and
malodorous.
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Infection
• Account for 13.1% of all pregnancy-related deaths in
US
• Puerperal infection is presumed when the mother’s
temperature rises to >= 38 degrees C (>=100.4
degrees F) on any two successive days after the first
24 hours postpartum and other causes are not
apparent.
• Infections directly related to delivery commonly affect
the genital tract, occurring in the uterus or
parametria.
• Bladder and kidney infections also commonly occur
soon after delivery
• Other causes of fever, such as pelvic
thrombophlebitis and breast infection, tend to occur
after the 3rd day postpartum
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HELLP Syndrome
• Hemolysis—breakage of red blood cells
• Elevated Liver Enzyme
• Low Platelet Count
• Complication of preeclampsia and eclampsia occurring in 25% of
these pregnancies; can occur postpartum
• Protein in urine, elevated blood pressure, and coma if hypoglycemic
• Symptoms
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Malaise
Nausea/vomiting
Pain in upper abdomen
Edema
• Treatment
– Management of blood clotting issues
– Urgent delivery require if fetal growth restricted (34 wks+)
• Complicated by
Objectives
• Recognize common and potentially lifethreatening postpartum complications
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Postpartum hemorrhage
Postpartum endometritis
Peripartum cardiomyopathy
Postpartum thyroiditis
Postpartum depression
• Direct the initial management of the ill
postpartum patient
• Know the appropriate threshold for consultation
with specialist
– Liver rupture, anemia, bleeding, and death
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Postpartum Hemorrhage
• Obstetrical emergency that can follow vaginal or
cesarean delivery
• Incidence – 3% of births
• 3rd most common cause of maternal death in US
• Definition
– Excessive bleeding that makes the patient
symptomatic (lightheaded, syncope) and/or results in
signs of hypovolemia (hypotension, tachycardia,
oliguria)
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Hemorrhagic Shock
• Hemorrhage is 28.8% of all pregnancy-related
deaths in US
• Blood loss greater than 500ml in vaginal birth
and 1000ml in C-sec
• Blood loss resulting in S/S of hemodynamic
instability
• Early PPH occurs w/in 24 hours of delivery
• Late PPH occurs w/in 24 hours to 6 wks
• 2-4% of all pregnancies in US
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Morbidity & Mortality
• Exposure to blood products
• Need for surgical intervention
• 13% of all maternal deaths deal with
bleeding and 1/3 are PPH
• Higher percentage among Asian and
Hispanic population
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• Which of the following is the most common
cause of postpartum hemorrhage?
– A. primigravida birth
– B. retained placenta
– C. uterine atony
– D. uterine rupture
– E. lacerations of the cervix
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Causes of Postpartum Hemorrhage
Four Ts
Cause
Approximate
incidence (%)
Tone
Atonic uterus
70
Trauma
Lacerations,
hematomas,
inversion, rupture
20
Tissue
Retained tissue,
invasive placenta
10
Thrombin
Coagulopathies 1
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Physical Assessment of PPH
• Hx including family hx and medication
check (hypertension & heart disease)
• Bimanual palpation
– Reveals bogginess
– Atony
– Uterine enlargement
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Postpartum Hemorrhage
• Risk Factors
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Prolonged 3rd stage of labor
Fibroids, placenta previa
Previous PPH
Overdistended uterus
Episiotomy
Use of magnesium sulfate, preeclampsia
Induction or augmentation of labor
• Not necessarily useful clinically as only about
10% of women with any of these risk factors
develop atony and many without risk factors
develop atony. PostPartumValloneMurphyDICCP
Causes of PPH
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Uterine atony
Lacerations of cervix and/or vagina
Retension of part or all of the placenta
Disorders of coagulation and thrombocytopenia
Trauma during delivery
Uterine inversion
Uterine rupture
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Risk Factors of PPH
PPH - Management
• Prolonged third stage of
labor
• Preeclampsia
• Mediolateral episiotomy
• Previous PPH
• Multiple gestation
• Arrest of descent
• Maternal hypotension
• Coagulation
abnormalities
• Lacerations of the cervix,
vagina, and perineum
• Asian or Hispanic
ethnicity
• Delivery with forceps or
vacuum
• Augmented labor
• Nulliparity, Multiparity (20
fold increase in risk) &
polyhydromnios
• Swift execution of a sequence of interventions
with prompt assessment of response
• Initial steps
– Fundal massage
– O2
• transfuse blood products as needed
– Examine genital tract, inspect placenta, observe
clotting
– Give uterotonic drugs
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Medications for PPH
• Oxytocics (Oxytocin)
– Produces rhythmic uterine contractions, can stimulate the gravid
uterus and has vasopressive and antidiuretic effects
• Ergonovine (Ergotrate Maleate)
– Used to prevent and treat PPH due to uterine atony by producing
firm contraction of the uterus within minutes
• Methylergonovine (Methergine)
– Works on smooth muscle causing a sustained tetanic uterotonic
effect that reduces uterine bleeding and shortens the third stage
of labor
• Carboprost (Hemabate)
– A prostoglandin the produces myometrial contractions that
induces homeostasis
• Misoprostol
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Uterotonic Agents for PPH
Drug
Side Effects
Contraind.
Store
Oxytocin
(Pitocin)
10 units/ml
Dilute 2040 units in
1 L NS
10 IU IM
Dose
Route Freq
IV
IM
Continuous
Infusion,
250 ml/hr
Nausea, vomiting
Water intox with
prolonged IV use
Hypersensitivity to
the drug
Room
temp
Carboprost
(Hemabate)
15-methyl PG
F2a
0.25 mg/ml
0.25 mg
IM
IMM
Q 15-90 min
not to
exceed
8 doses
Nausea, vomiting
Diarrhea
Fever/Chills
HA
Hypertension
Bronchoconstriction
Hypersensitivity to
the drug
Use with caution in
patients with HTN
or asthma
Refrig
Methylergonovine
(Methergine)
0.2 mg/ml
0.2 mg
IM
Q 10 min x
2
Q 2 – 4 hrs
Nausea, vomiting
Hypertension, esp
in pts with PIH or
chronic HTN
Hypotension
Hypertension
Preeclampsia
Hypersensitivity to
the drug
Refrig
Protect
from light
Misoprostol
(Cytotec)
100 and 200
mcg tabs
600-1000
mcg
PR
Hypersensitivity to
the drug
Room
temp
Single dose
Nausea, vomiting
Shivering
Fever
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Management
• Secondary steps
– Will likely require regional or
general anesthesia
– Evaluate vagina and cervix for lacerations
– Manually explore uterus
• Treatment options
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Repair lacerations with running locked #0 absorbable suture
Tamponade
Arterial embolization
Laparotomy
PPH – Preventive Measures
• correcting anemia prior to delivery
• episiotomies only if necessary
• active management of third stage
• NNT to prevent 1 case of PPH = 12
• assess patient after completion of
paperwork to detect slow steady bleeds
• uterine vessel ligation
• B-Lynch suture
– Hysterectomy
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Postpartum Endometritis
PP Endometritis
• Infection of the decidua (pregnancy
endometrium)
• Incidence
– <3% after vaginal delivery
– 10-50% after cesarean delivery
• 5-15% after scheduled elective cesareans
• Risk Factors
– Prolonged labor, prolonged ROM, multiple vaginal
exams, internal monitors, maternal DM, meconium,
manual removal of placenta, low socioeconomic
status
• Polymicrobial, ascending infection
– Mixture of aerobes and anaerobes from genital tract
– BV and colonization with GBS increase likelihood of
infection
• Clinical manifestations (occur within 5 days pp)
–
–
–
–
–
Fever – most common sign
Uterine tenderness
Foul lochia
Leukocytosis
Bacteremia – in 10-20%, usually a single organism
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PP Endometritis
PP Endometritis
• Treatment
• Workup
– CBC
– Blood cultures
– Urine culture
– DNA probe for GC/chlamydia
– Imaging studies if no response to adequate
abx in 48-72h
• CT scan abd/pelvis
• US abd/pelvis
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– Broad spectrum IV abx
• Clindamycin 900mg IV q8h and
• Gentamicin 1.5mg/kg IV q8h
– Treat until afebrile for 24-48h and clinically improved;
oral therapy not necessary
– Add ampicillin 2g IV q4h to regimen when not
improving to cover resistant enterococci
• Prevention
– Abx prophylaxis for women undergoing C-section
• Cefazolin 1-2g IV as single dose
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Peripartum Cardiomyopathy
• Rare cause of heart failure in late pregnancy or
early puerperium
• Definition
Peripartum Cardiomyopathy
• Incidence – 1:3000 to 1:4000
• Unknown etiology
– Potential contributors:
– Development of heart failure in last month of
pregnancy or within 5 mos of delivery
– No identifiable cause for the failure
– No history of heart disease prior to the last month of
pregnancy
– Left ventricular systolic dysfunction
•
•
•
•
•
Hormones
Inflammatory cytokines (TNF-alpha and IL-6)
Myocarditis
Abnormal immune response
Genetic and/or environmental factors
• LVEF <45%
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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PPCM – Risk Factors
PPCM - Diagnosis
Age > 30
Multiparity
Multiple fetuses
Women of African descent
History of PIH
Maternal cocaine abuse
Oral tocolytics with beta adrenergic
agonists > 4 weeks
•
•
•
•
•
ECG
CXR
Echocardiogram
Viral and bacterial cultures
Cardiology referral
– Cardiac catheterization
– Endomyocardial biopsy
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PPCM - Treatment
PPCM - Treatment
Similar to treating other types of HF
Digoxin
Diuretics
Vasodilator – hydralazine
Beta blockers – beta-1 selective
Class III antiarrhythmics
Anticoagulation
• IVIG showed increase in LVEF in small
study
• Heart transplantation
– If conventional therapy not successful
– Should avoid future pregnancy
– heparin if pre-delivery (due to short half-life &
reversibility), but may use Coumadin during 3rd
trimester & postpartum, w/ INR goal of 2.0 to 2.5
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PostPartum Thyroiditis
• Inflamed thyroid gland of unknown cause
– Can be hypo or hyperthyroid
– 5-7% develop thyroid disease after giving birth
• Risk Factors
– Prior hx of thyroiditis
– Hx of postpartum thyroiditis
•A variant form of Hashimoto’s thyroiditis
occurring within 1 year after parturition
Postpartum Thyroiditis
• Incidence – 3-16% of postpartum women
– Up to 25% in women with Type 1 DM
• Most have high serum levels of antiperoxidase Ab
• Thyroid inflammation damages follicles Æ
proteolysis of thyroglobulin Æ release of
T3 + T4 Æ TSH suppression
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Postpartum Thyroiditis
Symptoms
• Clinical manifestations
– 20-30%
• Hyperthyroidism 2-4 mos pp, lasting 2-8 wks,
followed by hypothyroidism, lasting 2-8 wks, then
recovery
– 20-40%
• Hyperthyroidism only
– 40-50%
• Hyperthyroid
–
–
–
–
–
–
–
• Hypothyroid
Feeling warm
Muscle weakness
Feeling tremulous
Anxiousness
Rapid heartbeat
Loss of concentration
Weight loss
• Hypothyroidism only, beginning 2-6 mos pp
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Postpartum Thyroiditis
• Symptoms and signs, when present, are
mild
– Hyperthyroidism
• Anxiety, weakness, irritability, palpitations,
tachycardia, tremor
– Hypothyroidism
–
–
–
–
Feeling tired
Constipation
Loss of memory
Intolerance to cold
weather
– Muscle cramping
– Weak feeling
– Weight gain
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PP Thyroiditis
• Diagnosis (continued)
– High or high normal T3 + T4, low TSH, low
radioiodine uptake (hyper phase)
– Low or low normal T4, high TSH (hypo phase)
• 65-85% have high antithyroid Abs
• Lack of energy, sluggishness, dry skin
• Diagnosis
– Small, diffuse, nontender goiter or normal
exam
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PP Thyroiditis
Treatments
• Medical
• Treatment
– Most need no treatment unless have
bothersome sx
• Hyper: atenolol or propanolol
– Avoid in nursing women
• Hypo: levothyroxine 50-100 mcg qd for 8-12 wks,
discontinue, re-eval in 4-6 wks
• Educate patient on sx, increased risk of developing
hypothyroidism or goiter, likely recurrence with
subsequent pregnancies
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• Naturopathic
– Testing is exceptional poor
• Must test
– TSH
– T4
– T3
– Hormone replacement
therapy
• Synthroid
• Amor-thyroid—Better
– Surgery
– GLUTEN FREE DIET
– SUPPLEMENTS
– Iodine
• Breast Cancer link
– Selenium
– Adrenal support
– Fish Oil
• Depression issues
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Treatments
fxáá|ÉÇ F
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• Acupuncture
• Shiatsu
• Herbs
cÉáà ctÜàâÅ VÉÅÑÄ|vtà|ÉÇá
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Phlebitis
• Attacks a small vein close to the skin (superficial phlebitis)
– More painful than life-threatening
– May be affected by hormones making women more afflicted
– 1 in 100 newly delivered moms due to hormone chxs
• Symptoms
–
–
–
–
Inflammation
Swelling
Tenderness
Can feel the clot (painful, tender, hot lump under the skin
• Treatment
– May go away on their own in 2-4 weeks on own
– Cold pack
– Anti-inflam drug/anti-inflam homeopathy
• Prevention
–
–
–
–
Birth control pills increase chances of phlebitis
Keep active—minimum 20 min walk 2-4X/wk
Relax with you legs up
Compression stockings
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Deep Vein Thrombosis
• Complicated in pregnancy by diagnostic
limitations and health risks of meds and 5X higher
occurrence because pregnant
• Severe form of phlebitis
• Triad of risk factors
– Hypercoaguability, stasis, and endothelial injury
• Pregnancy considerations
– Decreased flow velocity (1/3 at term) and increased
vessel diameter
– Venous statis related to compression of common iliac
vein by the uterus
• More common in left leg due to compression of the left iliac
vein by crossing right iliac artery at its origin from the aorta
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Deep Vein Thrombosis
• Symptoms
– Homan’s sign
• Slight pain at back of the knee/calf when foot is
dorsiflexed
– Unexplained sharp leg pain in only one leg
• Edema, leg tenderness, increased warmth, chx in
coloration (red), venous distension
• May have diffuse abdominal pain & dyspnea in
pregnancy
Diagnosis & Treatment
• Contrast venography—Used when other tests are inconclusive,
invasive
• Duplex ultrasonography—For thrombosis above knee
• Impedance plethysomography—Alternative to Duplex ultrasound,
but less specific/sensative
• MRI—Best for pelvic veins
• Compression Ultrasonography—For pregnant patients
• Initially Heparin given to thin blood (inter-venous) then changed to
Warfin for months
– May need compression support hose or undergo therapy for edema
• Heparin must be stopped before delivery, then started again 48
hours after delivery for six weeks to three months
• Warfarin is contraindicated because it is teratongenic and increases
risk of maternal and fetal hemorrhage.
• Side-effects
– Bleeding & lower platelet counts (thrombocytopenia)—Heparin
– Bleeding--Warfarin
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Phlebitis/DVT Prevention
Pelvic Thrombophlebitis
• Can occur within 30 minutes of being
still—good to have mother moving and on
her feet shortly after birth
• If prolonged labor, passive motion of legs
and walking excellent choices
• All massage to be toward the heart
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Thromboembolism
• Accounts for 19.9% of all pregnancy-related
deaths in US
• Increased risks because increases in
Cesarean/instrument assisted births, prescribed
prolonged bed rest after delivery, multiparity,
advanced maternal age and use of estrogens to
suppress lactation
• Risk of mortality outweighs fetal radiation risk
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• When the usual relative pelvic venous stasis
is combined with a large inoculum of
pathogenic anaerobic bacteria, a pelvic vein
thrombophlebitis is likely to develop, usually
on the right side of the pelvis.
• The clinical picture of pelvic thrombophlebitis
is characterized by a persistent spiking fever
for 7 to 10 days after delivery, despite
antibiotic therapy
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• Natural history of pulmonary embolism
– Pulmonary emboli usually arise from the thrombi
originating in the deep venous system of the lower
extremities; however, rarely they may originate in the
pelvic, renal, or upper extremity veins and the right
heart chambers.
– After traveling to the lung, large thrombi lodge at the
bifurcation of the main pulmonary artery or the lobar
branches and cause hemodynamic compromise.
– Smaller thrombi continue traveling distally, occluding
a smaller vessel in the lung periphery. These are
more likely to produce pleuritic chest pain by initiating
an inflammatory response adjacent to the parietal
pleura. Most pulmonary emboli are multiple, and the
lower lobes are involved more commonly than the
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• Respiratory consequences
• Respiratory consequences
• Acute respiratory consequences of PE
include increased alveolar dead space,
pneumoconstriction, hypoxemia, and
hyperventilation.
• Later, 2 additional consequences may
occur: regional loss of surfactant and
pulmonary infarction.
• Arterial hypoxemia is a frequent but not universal
finding in patients with acute embolism. The
mechanisms of hypoxemia include ventilationperfusion mismatch, intrapulmonary shunts,
reduced cardiac output, and intracardiac shunt
via patent foramen ovale.
• Pulmonary infarction is an uncommon
consequence because of the bronchial arterial
collateral circulation.
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• Hemodynamic consequences
• PE reduces the cross-sectional area of the
pulmonary vascular bed, resulting in an
increment in pulmonary vascular
resistance, which, in turn, increases the
right ventricular afterload.
• If the afterload is increased severely, right
ventricular failure may ensue. In addition,
the humoral and reflex mechanisms
contribute to the pulmonary arterial
constriction.
• Hemodynamic consequences
• Prior poor cardiopulmonary status of the
patient is an important factor leading to
hemodynamic collapse.
• Following the initiation of anticoagulant
therapy, the resolution of emboli occurs
rapidly during the first 2 weeks of therapy.
• Significant long-term nonresolution of
emboli causing pulmonary hypertension or
cardiopulmonary symptoms is uncommon.
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Symphysis pubis subluxation
Osteitis Pubis
• Pelvis makes a circle
• Extreme pubic pain
• Delivery knowledge
– Know baby presentation
– Labor tools used
• Adjustment
• Painful, non-infectious inflammatory condition involving
the pubic bone, symphysis, and surrounding structures
• S/S
–
–
–
–
–
Pain
Waddling gait
Low grade fever
Elevated sedimentation rate
Milk leukocytosis
• X-ray
– Sclerosis, rarefaction, and osteolytic chxs after 4 weeks
– Doctor protection
– Hand placement
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• Treatment
– Adjustment—pubic bone
– Anti-inflams and bedrest
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Coccygeal Subluxations Vs. Fx
• Back labor hx
• Falls
• Birthing positioning
– Think of mother’s weight on pelvis
• Filum Terminale
– Neurological considerations
• Internal Adjustment
• External Adjustment
Meralgia Paresthetica
• 4.3 in 10,000 complications with spinal anesthesia
• Syndrome of pain and/or dyesthesia in the anterolateral thigh
–
–
–
–
Dull ache
Itching
Numbness/tingling
Burning
• Can be caused when mother asked to pull knees back toward chest
in hard labor
– When prolonged damages femoral nerve
– Epidural blocks pain receptors that indicate a problem
• Entrapment mononeuropathy of lateral femoral cutaneous nerve (L2,
L3)
• Responds well to conservative tx but can re-occur
– Spinal cord stimulator
– Adjustments
• Therapies
• Surgery is performed with intractable pain that doesn’t respond to
conservative care.
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Obstetric Palsy
Medical Intervention
• Bilateral arm paralysis following a face presentation
– Nerve roots affecting the deltoid, biceps, coracobrachialis, and
brachioradialis
• C5-C6—Erb’s Palsey
• C6-C7—Klumpkey’s Palsey
• C5-T1—Arm has marbled appearance due to vasomotor
disturbances; may have Horner’s Syndrome
• Risk factors
–
–
–
–
–
–
Traumatic delivery (forceps, breech, transverse)
In-utero ischemia
Shoulder dystocia
Maternal diabetes
Large fetus
Cephalo-pelvic distortion
• Testing
– Electromyography (EMG), Nerve conduction (NC),
Spinal evoked potentials (SEP) , or Somato sensory
evoked potentials (SSEP)
• Surgical Intervention
– Had been avoided, but with new anesthesia and
microsurgery has revived interest
– Designed to clear up ruptures, avulsions of plexus or
isolated roots, grafting, or neuroma
• Treatment
– Adjustment of affected area
– Traction and passive exercises
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NEUROGENIC BLADDER
• The normal function of the urinary bladder is to store and
expel urine in a coordinated, controlled fashion. This
coordinated activity is regulated by the central and
peripheral nervous systems. Neurogenic bladder is a
term applied to a malfunctioning urinary bladder due to
neurologic dysfunction or insult emanating from internal
or external trauma, disease, or injury.
• Symptoms of neurogenic bladder range from detrusor
underactivity to overactivity, depending on the site of
neurologic insult. The urinary sphincter also may be
affected, resulting in sphincter underactivity or
overactivity and loss of coordination with bladder
function.
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NEUROGENIC BLADDER
• The somatic nervous system regulates the actions of the
muscles under voluntary control. Examples of these
muscles are the external urinary sphincter and the pelvic
diaphragm.
• The pudendal nerve originates from the nucleus of Onuf
and regulates the voluntary actions of the external
urinary sphincter and the pelvic diaphragm. Activation of
the pudendal nerve causes contraction of the external
sphincter and the pelvic floor muscles, which occurs with
activities such as Kegel exercises.
• Difficult or prolonged vaginal delivery may cause
temporary neurapraxia of the pudendal nerve and cause
stress urinary incontinence.
• Conversely, suprasacral-infrapontine spinal cord trauma
can cause overstimulation of the pudendal nerve that
results in urinary retention.
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•
1: Phys Ther. 1988 Jul;68(7):1082-6.Related Articles, Links
Incidence of diastasis recti abdominis
during the childbearing year.
fxáá|ÉÇ FM
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Boissonnault JS, Blaschak MJ.
Northwestern University Graduate School, Chicago, IL.
This study was conducted to determine 1) the incidence of diastasis recti abdominis
among women during the childbearing year and 2) the location of the condition along the
linea alba. Clinicians have long noted its presence, prenatally and postnatally, but the
magnitude of the problem is currently unknown. A cross-sectional design was used to test
71 primiparous women placed in one of five groups, based on placement within the
childbearing year. A commonly accepted test for diastasis recti abdominis was performed.
Palpation for diastasis recti abdominis at the linea alba was performed 4.5 cm above, 4.5
cm below, and at the umbilicus. Diastases were observed at all three places, but most
often at the umbilicus. A significant relationship (p less than .05) was found between a
woman's placement in her childbearing year and the presence or absence of the condition.
Diastasis recti abdominis was observed initially in the women in the second trimester
group. Its incidence peaked in the third trimester group; remained high in the women in the
immediate postpartum group; and declined, but did not disappear, in the later postpartum
group. These findings demonstrate the importance of testing for diastasis recti abdominis
above, below, and at the umbilicus throughout and after the childbearing year.
•
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PMID: 2968609 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2968
609&dopt=Abstract
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• Which of the following statements about
postpartum depression is true?
– A. Postpartum depression often occurs 9 to 12
months after delivery.
– B. Social support has little impact on the development
of postpartum depression.
– C. Those with obstetric complications are at
increased risk.
– D. Those affected are at increased risk for postpartum
depression with subsequent pregnancies
– E. Patients who have postpartum depression have no
higher risk of developing depression in later years
when compared to the general population.
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Postpartum Depression
• Most common complication
– Occurs in 13% (1 in 8) of women after pregnancy
– Recurs in 1 in 4 with prior depression
– Often begins within 4 weeks after delivery but may
begin later
• Multifactorial etiology
– Rapid decline in hormones, genetic susceptibility, life
stressors
• Risk Factors
– Prior h/o depression, family h/o mood disorders,
stressful life events
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Postpartum Depression
Depression
• Pattern of sx are similar to other episodes of
depression
– Depressed mood, anxiety, loss of appetite, sleep
disturbance, fatigue, guilt, decreased concentration
– Must be present most of the day nearly every day for
2 wks
• Not a separate dx from depression in DSM-IV; “postpartum
onset specifier” is used for mood d/o within 4 wks pp
• Screening
– Edinburgh Postnatal Depression Scale
– + screen with score >/= 10
– r/o anemia and thyroid disease
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• One in eight new mothers experience various degrees of postpartum
depression
• May occur gradually but can take a year to appear
• Hormonal changes affect the neurotransmitters
– 15-20% of pregnant women experience depression
• Cause low birth weight
• Cause preterm delivery
– 15% of these are severe
• Cause constriction of blood vessels
• High cortisol levels
• Life stressors
– Financial
– Work
– Social
• Supposed to be happy
– Family
• Feelings will flux moment to moment
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Perinatal Mood Disorders
•
•
•
•
•
•
•
“Baby Blues”
Depression/Anxiety
Obsessive-Compulsive Disorder
Panic Disorder
Psychosis
Postpartum Psychiatric Illness
Post-traumatic Stress Disorder
Baby Blues
• 80% of mothers
• Onset w/in first week
postpartum
• Symptoms up to three
weeks and resolve on
their own
–
–
–
–
–
–
Mood instability
Weepiness
Sadness
Anxiety
Lack of concentration
Feeling of dependency
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Depression/Anxiety
• 15-20% of moms
• Onset is usually gradual
• Symptoms
–
–
–
–
–
–
–
–
–
–
–
–
–
Excessive worry or anxiety
Irritable or short temper
Feeling overwhelmed
Hard to make decisions
Sad mood, guilt, phobias
Hopelessness
Sleep problems (too much or too
little)
Physical symptoms w/o apparent
cause
Discomfort around baby or lack of
feelings for baby
Loss of focus or concentration
Loss of interest, pleasure
Decreased libido
Change in appetite
• Risk Factors
– 50-80% risk if prior postpartum
depression
– Depression or anxiety during
pregnancy
– Personal or family hx of
depression
– Abrupt weaning
– Social isolation/poor support
– PMS or PMDD (premenstrual
dysphoric disorder)
– Mood changes with birth control or
fertility meds
– Thyroid dysfunction
• Treatment
– Psychotherapy
– Antidepressants
– Support groups
– Rapid hormonal changes
– Physical/emotional stress
of birthing
– Physical discomforts
– Emotional letdown
– Awareness and anxiety
about new responsibility
– Fatigue & sleep deprivation
– Disappointments
• Birth
• Spousal support
• Nursing
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Obsessive-Compulsive Disorder
• 3-5% of new mothers
• Symptoms
–
–
–
–
Intrusive, repetitive and persistent thoughts or mental pictures
Thoughts about hurting in killing the baby
Sense of horror and disgust
Behaviors to reduce anxiety
• Hiding knives, guns
– Counting, checking, cleaning or other repetitive behaviors
• Risk Factors
– Personal/family history of obsessive-compulsive disorder
• Treatment
– Therapy
– Antidepressants
– Support groups
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Panic Disorder
Psychosis
• 10% postpartum women
• Symptoms
–
–
–
–
–
–
–
–
• Causes
Episodes of extreme anxiety
Shortness of breath, chest pain, sensations of choking/smothering
Hot/cold flashes, trembling, palpitations, numbness or tingling
Restlessness, agitation or irritability
Fear of going crazy, doom, or dying
Panic attacks w/ no trigger
Excessive worry or fear
Want to run away
• Risk Factors
– Personal history of panic/anxiety disorder
– Thyroid dysfunction
• Treatment
•
•
•
•
1-2 per thousand
Onset 2-3 days postpartum
5% suicide and 4% infanticide rate
Symptoms
–
–
–
–
•
Visual/auditory hallucinations
Delusional thinking
Delirium and/or mania
Parnoia
Risk factors
– Personal or family hx of psychosis, bipolar disorder, or schizophrenia
– Previous postpartum psychotic/bipolar episode
• 1 in 3 will have another episode with pregnancy
•
Treatment
– Hospitalization
– Medication
– Support group
– Medications
– Stress Management
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Postpartum Psychiatric
Illness/Posttraumatic Stress
Disorder
• No data on prevalence or onset
• Symptoms
– Recurrent nightmares
– Extreme anxiety
– Reliving past traumatic events
• Risk Factors
– Past traumatic events (Abuse)
Etiology of Depression/Anxiety
•
•
•
•
•
Nutrient deficiency
Blood sugar instability
“Stress”
Medications
Alcohol, caffeine,
recreational drugs
• Situational Factors
• Medical conditions
(cancer, heart
disease, RA, MS,
Chronic pain, anemia)
• Hormonal/endocrine
• Allergies
• Toxins/Heavy Metals
• Treatment
– Postpartum doula
– Therapy
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Comprehensive Approach
Comprehensive Approach
• Evaluate the patient and rule out underlying
causes of disorder
• Anemia
– Fe deficiency vs. B12/folate
• Nutritional Deficiency
• Adrenal
• Thyroid
– Postpartum thyroiditis prevalence is 5-10% of all
women
– Can present as post partum depression
– Onset generally first 2-4 mos. post partum
– High cortisol, low DHEA
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Treatment Consideration
• Evaluate the underlying causes to target
the most effective treatment
• Choose least invasive treatment option
• Monitor nursing baby for potential side
effects of any treatment given to mother
orally (pharmacologic effects of herbs as
important as medications)
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Diet
• Goal: stabilize blood sugar
– Hydration needs to be adequate
• Especially in a nursing mother
– Three meals and 2-3 snacks
– Protein with each meal and snack
– Avoid refined sugar, flour and processed
foods
– Chromium
• Effective for “atypical depression”
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Fish Oil
• Maternal DHA status declines in the
second trimester associated with high
demand for fetal brain development
• Omega 3 fatty acids may be protective for
high risk pregnancy outcomes
• DHA supplementation may enhance
language development in breast fed
infants
•
Fish Oil
• EPA improves symptoms of depressed patients
already treated with antidepressants
• Double blind placebo controlled study
• 20 patients given 1g EPA bid
• Significant reduction in HAM-D score seen in 4
weeks
• No side effects
• Nemets, B, et.al. Addition of Omega 3 Fatty Acid to
Maintenance for Recurrent Unipolar Depressive Disorder,
Ann Psychiatry, March 2002;159;477-479
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Omega 3 Fatty Acids
Estrogen
Successful treatment of major depression during pregnancy and following
delivery with omega-3 polyunsaturated fatty acids
•
•
• After two weeks of treatment, 19 of the women experienced a clinical recovery as
defined by a score <7 on the Montgomery-Asberg Depression Rating Scale (MADRS).
Omega-3 polyunsaturated fatty acids health benefits
– Support the optimal neurological development of the fetus and infant (Birch et al.,
2000; Willatts and Forsyth, 2000).
– Risk of preterm labor is reduced in women who consume omega-3 fatty acids
during pregnancy (Olsen and Secher, 2002).
– Support the optimal neurological development of the fetus and infant (Birch et al.,
2000; Willatts and Forsyth, 2000).
•
Estrogen
– In a double-blind study of 61 women with major depression that began three
months postpartum, transdermal estrogen (as 17 ß-estradiol 200 µg/day) led to a
rapid improvement in mood (Gregoire et al., 1996).
– Second study, 23 women with major depression that occurred in the six months
following delivery took sublingual estrogen (as micronized 17 ß-estradiol, mean
dose=4.8 mg/day after the first week) (Ahokas et al., 2001).
– Inadequate levels of omega-3 fatty acids have been associated with depression,
including postpartum depression (Hibbeln, 1998; Horrobin and Bennett, 1999;
Peet and Horrobin, 2002; Peet et al., 1998), and these fatty acids (e.g., 1 g/day
to 4 g/day ethyl eicosapentaenoate)
– Used to potentiate the effects of antidepressant medications (Nemets et al.,
2002; Peet and Horrobin, 2002).
The health benefits following delivery.
– In infant formula can improve infant cognitive development and visual acuity
(Birch et al., 2000; Willatts and Forsyth, 2000).
– Positive mood effects
•
•
Estrogen appeals to patients because it is a naturally occurring substance.
Estrogen levels precipitously decline following delivery
– Estrogen deficiency underlies postpartum depression, but has not been
conclusively linked to low levels of estrogen or any other hormone (Hendrick et
al., 1998).
•
Risks
– Endometrial hyperplasia
– Thromboembolism
– Diminishes the production of breast milk in nursing mothers.
•
Not highly recommended
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Progesterone
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Nutrients
• B12
– cottage cheese, liver, oysters, swiss cheese
• Progesterone levels are low post partum
• Women with post partum depression are more sensitive
to the w/drawal of steroid hormones.
• Not evaluated in a clinical trial
• Natural progesterone is metabolized into
allopregnanolone, a neuroactive steroid that enhances aminobutyric acid (GABA) in the central nervous system,
producing anxiolytic and hypnotic effects (Rupprecht and
Holsboer, 1999).
• Synthetic progestogens do not help postpartum
depression and may, on the contrary, exacerbate the
symptoms (Lawrie et al., 2000).
– Not metabolized into GABA-ergic neuroactive steroids.
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• Folate
– Brewer’s yeast, rice germ, walnuts, soy beans, almonds,
broccoli
• Zinc
• Copper
• Pyridoxine (B6)
– Whole grains
• Thiamine (B1)
– Brewer’s yeast, wheat germ, soybeans, sunflower seeds
• Magnesium
– Tofu, legumes, seeds, nuts, whole grains, green leafy
vegetables
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SAMe
• Naturally occurring
molecule found in all
body tissue
• Plays a role in over 100
biochemical rxns
• Rapidly relieves
depressive symptoms (12 wks)
• Increases activity of
serotonin, dopamine, and
norepinephrine
• Peak plasma
concentration 3-5 hours
after ingestion
• Half life 100 minutes
• Readily crosses the blood
brain barrier
• Efficacy comparable to
tricyclic antidepressants
for major depression
SAMe – Caution/Side Effects
• Side effects can include flatulence,
nausea, diarrhea, anorexia
– Watch breastfeeding baby carefully
• Can induce mania in bipolar disorder
• Drug interacctinos
– Additive effect with SSRI’s
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5-Hydroxytryptophan
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Other Considerations
•
Skullcap :
–
• Precursor to serotonin from the amino
acid, tryptophan
• 5-HTP readily crosses the BBB
• Excellent safety Profile
• Effective for mild, moderate, and severe
depression-comparable to SSRI’s
• Side effects minimal
–
–
–
–
•
•
•
•
•
•
Tones and nourishes the nervous
system
Used with serious mental exhaustion,
depression and prolonged sickness
Aids in calming tension and stress
Improve sleep patterns
Side effects
Dizziness
Confusion
Twitching
Palpitations
– nausea
Abdominal upset
Abnormal skin coloring
Sun sensitivity
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Helps enzymes generate energy
Promotes nerve function
Promotes glucose transport
Side effects
•
•
•
•
Appetite loss
Breathing problems
Headaches
Unusual tiredness
Low Vitamin B1 (Thiamine)
–
Reduces depressive moods
Relieves anxiety
Depresses central nervous system
Antibacterial to heal wounds
Side effects
•
•
•
–
–
–
–
•
St. John’s Wort (Klamath Weed)*
–
–
–
–
–
Low manganese
–
–
–
–
–
Normal function of nervous system,
muscle and heart
Promotes normal growth and
development
Replaces deficiencies from pregnancy
and breastfeeding
Reduces depression
Reduces fatigue
Side effects
•
•
•
Skin rash or itching
Swelling in face
Wheezing
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Other Considerations
Herbal Ideas
• Recipe for bath-herbs in my files
OTHERS: Gotu Kola, Ginseng, Kelp, Black
Cohosh, Capsicum, Valerian, Mistletoe, Ginger,
Hops, Wood Betony
*WARNING: many herbs contraindicated if
mother is breastfeeding
–
–
–
–
–
–
1 C Sea salt
1 Large clove of fresh garlic
1 Ounce of uva ursi
1-2 Ounces of comfrey
1/2-1 Ounce of shepherd's purse
Boil large pot of water.. Add herbs, and simmer 30 minutes to an hour.
Strain. Add sea salt and pureed garlic..
• Garlic and sea salt-- antiseptic.
• Uva ursi -- healing for female organs.
• Comfrey -- soothing and is said to aid healing by causing the edges of
wounds to grow together.
• Shepherd's purse, -- preventing and controlling heavy bleeding.
• Another recipe
– 2 hands full of Comfrey
– 1 handful salt tied into a clean sock
– Simmer in water, throw sock and tea into the tub…adde a dropper of St
Johns Wort oil and Arnica oil to the water…Great for soreness
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Alternatives Recommendations
Alternatives Recommendations
• Support
–
–
–
–
Communicate your needs
Ask for help with the demands of caring for a newborn baby.
Consider hiring a doula
Consider pumping for the nighttime feedings and have your partner do at
least some of the nighttime feedings so you can sleep.
– Ask for help with housekeeping and preparing meals. Many people who
no longer have young children feel honored to be asked to care for the
baby for short periods of time.
• Exercise
• Promote sleep
– Inadequate sleep can make depression worse.
– Release inflammation and heat
– Restore balance & energy
• Meditation
– Encourages rest
– Restores inner balance and peace
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Continued…
Adjusting for Depression
Eating a well balanced diet
Regularly scheduled meals
Decreasing refined sugar, caffeine, alcohol, and chocolate may help.
REMOVE FOOD ALLERGENS!!!
Use of calcium, and B vitamins (B6) may also decrease symptoms.
•
Spend time with others
•
Make time to do what you enjoy
•
Give yourself a break –
– Being with others is a way to gain perspective
• Consider joining a support group for new mothers
– Lose ability to enjoy themselves
– Continue doing pleasurable activities even if you don't feel like it.
– Getting better takes time. Be realistic about the demands and expectations you
make on yourself.
•
• Identify the main sources of stress in your life
• Find the most effective way to cope with those
• Identify stressors that you are putting on yourself (trying to be "perfect",
doing too much).
• Set priorities and let unnecessary tasks wait.
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Dietary changes
–
–
–
–
–
– Learning to deal more effectively with stress may reduce depression.
• Acupuncture
– Releasing the body's mood-elevating compounds
– Reducing the depression hormone in the blood, providing perspective on
life, providing a feeling of accomplishment, enhancing self-esteem, and
increasing levels of (a found to be key in the development of
depression).
– As little as 10 minutes a day has been found to have beneficial effects.
•
• Stress Management
Negative influences
• CRANIALS
• C1
• Spinal tracts
– Lumbars
• Sympathetic vs. Parasympathetic
• Endorphins
– Acupuncture
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Did We Know Better?
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• Breastfeeding has been going on since
mammals existed on earth.
• The ancient Greek and Roman medical writings
from Hippocrates, Soranus, and especially
Galen included infant health and feeding to
some extent in their broader treatises on health.
• These beliefs were carried into the Middle Ages
by the Arabian School (Rhazes, Avicenna and
Averroes) and picked up in the Renaissance
medical writers (Bagellardus, Metlinger,
Roesslin, Phayer, Muffet, and de Vallambert)
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Did We Know Better?
• Presumably these beliefs spread in the same
way as the humoral ("hot-cold") theory of
disease causation through much of Asia and the
Middle East, via the Moors to Spain, and via the
Spanish conquerors to Latin America.
• These beliefs received a wider audience in
Europe with the advent of printing and the use of
vernacular languages in the fifteenth and
sixteenth centuries. They may lay behind the
remarkable similarity of many "traditional" beliefs
about infant feeding found throughout the world
today.
Did They Know….
• Breastfeeding duration
– An average duration of 3-4 years among
"primitive" peoples (although some breast fed
much less than this).
– Hawaiians were said to breast feed for five
years
– Eskimos for about seven years
– Breastfeeding continued for three years or
longer in 15 of 45 "primitive" cultures for
which he could find clear data
• Two years in 16 of them
• 18 months in 13 of them
• 6 months in one culture.
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Did They Know….
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• Issues in lactation management
• The late 1400's suggesting that it was normal to
breast feed for only about one year in Germany.
• In Italy in 1583, women gave pap by the third month
and stopped breastfeeding by the 13th month.
• During the 1800s, sustained breastfeeding seems to
have been considered harmful.
• In 1842, a physician writing in Lancet about epilepsy
which developed in a child who happened to have
been breast fed for three years, concluded, "The
worst symptoms of debility at last attended this
monstrous proceeding.
• By 1900, it was considered immoral in Tyrol.
– India—The discarding of colostrum and use of honey and
clarified butter to evacuate the meconium and the delaying of
breastfeeding until the fifth day was practised in the second
century BC.
– The Old Testament (Isaiah 7:15) refers to curds and honey to be
given to the son born of a virgin "until He knows how to reject the
evil and choose the good."
– The colostrum taboo was carried into the seventeenth century
English and French pediatric literature via ancient Greek and
Roman sources .
– Ettmuller in 1699 (5) and Smith (6), however, recommended that
colostrum be given.
• Galactagogues, and various devises to increase breast milk
production have long been common in many cultures
– Going back to around 1550 BC prompting speculation that failure
of the let-down reflex may have commonly occurred, perhaps as
a result of "fears of bewitchment or guilt over non-observance of
taboos, especially of a sexual nature."
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History of Artificial Feeding
• Issues in lactation management
• Rhazes in the tenth century set a precedent for many writers over the
years, claiming that many ailments are caused by "overfeeding".
– This has led many to insist that the mother must discipline the child
not to take the breast too many times or for too long a period each
time or at regular intervals.
– One of the first books on infant feeding was written by Guillemeau
and translated in 1612 into English. It recommended regimented
discipline of the child.
– Followed up on by Pernell in the second English pediatric textbook in
1653--Let not the child suck so often, nor so long
– The German Ettmuller's "Practice of Physic was translated into
English in 1699--Nothing is more apt to disorder the child than
suckling it too often
– Cadogan recommended four feeds per 24 hours for infants
– Smith who, in 1792, published the first mothercraft manual--four
hourly feeds be followed by about one month of age, since frequent
suckling stimulated lactation.
•
Feeding vessels dating from about 2000 BC have been found in Egypt.
– A mother holding a very modern-looking nursing bottle in one hand and a stick,
presumably to mix the food
– Clay feeding vessels were found in graves with infants from the first to fifth
centuries AD in Rome.
•
•
"Hand rearing" was criticized already by Soranus of Epheses, a Roman
physician of the second century AD who chided those foolish people who
begin artificial feeding too early.
Records from foundling homes in England and France show that the vast
majority who were artificially fed died.
– Sir Hans Sloan wrote that the mortality of suckled infants in Britain in 1660 was
19%; for dry nursed infants it was 54%.
– In Rouen, France data from the two-year period 1763-5 showed that of 132
foundlings fed diluted cow s milk, with pap, soup and cider added at three
months, only five survived.
– In 1753, the governor of the Vasa District in Sweden received permission for the
King to fine those mothers who did not breast feed.
•
Bottle feeding began to work somewhat better as technology for
evaporating and canning milk (reducing its curd tension and sterilizing it)
was developed in the mid nineteenth century.
– Pediatricians became commercially involved in artificial feeding in Paris in 1903.
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And Now….
• It was noted in the 1970’s that formula fed
babies had higher death rate due to malnutrition
and recurrent infectious diseases
• In 1990’s breastfeeding was assoc with
decreased death rates due to URI and diarrhea
–
–
–
–
Bacterial contamination in water
Bacterial contamination in bottles
Recurrent episodes of infectious gastroenteritis
Watered down by those in poverty to make last longer
Going Against Design?
• Body is designed for it
– Anatomically
– Neurologically
• Hormonally
• Emotionally
• Countries that utilize breastfeeding and midwifery have
better infant mortality rates
• Only in 20th century we think we can do it better
– Modified mammalian milk (cow formula)
– Unmodified mammalian milk (cause metabolic problems in
infant)
– Grain/legume based beverages (soy formula or gruel)
– Wet nurse
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Composition of human breast
milk
•
•
•
Lactose (carbohydrates)
Contain whey protein, casein
proteins, and non-protein nitrogen
Infants have softer, less foul
smelling stools…ideal for GI tract
– Bacteria in GI tract only found in
breastfed babies
•
•
•
Composition varies based on time
of day (longer you feed the higher
the fat content)
Odor and taste of breast milk
changes to help child adapt to
different tastes
Vitamin K and D (may need to be
supplemented after birth)
•
Minerals
– Sodium, Potassium, Calcium,
Magnesium, Iron, Zinc, Copper,
Selenium, Chromium,
Manganese, Molybdemun, and
Nickel
– Poor in Iron
•
Anti-infective properties
–
–
–
–
–
–
–
–
–
–
–
Immunoglobulins IgA, IgM, IgG
Complement
Chemotactic factors
Lactoferrin
Lysozyme
Lactobacillis Bifidus growth factor
Cytokines
Macrophages
T & B Cell Lymphcytes
Plasma & Neutrophils
Interleukins
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Hormones of Breastfeeding
• Prolactin
– Produced by the
adenohypophysis (ant pit)
and released into the
circulation
– Produces milk
– Controlled by the
dopaminergic system
– It takes several minutes of
sucking to cause prolactin
secretion
– Inhibits ovulation
• Oxytocin
– Produced by the
neurohypophysis (post pit)
– Suckling stimulates the
neurohypophysis to
produce and release
oxytocin intermittently
– Produce milk let down
– Causes uterine
contractions
Others for production: Insulin, Cortisol, Thyroid hormone, Parathyroid
Hormone, Parathyroid hormone-related protein, and human growth hormone.
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Changes in Composition
•
Birth to three days
•
4-10 days
– Colostrum—thick, yellowish milk
• Increased Ca, K, Proteins, Fat-soluable vitamins, mineral, and antibodies
– Intermediate between colostrum and mature milk
– Volume increases
•
10-termination of breastfeeding
– Energy—750 kcal/liter
– Lipids (Mom’s diet doesn’t affect fat amount, just type)
• Triacyl-glycerols
• Phospholipids
• Fatty acids
– Casein—lower concentration than cow’s milk
– Whey
•
•
•
•
•
Alphs-lactalbumen
Lactoferrin
Lyzozyme
Albumen
Immunoglobulins
– Nonprotein Nitrogen—Used in amino acid synthesis
– Lactose
• Major carbohydrate in breast milk
– Galactose
– Glucose
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