Pregnancy

Bringing new mothers’ pain out of the shadows

More needs to be done to raise awareness about the devastation of postpartum depression among the public and medical community and to make effective treatment widely available.

Kimberly Wong

Public defender Kimberly Wong, who suffered severe postpartum depression, founded the Los Angeles County Perinatal Mental Health Task Force to raise awareness about the illness. (Christina House, For The Times / July 29, 2012)

By Kurt StreeterJuly 29, 2012 

Just like for so many others, including my wife, Kimberly Wong didn’t see the darkness coming, and nobody warned her that it could.

Here’s what happened. After years of trying, Wong got pregnant and at first everything went perfectly. The lead-up, the birth, the first week with the new baby, a cute little girl she and her husband named Marley.

Then out of nowhere this tough-minded public defender crumbled. Wong’s skin felt like it was being zapped by a cattle prod. Her resting heart rate was often 100. She could barely eat, sleep, slow down or think cogent thoughts.

Her doctor told her she was simply a high-strung lawyer who needed to relax. So she blamed herself, which made matters worse.

It didn’t help that the doctor’s advice made no sense. Wong had something relaxation can’t cure. She’d been hit by postpartum depression, brought on by, more than anything else, whipsaw hormonal changes that come with giving birth.

This isn’t something we can afford to keep sweeping into the shadows.

Experts say 10% to 20% of new mothers experience it: a steep drop in mood that’s far more devastating and lasts far longer than two or three weeks of the so-called baby blues.

Wong had the worst type. She penned a suicide note. By luck, her husband walked in on her. He took her to a Mid-City mental hospital so she wouldn’t harm herself. Nobody at the hospital had much expertise in what she was battling.

That’s when Wong realized how few options there are for women who need psychological help related specifically to motherhood. She had to drive 50 miles to find a doctor and a support group that really understood.

You should know that time has passed, about eight years since the height of it, and Wong and her family have bounced back. In fact, she has turned her struggles into something good.

“I’m trying to make sure other moms don’t go through what I did,” she says.

When she’s not working at the public defender’s office, she focuses on the nonprofit she started: the Los Angeles County Perinatal Mental Health Task Force. Sure, clunky name, but can there be a more important cause?

Experts say that in L.A. County alone, about 22,000 new mothers suffer from this awful malady every year.That’s 22,000 women — as well as their babies and partners — who need special support and too often aren’t getting it.

The task force — bare bones, operating largely on the energy of volunteers — aims to push us out of the shadows: moms and families who need help but are too embarrassed or just don’t know where to turn; doctors and social workers who are either ill-informed on the nuances of this illness or just don’t look hard enough for the warning signs.

Wong’s doctors didn’t really talk about the possibility she could grow terribly depressed after giving birth, she said. They should have.

She’d suffered childhood trauma: Her mother died when Wong was 11. There was a history of mental illness in her family, and she’d struggled to conceive. Those three facts put her at risk, but no doctors warned her, nobody came up with a plan that could have shielded her from near-fatal darkness.

“There’s just so much stigma that needs to be shattered,” Wong says. “I want people to talk about this like they talk about diabetes or having a bad heart. Not enough has changed since this happened and when it did happen I could barely get help.

“I’m a professional from West L.A. and it was hard enough for me,” she adds. “So think about women in poor communities with little access to good healthcare. Add it up and so many are suffering and the long-term effects for families can be devastating. Yeah, we need to talk.”

I know.

After the birth of our son in 2010, my wife battled postpartum depression. It wasn’t anywhere nearly as serious as what Wong went through and that’s important to know: This malady shows up in different strengths.

My wife’s was a more typical case. She wasn’t close to hurting herself or being put in a hospital. She did everything anyone could ask for our son. But for long, long months she lived in a world of sharp, shattering emotion that could have been avoided if we’d known more or had more aggressive help.

It could have broken my wife. What if she hadn’t had a partner to help? What if she had been poor? We’re insured, and even then it took a while for her doctors to understand how serious this was. But eventually she found a therapist who could talk her through the trouble.

Part of the problem is we live in a world swaddled in golden-hued mythology about parenthood. It’s supposed to be full of nothing but joy. If it isn’t, then moms are told to get more sleep and toughen up. That’s not helpful when depression sinks in its claws.

“A lot of us hide from this issue,” says Wong. “That has to change.”

She’s talking. So am I. So is my wife, who pushed me to write about her ordeal. If you care about mothers and children and families, well, you should be talking too.

kurt.streeter@latimes.com

Copyright © 2012, Los Angeles Times

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What is a Doula and Why Do I Need One?

So you’re having a baby? Great! You’ve decided on a doctor or a midwife, you’ve been taking your prenatal vitamins and you may even be starting to think about the birth itself. You’re in the beginning stages of developing a team of people who are going to support you through the birth process.

Regardless of whether you planning on delivering your baby home, at a birthing center or at a hospital, one of these people you might consider having present at your birth to support you is a DOULA.

A DOULA? WHAT IS A DOULA?
In essence, a doula is a fancy word for an old concept. In cultures all over the world, women attend births. Women have assisted other women in giving birth for thousands of years. With the onset of industrialization and the tendency for birth to be a medical procedure, rather than a naturally occurring event, the concept of a birthing assistant has fallen by the wayside. In recent years, the idea of employing women to attend births has come back into favor and thus enters the doula.

A doula (usually a woman) is a person who assists women with the birthing process. A birth doula is “a supportive companion professionally trained to provide physical and emotional support during labor and birth…She provides continuous support, beginning during early or active labor, through birth, and for approximately two hours following the birth. The doula offers help and advice on comfort measures such as breathing, relaxation, movement, positioning, and massage. She also assists families with gathering information about the course of labor and their options. Her most critical role is providing continuous emotional reassurance and comfort.”

http://www.transitiontoparenthood.com/ttp/Doula/doulahome.htm

Some hospitals are even starting to provide doulas to women when they come to the hospital in labor, but this is rare. Woodwinds Hospital, a local hospital in MN, has a volunteer program providing this service called Doulas at Woodwinds.

WHAT DOES A DOULA COST?
Most doulas charge a flat rate for the entire pregnancy and delivery and all services rendered during this time. As I recall, the cost generally ranges from somewhere around $800.00 – $1,500.00. (Just an estimate.)

WHAT DO YOU GET FOR THE COST?
Doulas general provide services for three purposes: (a) prenatal visits, (b) delivery of the baby, and (c) postnatal visits. The doulas are on call during your birth and will be there regardless of the day or the time of day, unless they have informed you otherwise. The frequency and content of the visits may vary from doula to doula so be sure to ask lots of questions when interviewing your doulas.

1. Doulas usually do a few prenatal visits and will help you prepare a birth plan. They will talk to you about what you want during your labor and delivery and go over some of the choices you might have (types of pain relief, cord cutting, membrane stripping, etc.)

2. Doulas come to your house when you start to go into labor regardless of where you plan on giving birth. Their philosophy is geared towards laboring at home for as long as possible. If you go into labor quickly and are delivering at a hospital they will come as soon as you are admitted and will stay with you until the baby comes and for a few hours afterwards. Their rate includes your entire labor even if you labor for 48 hours, God forbid. If you deliver your baby in your home or in a birthing center, they would do the same thing, only in those places instead.

3. They also make one or two visits to your home after the baby has gone home with you. They will assist with breastfeeding, comforting your baby and adjusting to being a mom, if it’s your first time.

WHAT IS THE ROLE OF A DOULA DURING THE BIRTH?
The role of the doula is to assist the birthing mother with whatever it is that she needs. She is like a personal assistant. If you want her to clear the room of people, she will do that. If she wants you to get your husband or partner to help out or give a massage, she will do that. Basically she is at your beck and call throughout the labor. She will help you find good positions to labor in and will be very active or play a background role depending on what you want. If your partner is actively involved in the delivery she might provide gentle suggestions on helping you through the labor and delivery. Her main role is to act as your advocate and to see that you are getting your needs met such that the delivery is as comfortable as it possible can be.

If you end up having a Cesarean the doula can also enter the operating room. They usually have a limit on how many extra people can be there so you may have to choose between your birthing partner, if you have one, and the doula.

DO DOULAS HAVE MEDICAL TRAINING?
Doulas are not medically trained in the traditional sense. They do come with tons of knowledge about birth and labor and will provide you with suggestions about when to rest and when to move around and what positions you might try during labor. However, they are trained not to communicate with the medical staff directly regarding your medical condition. They will prompt you to communicate to the medical staff about a wish or desire that you had (such as not wanting the cord cut or skin-to-skin contact, etc.).

HOW DO I GO ABOUT FINDING THE RIGHT DOULA FOR ME?
1. The hospital where you are delivering may have a list of doulas that you can contact. In addition, you can read about them on the web (they may have their own websites) and if they look like someone you are interested in they will meet with you so that you can see if you like them and if you want to hire them.

2. On-line directories such as this one: http://doulanetwork.com/directory/Minnesota/ may be available in your area as well.

3. In Minnesota we have something called the Childbirth Collective and they have a “Meet the Doulas” night. It’s a great thing because you can meet a bunch of doulas all at one time and if you see one you like you can try to get an appointment set up for a meet and greet to see if you want to hire them.

From their website: The Childbirth Collective is a “collective of birth professionals who support women and families during the childbearing year. Perhaps you are looking for a birth doula, midwife, birth photographer, massage therapist or a postpartum doula. The Childbirth Collective is the place to connect with a growing and passionate community that cares about how you birth.”

Regardless of where you find your doula, make sure you interview a few so that you are comfortable with the one you choose. She is going to see you through one of the most challenging and amazing experiences of your life. Liking your doula will only make it a more positive experience.

WHAT ARE THE BENEFITS OF A DOULA?

From: “What is a Doula?

  • Reduces the need for forceps or vacuum extractor by 41%
  • Reduces need for Cesarean by 26%
  • Decreases medical intervention in labor
  • Reduces use of pain medication by 28%
  • Reduces dissatisfaction with birth by 33%
  • Reduces length of labor

Six weeks after birth, mothers who had doulas were:

  • Less anxious and depressed
  • Had more confidence with baby
  • More satisfied w/ partner
  • More likely to be breastfeeding

Homebirth Midwifery Care, Birth and Postpartum Doula Support and Massage Therapy Center http://www.geneabirth.com/

These two women look they provide a wonderful array of services. They provide Midwifery services, Doula services and Birth Massage.

They will also assist in at-home births for VBAC women, also known as the HBAC (Home Birth After Cesarean).

Awesome!

The massage service includes a two and a half hour massage during your labor with a certified prenatal massage therapist. Their massage therapist has also been a doula for eleven years and can guide you with the best positions to be in for early and active labor. The service includes meeting with the therapist to discuss the type of massage you would like to use in labor, and picking out the scents/s you would like to use in labor. She will then make an oil using Young Living Oils that you will bring home with you. In labor, the massage therapist will come to your home or visit you at the hospital/birth center for a two and a half hour massage that will help you to enter your labor in a calm and centered place. This massage is specifically tailored to you and your needs. She can come at any point during your labor, but early labor is usually the best.

NOTE: I know that for you around the country this particularly birth center might not be a possibility but perhaps there are other birth centers in your area that offer similar services. It’s good to know that places like this exist.

Additional Resources:

What is a Doula? (http://www.dona.org/mothers/index.php)
DONA International (http://www.dona.org/)
What is a Doula? (www.transitiontoparenthood.com/ttp/Doula/doulahome.htm)

Children, Pregnant Women and Heat: It Can Be Dangerous!

http://yosemite.epa.gov/ochp/ochpweb.nsf/content/heat.htm

Extreme Heat: Effects on Children and Pregnant Women

Heat-related illnesses are common, yet preventable on hot days. Children and pregnant women need to take extra precautions to avoid overheating on days of extreme heat. Dehydration, heat stroke, and other heat illnesses may affect a child or pregnant woman more severely than the average adult. Download a copy of this information (PDF) (2 pp, 80K, About PDF).

Why are children more susceptible to extreme heat?

  • Physical characteristics – Children have a smaller body mass to surface area ratio than adults, making them more vulnerable to heat-related morbidity and mortality. Children are more likely to become dehydrated than adults because they can lose more fluid quickly.
  • Behaviors – Children play outside more than adults, and they may be at greater risk of heat stroke and exhaustion because they may lack the judgment to limit exertion during hot weather and to rehydrate themselves after long periods of time in the heat. There are also regular reports of infants dying when left in unattended vehicles, which suggests a low awareness of the dangers of heat events.

How do I know if my child is dehydrated?

  • Decreased physical activity
  • Lack of tears when crying
  • Dry mouth
  • Irritability and fussiness

What should I do if my child has become dehydrated?

  • Have the child or infant drink fluid replacement products
  • Allow for rehydration to take a few hours, over which children should stay in a cool, shaded area and sip fluids periodically
  • Call your doctor if symptoms do not improve or if they worsen

How do I know if my child has suffered a heat stroke?
Heat stroke, a condition in which the body becomes overheated in a relatively short span of time, can be life-threatening and requires immediate medical attention.

  • Skin is flushed, red and dry
  • Little or no sweating
  • Deep breathing
  • Dizziness, headache, and/or fatigue
  • Less urine is produced, of a dark yellowish color
  • Loss of consciousness

What should I do if my child has suffered a heat stroke?

  • Immediately remove child from heat and place in a cool environment
  • Place child in bath of cool water and massage skin to increase circulation (do not use water colder than 60F – may restrict blood vessels)
  • Take child to hospital or doctor as soon as possible

How can children be protected from the effects of extreme heat?

  • Hydration – Make sure children are drinking plenty of fluids while playing outside, especially if they are participating in sports or rigorous physical activity. Fluids should be drunk before, during and after periods of time in extreme heat.
  • Staying indoors – Ideally, children should avoid spending time outdoors during periods of extreme heat. Playing outside in the morning or evenings can protect children from dehydration or heat exhaustion. Never leave a child in a parked car, even if the windows are open.
  • Light clothing – Children should be dressed in light, loose-fitting clothes on extremely hot days. Breathable fabrics such as cotton are ideal because sweat can evaporate and cool down the child’s body.

How do I care for my infant during hot weather?

  • Check your baby’s diaper for concentrated urine, which can be a sign of dehydration.
  • If your infant is sweating, he or she is too warm. Remove him or her from the sun immediately and find a place for the baby to cool down.
  • Avoid using a fan on or near your baby; it dehydrates them faster.
  • A hat traps an infant’s body heat and should only be worn in the sun to avoid sunburn.
  • Never leave an infant in a parked car, even if the windows are open.

Why are pregnant woman especially at risk during periods of extreme heat?
An increase in the core body temperature of a pregnant woman may affect the fetus, especially during the first trimester.

How can pregnant women protect themselves from the effects of extreme heat?

  • Wear light loose fitting clothing
  • Stay hydrated by drinking six to eight glasses of water a day
  • Avoid caffeine, salt, and alcohol
  • Balance fluids by drinking beverages with sodium and other electrolytes
  • Limit midday excursions when temperatures are at their highest
  • Call doctor or go to emergency room if woman feels dizzy, short of breath, or lightheaded

Where can I find more information about extreme heat?

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Choosing a Pediatrician: It’s Like Going on a Date!

When my baby was about six weeks old my pediatrician told me that my baby shouldn’t be nursing for more than twenty minutes per breast. More than twenty minutes, she informed me, and “She is using you as a pacifier.” What? She’s using me as a pacifier? Is that bad? Hello, parenting decision. And here I thought she was eating. “But maybe she’s just hungry…,” I mumbled. 

“No. She’s using you as a pacifier.”  There was no hesitation; no ands, ifs, or buts about it. It was definitive. My child was using me. I was being used.

Later, when my child was about six months old, this same pediatrician informed me that my baby no longer needed to be nursing at night. “A baby this old has no need to be nursing at night any more. She can sleep through the night just fine. If you continue to nurse her at night like you are now, she’ll be yours for life.”

What did that mean, she’ll be mine for life? Isn’t she already mine for life? Did she mean that my baby will still be wanting to nurse as a teenager? I didn’t get it. The only think I could figure is that she wasn’t in favor of long-term nursing. That then raised  more questions for me. How long did I want to nurse at night? Isn’t that for the baby to decide? I was confused and my baby’s doctor wasn’t making it very easy for me to wrestle with these tough parenting issues. She was giving flat out advice and that style just wasn’t working for me.

It was at this point that I realized my doctor and I needed to break up. I would do it gently. “It’s all about me. It has nothing to with you. Really!” The fact that we probably didn’t really see eye-to-eye on some pretty important parenting practices was a big part of the problem, but even bigger was the fact that I didn’t feel there was space in the examining room for my opinions. And what did I know? This was my first baby. I didn’t feel very confident in disagreeing with her and there was no room for conversation or objection or even curiosity. I simply didn’t feel comfortable in our relationship anymore. And counseling clearly wasn’t an option.

The pediatrician-parent relationship is a complex and important relationship, especially for the first-time parent. During those really early months of your baby’s life a zillion questions come up about caring for this new little being. And the books just don’t have the answers. (Either that or you’re too sleep deprived or petrified to read them.) So who do you turn to? Your pediatrician. Your pediatrician and the clinic where you have those appointments every week. And don’t kid yourself—in between those appointments, you’ll end up calling about anything from a pimply butt to a red face. Maybe she has the measles! Maybe it’s a life threatening rash! I’d better call the doctor.

Choosing a doctor before the baby comes is one of the most important things you will do prior to giving birth. As soon as that baby is out of the womb she already has about ten doctor’s appointments lined up that she’ll need to go to over the course of the next couple of months. During those first visits the doctor will be direclty and indirectly evaluating you as a parent and whether that baby is thriving in your care: Where does the baby sleep? How long does she sleep? What is she eating? How much is she eating? How much does the baby weigh? How much has she gained since I saw her a week ago? Is she breastfeeding or bottlefeeding? How much and for how long?

And then the big question: “Your baby is scheduled for three vaccinations this visit. Do you want to give them all?”

Because of all the decision-making that goes into parenting and caring for your baby, you need to find a doctor that fits your personality, your parenting style and your expectations of a physician. You and your doctor might not agree on every issue but hopefully you will enter into a relationship with someone who will  listen and honor your decisions as a parent while giving you the information you need to make informed choices. Most importantly, you will want to find someone you like as a person and whose opinion you respect.

I initially chose the doctor that I did because she seemed to be a pretty liberal doctor and was open to a delayed vaccination schedule. However, six months after the baby was born we split up because of irreconcible differences. The marriage was annuled. Our views on breastfeeding seemed to differ pretty radically and our communication didn’t feel like a two way street.

If you and your doctor have radically different ideas about how to care for a baby, it might not be a good fit. It’s kind of like going on a first date. You may think you’re in it for the long haul but as you find out more about the potential partner, your opinion may change over time. If you can get it right the first time, it can make things a little bit easier.

Part of the reason this relationship with your doctor is so important is because parenting requires loads of on-the-fly decisions regarding your baby’s health and well-being. In addition to the “What do I do right this second?” decisions, it also involves the questions about “How do I want to parent my child over the next year or two years?” Some of these decisions will be about issues that you will want to run by your doctor. When do I introduce solids? When do I stop breastfeeding? Is it safe to co-sleep with an infant? How long should a breastfeeding session last? These are topics that you’re going to want to discuss openly and honestly with your pediatrician, and the more comfortable you feel with your doctor, the better. Every doctor has their views on raising children and if your doctor’s methods are drastically different from what you want and care about, you won’t be getting the most out of the relationship.

Looking back on the process of choosing a pediatrician, I realize that I grossly underestimated the importance of finding a doctor that I liked as a person and whom I would respect.

When you pick a pediatrician you want to pick someone to whom you really want to go for advice; someone who will be open to hearing your opinions and point of view; and someone whose opinion you will trust. You want someone you can stay with for years to come. Find a pediatrician to walk down the aisle with and one with whom you can work, both in sickness and in health!

Vaginal Birth after Caesarean – The Key is Finding the Right Doctor and Hospital

The article below states that: “Most doctors or hospitals don’t have access to 24/7 hospital coverage by physician services in obstetrics, gynecology, anesthesia, neonatology with a neonatal intensive care unit, operating room availability for emergent Caesarean deliveries, massive blood banking and expert nursing.”

When I delievered my baby as a VBAC, at the age of 41, I did so in a small hospital in a small town, about 20 miles from the closest NICU. My doctor told me that their hospital had recently become approved for VBACs. My understanding of his explanation was that certain measures had to be taken in order to be allowed to perform VBACs. For instance, an anesthesiologist needed to be present in the hospital at all times in case of an emergency C-section. Hudson Hospital, where I delivered, did not have a neonatal intensive care unit (NICU). I was told that if a baby were to need immediate care it would be transferred to a hospital with these facilities.

A friend of mine gave birth to her second and third child vaginally in a birthing center in Wisconsin, attended by midwives, after having had her first child via Cesarean. Although I did not see the birthing center myself, I was told it was across the street from a hospital in the case of a need for emergent care.

She ended up giving birth the first time by Cesarean due to a diagnosis of “failure to progress.” She told me that she believes had she been in a hospital that her second two babies would also have been delivered by Cesarean. She believes that the midwives were more tolerant of a longer labor and helped while she progressed through the early stages of labor.

Here is the article to which I was referring:

Vaginal birth after c-section is option for women, not for some doctors, hospitals.

ScienceDaily (May 11, 2012) — Melissa Lunsford wants a vaginal delivery for her fourth child. Following a series of Caesarean and vaginal deliveries for her other children, she couldn’t find a doctor or a hospital willing to give her the vaginal birth option for her current pregnancy.

Unfortunately, too many women like Lunsford face the same challenge, says an advocate of vaginal births after Caesarean (VBAC) from Ben Taub General Hospital, one of the top VBAC-delivery hospitals in Texas.

“For some clinicians and hospitals, the prospect of offering a trial of labor after a Caesarean delivery is too risky. While risks exist, the possibility of delivering vaginally is still a viable option for many women,” says Dr. Christina Marie Davidson, chief, Obstetrics and Gynecology Services, Ben Taub General Hospital, and assistant professor, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine.

Finding a physician and hospital that offers VBAC procedures can be difficult. Most doctors or hospitals don’t have access to 24/7 hospital coverage by physician services in obstetrics, gynecology, anesthesia, neonatology with a neonatal intensive care unit, operating room availability for emergent Caesarean deliveries, massive blood banking and expert nursing. At the Harris County Hospital District, the health system that operates Ben Taub General Hospital and Lyndon B. Johnson General Hospital, the Women and Infant Services has all medical coverage needed to make VBACs a viable option for women even after more than one Caesarean delivery.

In fact, Ben Taub and LBJ hospitals share the state’s highest VBAC rates of all hospitals, respectively 27.86 percent and 29.58 percent, according to a 2009 report by the Texas State Department of Health Services. The rates of Ben Taub and LBJ hospitals are routinely three times higher than the national VBAC rate of 8 percent.

“We believe women should have that choice. We can’t guarantee that they’ll have a VBAC delivery every time, but we can certainly plan for it,” Davidson says.

Factors associated with an increased likelihood for a successful VBAC include:

• Not facing a similar condition for the previous Caesarean

• Successful vaginal delivery or VBAC in past

• Previous Caesarean not for cervix complications or infant not descending through birth canal

• Labor starts on its own

• Younger than 35 years of age

After being repeatedly told of the inherent risks and dangers, Lunsford sought answers and comfort on the Internet. Her research of successful testimonials gave her hope. She next began an arduous search for a VBAC-friendly doctor.

“Everyone I talked to, including my friends, basically told me it was silly to think of delivering vaginally again after a Caesarean. But, it is important to me and something I knew I wanted,” she says.

After contacting 10 doctors to deliver her baby, Lunsford finally found Davidson, who not only had the expertise, but who’s also an impassioned supporter of VBACs.

“Women who choose to have a vaginal birth after Caesarean should have that option and not be discouraged because of a lack of knowledge or resources,” Davidson adds.

For Lunsford, the chance to deliver her son as naturally as possible is worth the effort.

“It is important to me and important to my entire healthcare team,” she says.