Postpartum Depression

Congratulations! Your little bundle of joy has arrived and you couldn't be happier! You show off your new little one to family and friends with a heart full of pride and a smile from ear to ear. Wrapped in a carefully chosen outfit, you transport your baby home to begin a new chapter in your life. In your mind, things will be idyllic. You can just imagine it now.

You will have plenty of time to rest while baby rests and even have time to catch up on cleaning the house. You will have a delicious and nutritious meal ready each evening by the time hubby comes home from work. He will find you looking gorgeous and holding a sweet-smelling, cooing baby in one hand and a tempting appetizer in the other.

After dinner, baby will quickly settle down to sleep through the night while you and hubby cuddle in to make up for those six weeks after the baby was born. Life is good.

Your daydream is shattered by the shrill sound of your baby crying.

How a such a tiny thing can make such a big sound so often in one hour amazes you. Doesn't he realize he was just fed? And how many diapers does a baby go through in one day? You change the baby for what seems like the ten-thousandth time that day, and feed him again. Holding him over your shoulder to burp him, you feel certain he will drift off to sleep and you can begin to tackle that mountain of dishes in the kitchen you haven't had time for yet today. Then you hear a guttural sound emanate from your baby and feel a sticky, wetness drip down your back. "Did he just spit up on me, again?" Hubby walks in from work, takes one glance at the chaos and heads for McDonalds.

After a quick dinner of hamburger and fries, there is no cuddling, because someone is colicky. You take turns walking baby back and forth, hoping to settle down the incessant crying. Finally you give in to what you have wanted to do all day long and join the baby in his crying. Exhaustion, sleep deprivation, frustration and disappointment have all taken their toll on you. .

Welcome to the world of Postpartum Depression

Researchers estimate as many as 80% of all mothers experience some type of Postpartum Depression, sometimes referred to as "Baby Blues". They may just feel sad, for no specific reason, or as one young woman described it to me the other day, "I just wasn't me anymore." Some feel upset, afraid, alone or unloving toward their partner or baby.

The Baby Blues

The Baby Blues is a period of more sensitive emotions - similar to that experienced in the first trimester of pregnancy - but accentuated with the exhausted and sleep deprivation of caring for a newborn. This occurs in approximately 50% of all postpartum women and may last from a few days to a couple weeks after delivery, peaking within 3-5 days of delivery. Symptoms of Baby Blues may include:

• Crying for no apparent reason, or more easily than usual
• Difficulty sleeping even when tired
• Feeling irritable, or "on edge" emotionally

Baby Blues is a temporary state and is considered a normal part of the postpartum condition. This is not a weakness or a character flaw, it is not a sign of being a "bad mother", it is simply part of giving birth. Baby Blues is not related to stress or more likely to occur because of the mother's previous mental illness.

One of the key factors in determining if what the new mom is experiencing is Baby Blues or something more serious is Baby Blues will not interfere with the mom's ability to care for herself and her baby. Also, for most women the symptoms remain mild and go away on their own.

Postpartum Non-psychotic Depression

But for another 10-20% of mothers, Postpartum Depression can be more than just "Baby Blues", it can be a more severe form of emotional distress, sometime called Postpartum Non-psychotic Depression. This usually occurs within a few months of delivery. Risk factors include:

• Previous major depression
• Previous Postpartum depression
• Psychosocial stress
• Inadequate social support
• Previous premenstrual dysphoric disorder
  

Symptoms of Postpartum Non-psychotic Depression may appear from 24 hours to several months after delivery:

• Sad mood, frequency crying; crying easily
• Inability to find pleasure in things that were once pleasurable
• Trouble sleeping, even when fatigued
• Anxiety, extreme worry over the baby's safety or her own safety
• Changes in appetite, either not eating or over-eating
• Fatigue
• Feelings of inadequacy as a parent
• Decreased interest in sex
• Inability to concentrate
• Feelings of rejection
• Suicidal thoughts or expressions
• Inability to properly care for the baby
  

If you have postpartum depression, prompt treatment can help you receive help for your symptoms — and begin enjoy your baby. These symptoms should be taken seriously. If you have these symptoms, or a new mother you know has these symptoms, it is imperative that she see a health care provider for proper treatment.

Postpartum Psychosis

Rarely, an extreme form of postpartum depression known as postpartum psychosis develops after childbirth. This is the most serious of all the Postpartum Depression categories and usually manifests itself within three weeks of giving birth, but can last for much longer. Thankfully, it is rare, but it requires immediate attention. A woman with Postpartum Psychosis may have periods of seeming well, and may even appear to have recovered. Women who have thoughts of hurting their babies are more likely to act upon those thoughts if they are suffering from Postpartum Psychosis. If untreated, postpartum psychotic depression has a likelihood of coming back after the postpartum period and after the birth of other children.

When to seek immediate help:

• Inability to sleep more than 2 hours per night
• Thoughts of hurting yourself or killing yourself
• Thoughts of hurting your baby or other children
• Hearing voices or seeing things
• Thoughts that your baby is evil
  

What Will Happen When I Seek Help?

Diagnosing Postpartum Depression can be missed because women often feel ashamed of being truthful to health care providers about their feelings. Also, these feelings can be so common, in so many varying degrees, and are the same as those of many other mental illnesses, the exact diagnosis of Postpartum Depression can be overlooked. During an evaluation, you can expect your health care provider to ask you about your symptoms, what they are, how long they have lasted and how bad they are. It is important to be as truthful as possible to these questions. You will also be asked about any risk factors you may have for depression, such as a family history of mental illness, drug and alcohol usage, family, marital or financial problems. To help with your diagnosis, your health care provider may use the Edinburgh Postnatal Depression Scale. In this questionnaire, 10 questions help to indicate your probability of having postpartum depression.

How is Postpartum Depression Treated?

The plan of care for Postpartum Depression will depend upon the severity of your depression, based upon the answers you have given your health care provider. There may be several aspects to your care, including referral for psychological help, individual and/or group therapy, medications, marriage counseling, support groups and financial counseling. There are also some things which you can do to aid the therapies suggested by your health care provider.

• Don't be afraid to ask for help, especially in caring for the baby
• Surround yourself with supportive family members and friends
• Take care of yourself.
• Get as much rest as you can -- rest when the baby naps.
  
• Try not to spend much time alone.
  
• Spend some time alone with your husband or partner.
  
• Take a shower and get dressed every day.
  
• Get out of the house. Take a walk, see a friend, do something you enjoy. Get someone to take care of the baby if you can; if you can't, take the baby with you.
  
• Don't set unrealistic expectations.
• Don't worry too much about the housework. No one is a Super-Mom. Ask friends and family for help.
  
• Talk to other mothers. You can learn from each other, and their experiences can be reassuring.
  

Untreated, Postpartum depression symptoms can continue for months or years. The illness can cause prolonged misery for the mother and her family, hinder bonding of the mother and baby and even be dangerous if the mother considers hurting her child or herself. Intervention and support are essential.

Image by nyki_m via Flickr

Other Support References Depression After Delivery

• (800) 944-4PPD National Women's Health Information Center -
  
• (800) 994-9662 Postpartum Support International (PSI) -
  
• (805) 967-7636 American College of Obstetricians and Gynecologists Depression
  
• After Delivery Postpartum Depression Postpartum Support International
• http://www.mamalove.org
  
• http://postpartumdadsproject.org/
• www.postpartum.net
  

Please take a few minutes and watch this incredible video by Sarah Pond on Postpartum Depression:

Don't keep the pain to yourself,

speak up, get help,

and begin to enjoy your baby again.

My Legs! I Can't Feel My Legs!

Earlier this month, we discussed epidural anesthesia, both for labor and for pain management after Cesarean Section. Although it is an obvious side effect of epidural anesthesia, one aspect we didn't discuss directly was that any form of regional anesthesia causes the affected area to become numb. Really numb. Even though this is the goal of regional anesthesia, some women appear surprised at the depth of the anesthesia and some women don't like the feeling.

I was prompted to write this by a discussion I had today with a young woman entering her

Image via Wikipedia

second trimester of pregnancy. She has questions about labor and pain management during labor. A previous experience with regional anesthesia for an unrelated surgery, left her feeling anxiety about the numbness she had felt in her legs. She was telling me she felt she may encounter those same feelings again if she chose to receive an epidural.

I have had several patients who clearly did not like the sensation of numbness that the epidural caused. One of these patients stands out in my mind.

The morning started with this young couple coming in for an induction of labor for their first baby. They were cheerful and pleasant and nothing during the events of the morning even hinted at the fear and panic, which would define a large part of the afternoon. As is often the case, once Wendy’s contractions became regular and a good labor pattern developed, we called the anesthesiologist to place her epidural.

Usually after this, the woman sleeps, watches television, or visits with her family and a calm serenity falls over the room as numbness displaces the pain of the contractions. However, as Wendy’s legs began to become numb, the room was anything but serene. Once she realized she could not move her legs (not because she was “paralyzed” but because her very numb legs felt too heavy to her for movement), she began to experience true panic. Her heart rate sped up until it was more than doubled, causing pressure and tightness in her chest which in turn only added to her sense of panic. She struggled in vain to change her position, to make her legs move. Her motions became frantic, her eyes were wide with fright. Her breathing was rapid and even gasping at times. The more her husband insisted she “just relax,” the more terrified she became. With wild eyes, she begged me to make her epidural “stop.” I turned off the epidural pump knowing that she would remain numb for at least another hour. Her husband lost patience with her, telling her that her fear was unfounded.

“Just get over it,” was his frustrated suggestion to her.

I knew the panic, the terror, she felt. I tried to explain to him that she could not control or rationalize away the fear that gripped her. Watching her, my thoughts raced back to memories of my own moments of terror. The first occurred with my first experience in an MRI tube. I had no idea that the tight, confined space would cause my heart rate to soar and my chest to squeeze so tightly it seemed breathing would soon be impossible. As waves of nausea rushed in with the pain, I had the feeling I was going to die, and imminently. The MRI technician took me out of the tube and was comforting and encouraging and I decided to try again.

“I can handle this,” I thought, “after all, I teach other people how to relax in childbirth classes! Surely, I could do it now! ”

However, it was useless. After only a few seconds -- they never even turned the machine on -- it was necessary to again pull me out of the tube. This was not as embarrassing to me, however, as the incident at the fair.

My husband, daughter, and I had gone to the State Fair. Since my husband usually experiences

Image by cornfusion via Flickr

nausea riding the rides, I was the one who was frequently my daughter’s riding partner. This night was different as my husband surprised me by deciding to ride “The Scrambler” with us. As amusement park rides go, this one was benign. The ride had several arms each ending in an open-air car. The arms rotated and then turned abruptly at ninety-degree angles. I had ridden this ride hundreds of times with no problems but never before with two adults and an older child.

The three of us squeezed into the ride and we were hip to hip to hip. A business card couldn’t have been squeezed between us! My husband reached down and pulled the safety bar up over our legs. Now our movement was limited not only side to side by also up and down. In fact, I found I couldn’t move my legs at all. No matter how hard I tried to wiggle them loose, we were packed in so tightly, I couldn’t move at all. That was when the panic set in. You see, my problem wasn’t with tight spaces, in fact some tight spaces can feel very comforting, almost like swaddling a baby. My problem was with the issue of control, could I control the situation? Could I willingly move out of the tightness, the restraint, if I desired?

When it became apparent that the answer was “NO!” then panic began to take over. If I could have reached my legs to chew them off, I think I would have tried. I looked at my husband with frantic eyes, my heart already racing. His encouraging, soothing words could not calm my escalating fear. I tried to slow my breathing, even tried to calm myself down so my heart rate would return to normal. I knew physiologically what was happening, but I also knew that no matter how hard I tried, I could not move, and the fear was larger than the knowledge. Finally, my husband got the attention of the man running the ride.

“You’ve got to get her out of this ride, NOW!” He was authoritative with both his expression and his tone. The attendant unlocked the safety bar and I jumped out of the ride and ran to the side as fast as a chased rabbit, feeling depressed and defeated.

Over time, my fears of restraint eased, as my husband taught me that my fear was not of the situation, but rather of the panic, which accompanied the fear. That insight, and the practice of keeping my thoughts on “whatsoever things are true, whatsoever things are just, whatsoever things are pure, whatsoever things are lovely, whatsoever things are of good report” helped to keep the panic at bay. Still I believed that once the panic occurred, there was no way to end it except by escaping the situation. That was until I met Wendy.

As Wendy wiggled and writhed in her panic and fear, my heart went out to her. I knew what she was feeling. I called her doctor to see if he had any suggestions, but we were powerless to help. We couldn’t speed up the epidural wearing off. We couldn’t give her any medication to help her deal with her anxiety because her baby would be born with an adult dose of the drug in his baby-sized system. All I could do was pray for her and reassure her that she was going to be OK, that she wasn’t going to die, and that I was going to stay right with her and make sure she was alright.

I told everything that was normal. “You are getting plenty of oxygen; your oxygen rate is 99%.”

“Your blood pressure is normal.”

“The baby’s heart rate is fine.” As I did this, I tried to imagine what this delivery would be like with this writhing, frightened, numb woman. Then the thing that I never imagined could happen did happen.

Wendy calmed down.

Her heart rate began to slow down and her breathing became slow, regular and easy. She was still numb, but the fear subsided and the panic passed. It wasn’t long before she was ready to push and then ready to deliver. The birth of her baby was calm, serene and sweet…and such an inspiration to me.

For the first time I realized the panic could subside even in the situation, I had seen it happen before my eyes. Even in a time of fear, our spirits can know love, peace, and joy. The anxiety could resolve even if the situation did not change one bit. I started the day expecting to be the teacher, and in such an unexpected way, my patient became the teacher and taught me one of the most valuable lessons of my life.

Oh No! A Stretch Mark!

I was approached last night by someone asking me about how to prevent stretch marks. While I was glad to share the information with this person, I was surprised to be asked this by a 60+ year-old man!

Stretch marks, or striae gravidarum, are easily one of the most dreaded of the changes to a woman's body during pregnancy. Appearing in 50 - 90% of all pregnant women, the majority of stretch marks can be found on the lower abdomen, but they can also be found on the thighs, hips, buttocks, breasts and arms of women. While not painful, the stretching of the skin may cause irritating itching. Applications of lotion can help with the increased dryness or itchiness of the skin, but will not prevent stretch marks no matter how diligent your application.

Image via Wikipedia

The unfortunate truth is that there is no absolute way to prevent stretch marks during pregnancy. I know that is not what you wanted to hear, but it is the truth.

The reason most stretch mark creams can't prevent or completely remove existing stretch marks (even the very expensive creams) is because they concentrate their effectiveness on the epidermis, the outer layer of the skin. The majority of damage caused by stretch marks is a combination of damage in the epidermis and the dermis, the middle layer of your skin.

Human skin is usually fairly elastic. When the skin is stretched to the point where this elasticity breaks down, when it's overstretched, the normal production of the major protein that makes up the connective tissue in your skin, called collagen, is disrupted. Microscopic bleeding occurs as well as tissue inflammation. This gives the characteristic reddish purple look to the new stretch mark.

As the dermis layer of the skin is stretching, causing the bleeding, the epidermis, or outer layer of the skin, is also stretching, making it translucent enough for the reddish purple of the newly formed stretch mark to be seen underneath it.

At first, stretch marks appear indented but as they heal, scar formation occurs. Fortunately, over time the marks fade to a silvery color that is a few shades lighter than your natural skin tone. The lighter color occurs because the disruption of the collagen production caused by the overstretching of the dermis, may cause loss of skin pigment producing cells. The turning of the stretch mark from purplish red to silvery white is little consolation to most women.

You may find many advertisements and web sites which promote products to prevent stretch marks. Look at these carefully. Most, if not all, are probably selling a particular product. They may even be disguised as a "scientific study" showing which product prevents stretch marks the best, but if you follow through to the end, most will eventually lead you to purchase a particular product.

There are some ways to know if you are likely to get stretch marks or not. There are factors in our lives which can contribute to our likelihood of developing stretch marks:

• Our family history --ask your mother, your sister, your grandmother if they have stretch marks. The same hereditary traits that would make us prone to wrinkles will make us prone to stretch marks.

• If you had them with a previous pregnancy, or if you developed them during puberty -- some girls will develop stretch marks over their breasts, hips and thighs during puberty. If you have faint silvery stretch marks from puberty, there is a good chance you may develop them with a pregnancy.

• Weight gain -- the more rapid or excessive the weight gain, the higher the likelihood of stretch marks.

• Ethnicity -- Dark-skinned women are less likely to get stretch marks.

• Nutritional Status -- staying well hydrated and keeping yourself well-nourished reduces your chances of stretch marks.

While there is no product to help you prevent stretch marks, there are some important things you can do to maximize your skin health and minimize your chances of stretch marks:

• Maintain a healthy intake of foods which contain a variety of vitamins and minerals and a sufficient amount of protein. Many pregnant women do not take in the recommended 60gms of protein daily (or 6-8 servings of protein).

• Keep your skin well hydrated. Drink enough water to keep your urine a pale yellow. Water helps to keep your skin elastic.

• A regular exercise program will increase overall circulation.

• Do not scratch areas of skin likely to form stretch marks. Using lotions and oils for itchy skin can help to relieve the itch. Scratching can actually add to the damage that may be already occurring.

• Massage itchy areas. Massage increases circulation and can encourage new cell growth.

• If possible, try to stay within the healthy pregnancy weight gain limits. Try to have your weight gain during pregnancy be slow and steady. Sudden spurts of grown can increase your chances of stretch marks.


If you find that you develop stretch marks with your pregnancy, there are a few options that may help after your baby is born. A few studies have shown that Retin-A (tretinoin) cream may reduce both the length and the width of stretch marks. Retin-A requires a prescription and is most effective applied soon after delivery, while the marks still have their dark coloration. If you are breastfeeding, however, you should avoid this topical medication, because it is thought to cross through the breastmilk to the baby.

Another option for stretch marks is laser therapy. Different types of lasers might be used depending up on the color and age of the stretch marks.

While stretch marks cause no impairment upon your general health and they do not reduce your ability to function on a day-to-day basis, if they bother you, even after they have faded to a silvery color, you may want to consult with a dermatologist to discuss avenues of treatment. While very few insurance companies would pay for these cosmetic treatments, you may find it well worth the out of pocket investment to increase your self confidence and self-esteem.

The Last Baby

Eighteen years ago today I gave birth to my last baby.

It was a wonderful experience, surrounded by my friends at work and my husband at my side. My children and our mothers waited in a nearby room to see our little girl soon after she was born.

Her brother, nine years old at the time, was so in love with her he didn't want to leave her to even go eat. She looked and weighed the same as her sister, then eleven, had when she was born.

It was a special beginning to a very special relationship. The baby became a beautiful toddler, a smart child, a tremendous teenager and now a wonderful adult.

Image by juliecampbell via Flickr

May each of you who are looking toward the birth of a child be blessed with such a child as this.

"In, Two, Three; Out. Two, Three..."

Sitcoms featuring laboring women invariably show one of two things: either the woman is screaming and clutching in pain, or she is using a variety of breathing techniques, usually at the coaching of a well-intentioned but ineffective labor partner.

When coupled with well-practiced (the key words in this sentence) Progressive Relaxation, breathing techniques can be a great aid to the woman who chooses to not to use, or to minimize the use of medications during labor.

Image by doroquez via Flickr

Breathing during labor does not come "naturally" however, and I find it ironic that we term a woman who goes without medication as "going natural". To be successful at handling labor without medication, a couple needs to have practiced both breathing techniques and relaxation well in advance of those first contractions.

During the twenty years I taught childbirth classes, I would see many couples come to class and only half-heartedly participate in the breathing section of the classes. Some of these were even couples who had stated they desired to "go natural". I was not surprised when they presented in labor and after the early, easy contractions morphed into the serious, painful ones, they opted for medication, and epidural or both. In fact, one of our anesthesiologists calls these patients a "delayed epidural".

For me, Progressive Relaxation was the foundation upon which all the other tools and techniques for labor were built. If you can learn to relax your muscles at will, the other techniques will work much better for you. If you can learn to truly relax, almost any breathing technique can be effective.

I had a patient once who was laboring with her second child. She had mastered relaxation. In fact, she was so incredibly controlled and relaxed with her labor, when I lifted her arm to apply the blood pressure cuff, it was so limp it was as if she were a dead person. She never made a sound, never a moan, never issued a complaint until almost the end of her labor. She simply kept her eyes closed and her body perfectly still. Then, almost before the baby was born, she opened her eyes and whispered, "I've got to push." To this day, I marvel at her sense of control and relaxation.

To aid relaxation, are systematic breathing techniques. You will find many different types of techniques in many different sources. Practice different ones until you find several you feel comfortable doing. You will need a slow breathing technique - often used for the earlier contractions of the early phase of labor; a faster paced technique, often used during active labor; and pattern paced breathing, primarily for use during the difficult phase of transition.

As you try a new breathing technique, ask yourself the following questions:

• Do I feel as if I am getting enough air?
• Does this technique help me stay calm and relaxed?
• Does this technique help me to focus my attention?

Remember, the primary goal of breathing techniques is to aid in relaxation. I have seen couples come in who treat breathing as a cruel master who must be obeyed. They feel as if with each contraction they must both breathe at a particular rate, in a certain manner, using certain sounds. No wonder they both end up tense, frustrated and exhausted after a few hours.

No breathing technique is perfect and you won't be perfect executing it with every contraction either. But if it helps you to focus and relax, then you have met your goal.

CLEANSING BREATH

The Cleansing Breath is simply a big sigh. It is a time to provide adequate oxygenation to the mother and baby, focus on Progressive Relaxation to release any tension and to be a symbol to everyone in the room that a contraction is either beginning or ending. It is recommended to use a Cleansing Breath at the beginning and ending of each contraction.

SLOW PACED BREATHING

Slow paced breathing is a deep-chested breathing. It is deeper and slower than your regular breathing and involves stretching out the chest wall muscles. This stretching of the muscles and then allowing the chest wall to subsequently relax, aids in overall relaxation. It also provides excellent oxygenation for both mother and baby. The slow rhythm of the breathing enhances coping skills by adding a layer of diversion.

This breath should be about half as many breaths per minute as your normal resting breathing rate. If this feels uncomfortable to you, or you feel "air hunger", adjust the rate until you feel comfortable. The important thing is to aid relaxation, not to follow a rigid set of rules. As you breathe, you should notice your chest and abdomen moving in a relaxed way. Try not to raise your shoulders as you breathe, as this will contribute to shoulder tension and soreness as your labor progresses.

Slowly breath in to a count of three and then out to a count of three. Often we teach couples to have the coach give verbal cues for breathing because in labor the mother (who may normally be cool as a cucumber) may forget everything about the breathing techniques. It is also recommended that your coach practice tactile cues as well. Simply running a fingertip up and down on a body part can cue the "in and out" of the breath. This can break up the monotony of the verbal cues, give the coach a break for his/her voice and give a softer sound to the room.

This breathing technique should be the technique of choice for much of labor. When you find it is no longer effective, move to another technique. You can switch back and forth between techniques, even within the same contraction if you need to, to add to the effectiveness of your breathing techniques.

You will know it is time to begin using breathing techniques with your contractions when you can no longer walk or talk through a contraction. You should use Progressive Relaxation and the Cleansing Breath from the beginning of labor, however.

MODIFIED PACE BREATHING

This is a faster paced breathing, usually associated with a later phase of labor. It shouldn't exceed twice your normal breathing rate, though. This is a quick, shallow, upper-chest breath. Changing patterns from the slow, deep breathing, to the shallow, quick breathing can keep you alert and focused during labor.

This breathing technique uses more energy on your part, and you will find yourself becoming tired sooner. You may want to shift back to the slow paced breathing some to rest your muscles.
This breathing is a "In, 2, Out, 2; In, 2, Out, 2", type of breath.

PATTERN PACED BREATHING

This used to be called "He-He-Ho" and I still think of it that way. This breathing technique is performed at the same rate as the modified paced breathing, but it has a pattern to the breathing. A soft blow is interjected at regular intervals, creating the rhythmic pattern. Maintaining this pattern requires more concentration on your part and is designed to help with the stronger contractions. The rhythmic sound of the technique can also produce a calming effect. You can vary the pattern and ratio of breaths to blows to suit your contraction and whatever is comfortable to you. You may want to do three breaths and a blow, four breaths and a blow, or at some point you may want to do one breath and one blow.

The breathing for this technique would be: "In and out, In and out, In and out, In and blow. In and out, In and out, In and out, In and blow."

HYPERVENTILATION

Occasionally when practicing breathing techniques, hyperventilation can occur. This is a situation in which you take in more oxygen than you breathe out, either because you are breathing too deeply, too rapidly or unevenly. You may feel dizzy or lightheaded. You may feel tingling around your mouth or hands. If this occurs, simply place your cupped hands over your mouth and nose and breathe your exhaled air for a couple of minutes. Then examine your breathing technique to correct the imbalance. If the sensations do not resolve, call your health care provider.

CONCLUSION

Your breathing techniques will be closely linked to your sense of calm and your ability to relax in labor. Whether you plan to use them for your whole labor, or just until you can have your epidural, how effective they will be for you is dependent upon how much time you have invested in them beforehand. There is nothing magical in the breathing techniques themselves, they simply give you a focus of concentration, decrease your awareness of pain and facilitate relaxation.

The Amazing Power of Touch...

There are few things that can help the laboring woman more than the simple power of touch.

I have had patients before who were having a difficult time dealing with their contractions. I would take their arm in my hands and slowly and gently begin to massage their arm and hand, moving my hands up and down their arm. Moving my hands slowly and rhythmically along their arms in a gentle flowing manner while encouraging them to breathe and relax, seemed to help them to move their focus from what was happening in their uterus to what was happening on their arm. The relaxation of the muscles of their arms gradually began to spread to other muscles and the patient became calmer and less agitated as she began to breathe and relax, to go with the flow of labor instead of fight against it.

Image by Getty Images via Daylife

Learning which massage techniques are effective for your partner is a great investment in time before labor begins, so that you can help her to deal with contractions and even the tension and stress of having a new baby at home. In fact, I recommend that you each begin the practice of alternating a three to five minute massage for each other daily. One of you gets the massage one day, the other the next. While you may say "Three minutes? What kind of a massage is that?" Three minutes is better than no minutes. You may that just as you enjoy receiving your massage, you will enjoy giving the pleasure of a massage to your partner as well.

Massage techniques at home do not have to be complicated, but massage conveys such wonderful messages. It says, "I care about you. I want to help you to be more comfortable. I want you to have less stress."


When performing massage, there are some things to keep in mind to make it more enjoyable:

• Let your hands contour to the body part being massaged.
• Use firm, slow moving strokes to communicate calmness, relaxation and support.
• Keep at least one hand continuously on the body at all times to avoid the startle reflex.
• Your hands may be warmed or cooled. Lotions and oils may also be warmed or cooled.
• Massage that results in tickling is not effective and does not build trust.
• When receiving the massage, use your partner's touch on your muscles as a signal to release the tension from those muscles.

Here are some different types of massage:


Effleurage

This light, gentle, brushing type of massage is a soft stroking which is very effective over the face, abdomen or extremities. When used over the arms and legs, be sure to go in the direction of hair growth.


Squeeze Massage

Contour the body part with your hands and apply gentle pressure with the thumbs. Then gently pull the thumbs apart. Avoid this massage over bony parts.

Gentle stroking

Make circular strokes with the flat part or heal of the hand. Separate the hands as if pressing out the pages of a book. Cover the whole back.


Pressure Massage


Apply slow and steady pressure to a specific point. Using your fingertips or knuckles, apply pressure --to the top of the shoulders, or the sides of the lower back - and then gently lean into the point to increase the pressure. Then gradually remove the pressure as well.

Kneading

This massage is what is envisioned by the word massage. This massage should be used on muscles that are already warmed up by other forms of massage. The motion is similar to kneading bread or twisting a towel. Gently rub the muscle in opposite directions with the two hands. Make certain your touch is not too firm -- resulting in pain, or too gentle -- resulting in skin irritation. Using feedback from your partner can help you both learn just what amount of pressure results in the best relaxation for each other.

Raking

Open your fingers wide and gently rake down the body part as if you were raking leaves off the body. Use gentle downward stroking. If your fingernails are long, use particular care when using this technique.

Pressure Point Massage

If you have ever had a headache and found yourself rubbing your temples, you have done pressure point massage. This massage stimulates your body's production of endorphins (naturally occurring Morphine-like substances). You can use firm, continuous pressure, intermittent pressure, or pressure with circular movement.

Hand Massage

There are few massages more relaxing to the laboring woman than hand massage. When performing hand massage, concentrate on the muscular areas of the palm as opposed to the bony areas of the back of the hand. Circular, intermittent or continuous pressure - or a combination of all three- may be used.

Scalp Massage

Scalp massage can be very relaxing during labor, especially early labor. If your partner enjoys having her hair brushed now, she may enjoy scalp massage a great deal during labor. Using the pads of your fingers, make slow circular motions around her scalp until the whole scalp has been covered. Finish up with a nice brush of her hair from root to tip.

Massage is most effective if the techniques are practiced before hand.

How Do I Know When My Water Breaks?

This is one of the things that many women fear the most during pregnancy...the thought that they will be out in public and their water will break in front of everyone.

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Actually, most women do not begin labor with their membranes spontaneously rupturing. Think about it, when was the last time you were in the grocery store, or anywhere in public, and you noticed a pregnant women break her bag of water? I've never seen that happen in public. So if that has been a fear of yours, you can probably move it down the list a few notches.

But how do you know if your water has broken?

When the membranes rupture, either a sudden gush of fluid, or a slow, continuous trickle may be felt. If you experience the sudden gush, it may be a good amount of fluid. It may even run down your legs and leave a pool of fluid in the chair where you sat. When you get to the hospital, you may leave a pool in the wheelchair. And it just keeps coming, too! Don't try to stop the flow with a towel or a tiny sanitary pad, instead get one of your baby's diapers. Yes, that's right, a baby diaper. They are made to be highly absorbent, they have that nice hour-glass shape and they are lined with plastic. They are the perfect thing to wear to keep from getting the car, your pants and everything else in sight soaked with amniotic fluid!

If you don't experience the big gush, you might experience the slow, steady trickle. This can happen if the tear in the membranes occurs higher up in the sac. The amniotic fluid slowly trickles out and down. This is not the same thing as urine. If the fluid looks like urine and smells like urine, well, it probably is urine. Remember, you have a lot of pressure on your bladder during the end of pregnancy, as well as a little baby who doesn't mind reaching out and trying his or hand at punching every now and then, too.

If you think it might be urine, you can try to stop the flow. If it still continues, it just might be your bag of water. Another way to help determine if this is your bag of water, or urine, is to completely empty your bladder, and then wear a sanitary pad. If you continue to wet the pad, you may have a leak in your amniotic sac.

Another thing complicating this whole "Is my water broken" thing, though, is that toward the end of pregnancy, most women will develop a clear discharge called leukorrhea. Leukorrhea is caused by increased secretions from the cervical glands and the vaginal walls, partly due to the high-estrogen state of pregnancy.

If you think your water is broken, what should you do?

Your health care provider will be asking you some questions about your membranes rupturing, so pay attention to some details.

Amount, how much fluid was there? Was it a trickle, or a big gush? A tablespoon or a liter?

Color, was the fluid clear, white, yellow, green? If the fluid was green or brownish, it could indicate the baby has already had a bowel movement in the fluid, an important thing for the baby's health care providers to know.

Time, when did your water break, or when did you first notice the leaking?

Smell, what did the fluid smell like? Was there a foul odor? Amniotic fluid has a distinctive odor, but it doesn't normally have a foul odor.

If you water has broken, notify your health care provider with all of this information. You may be directed to come in to your birth center or hospital, or you may be told its alright stay at home for awhile. It is important to know that from the time your membranes rupture, the last safeguard from infection is gone between the baby and the vagina. For that reason, exams will most likely be limited and so should anything else that would enter the vagina. This would include intercourse and of course, tampons. Do not douche. Anything introduced into the vagina can transport bacteria to your cervix and to your baby. Ask your health care provider before hand how he or she feels about your use of a tub after your water breaks. Some feel a tub might wash away any evidence they would use to confirm that your water was broken, if they would need that.

If my water breaks, does that mean the baby is coming soon?

Many people believe that once your water breaks, the baby will be close behind, however, there is no correlation between the timing of the rupture of the membranes and the birth of the baby. Some women will have their membranes artificially ruptured my their health care provider, some women will rupture their membranes before they ever have the first contraction and some women will not rupture their membranes until immediately before birth.

I can clearly remember one time when I had a patient in labor whose membranes ruptured spontaneously. I was a fairly new Labor & Delivery nurse and I was pushing with a patient, sitting on the side of her bed and holding up both feet while watching her progress. When one of the older, much more experienced nurses suggested I "not do that", I couldn't understand why. I thought perhaps she was concerned about my ability to lift up both of the woman's legs. As I glanced back between my patient's legs, my arms outstretched widely supporting her feet, I had the fleeting thought of wonderment at the silvery, glistening object between the patient's legs. I only had a moment because just as it dawned on me that what I was looking at was the amniotic sac stretched out as tightly as possible, that glistening bag of water broke and I found myself drenched in a flood of amniotic fluid. I was soaked all the way through my scrubs to my underwear, and as I was shaking amniotic fluid off my face and out of my hair, I could hear the chuckles of more experienced nurses who were taking great amusement in my learning of the lesson to stay out of the "line of fire". It was a lesson I have found useful and have remembered for over thirty years.

Oh, What a Beautiful Baby!

This evening, I was the scrub nurse on a delivery of a very beautiful baby. I think the word the physician used to describe her was, "Cherubic". She had a headful of dark, thick hair and full round cheeks. Even while being born, her eyes were expressive with that "What is happening to me?" sort of look.

There's not any lesson to this, except to share with you that after thirty years and 2,623 babies, this was 2,624, birth is still amazing and the babies are still awe-inspiring. Every birth is still a miracle and a beautiful thing to behold.

I was in a different delivery earlier (we were busy today) and was actually watching the delivery from an angle that I had never seen it from before. I was tired and had decided to sit down beside the bed to wait until the baby was born to do what I needed to do to assist the nurse. Watching from the side as the baby's head slowly eased out, being supported gently by the physician as she helped to avoid any lacerations, was fascinating. It gave such a different perspective that I found myself wishing I had a video camera in my hand.

The design of birth is perfect and it usually happens so perfectly, like a slow ballet in which n

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o one really sees all the intricate movements and steps, they just realize that somehow they have seen something glorious.

How blessed I have been to be a part of that for so many years.

What About Dad? The Father's Emotional Response To Pregnancy

When we think about pregnancy, we most naturally think first of the mother. Of course, she is the one to carry the baby, to go through labor and to deliver the baby at the end of pregnancy, but both men and women have significant responses to pregnancy. So, let's take a look at how father responds to the positive pregnancy test.

There is a range of responses men may have to the news their spouse is pregnant. Just as a woman has multiple reactions to the new she is pregnant, the father, too, may have varied feelings and responses including denial, anger, fear, frustration, joy and elation.

Image by super-structure via Flickr

ACCEPTANCE

While a woman is often accepting of the pregnancy as soon as it is confirmed, acceptance is the major developmental task to be achieved by the man throughout pregnancy. He has no feelings of morning sickness, even though he can see the effects of it on his spouse. He has no feelings of intense fatigue, even though he may notice his partner sleeping more in the first trimester than usual. His first step is to accept the reality of the baby which can be difficult since the baby is something he cannot see or feel or touch.

As the pregnancy continues and more concrete evidence of the baby becomes available, such as hearing the heartbeat, or seeing the ultrasound, the father can accept the pregnancy more and more and he may find that he is redefining himself in terms of being a father.

Once the father has accepted the reality of the child, he needs to begin to emotionally begin preparation for the changes that will take place to his wife and to his family. He may feel confusion at the "narcissistic" or self-centered response of the mother. Suddenly, her whole existence revolves around what is happening in her uterus and her body and he may find himself feeling "left out". He may have feelings of jealousy, but may not feel as if he has the liberty to express these feelings to anyone. With the mood swings that are common for mothers during pregnancy, he may especially feel hesitant to express this to her.

DETERMINING A ROLE

He may find himself more withdrawn and introspective as he balances the expectancy of the baby and these other feelings he is having. The role the father takes on during pregnancy depends upon his childhood experiences, the experiences of his peers, the relationship he has with his wife and his own personality. Some men take on an instrumental role as the caretaker over the new expectant mother. Some men maintain an emotional distance as a passive, detached observer. They don't actively interact in any of the aspects of the pregnancy. Some men are expressive in their role, trying to experience as much as the pregnancy as they can. These are usually the first ones to wear the "Empathy Belly" in childbirth classes.

As the pregnancy continues and becomes evident by looking at the mother, the father may feel more and more protective and supportive. Some fathers may feel fear at intimacy because of the fear of "hurting" the baby. Mothers may falsely interpret this as his not finding her new shape attractive. Actually, a significant number of men find the pregnant body to be unusually attractive. Of course, there are those men who find that pregnancy diminishes a woman's sexuality. For those men, dealing with those feelings can be even more confusing for them.

Fathers may also find themselves concerned about the impact the pregnancy will have on the finances of the family. They may be concerned about their role as a support person during labor, and about their role as a father. Their own childhood background, with any unresolved issues there, will begin to affect their attitudes toward fatherhood now.

As the end of pregnancy approaches, most men have accepted the reality of the baby and begun to map out how they define their roles both in childbirth and parenting. Today, most men choose to be present with their wives during childbirth. Some men come to labor and delivery exerting themselves over their wives' wishes and desires, even answering questions for her..Some men come to labor and delivery detached, almost "too cool" to be involved. It may be that these men don't feel "too cool" at all, but in reality don't know how, or how much, to reveal the emotions inside of them. They desire to be helpful and supportive of their wives, but may feel inadequate to do so.

Another factor is the obstetric team themselves, which can disempower the father in his role. Health care providers do well to acknowledge the importance of the father's role in delivery with his wife. He is the only one that is there with the single purpose to support her and meet her emotional needs. He is the only one there that has any vested interest in both the mother and the baby. Nurses and physicians should not limit their concerns to the mother/baby couplet, but should consider the entire family, father and other siblings included. Questions and concerns from al in the family should be acknowledged and welcomed.

WHAT CAN HELP THE FATHER ADJUST TO PREGNANCY

• If the mother encourages the father to join her for prenatal visits where the fetal heart beat can be heard, and to attend the ultrasound, these will greatly reinforce the reality of the baby and increase readiness for fatherhood. Preparing the nursery or space for the baby also adds to the concrete fact that a baby really is coming.

• If the father attends childbirth education and infant care classes, the information and experience gained and give the father a sense of confidence and self-assurance, especially in regard to infant care.

• The mother and father need to clearly discuss both of their perceptions of the father's role during childbirth. If she sees him as her primary support person, but he feels inadequate in that role, and sees himself more in the background, they will both have disappointment in the experience. The mother needs to understand that his desires and expectations at delivery are just as important to him as hers are to her.

I was taking care of a couple once who had to rush to the hospital. In the rush, they had forgotten their video camera. The mother wasn't concerned about it at all, she had brought a camera and that was sufficient for her. But for the husband, he had envisioned throughout the entire pregnancy that his role would be that of videographer. He had planned how to shoot each scene, the "interviews" he would do with the doctor and nurses, and how he was going to introduce the baby on the video. When they realized they didn't have the video camera, he was sincerely upset. His whole reason for being there, in his mind, was now gone.

• The mother lets the father know that his responses and feelings will be accepted, just as hers will be. We know that women can respond to labor in ways they would respond to other situations. We expect everyone in the family to forgive them because those behaviors can be common during labor. Fathers, too, may respond in ways they would never do otherwise. Some men are so fearful of behaving or responding in public in a way that is uncharacteristic for them, they may prefer to block all responses altogether. A father who has been reassured throughout pregnancy that he will be accepted during childbirth is more likely to respond in an open, honest manner.

Once I took care of a couple when the father was obviously thrilled at the prospect of becoming a father. He not only did what his wife asked, but often anticipated her needs as well. When preparing for delivery, his excitement could barely be contained and I had to laugh out loud at his exuberance. When the moment of delivery actually came, I looked across the bed at him and he was gone. "Where did he go? Did he pass out?, " I wondered. I leaned over the mother to see what had happened to him and saw him on the floor on his knees.

"Are you okay?", I asked.

With tear-stained cheeks he looked up at me, his face full of radiant joy and said, "I was thanking the Lord for a perfect, healthy baby."

For most men, becoming a father is just as wonderful an event as becoming a mother is to women. As a father, you will laugh and cry, you will make mistakes, and hopefully be willing to apologize to your children for doing so. You will learn along with your child, and you will learn so much about life, and yourself, that you never knew.

"Parenting forces us to get to know ourselves better than we ever might have imagined we could -- and in many new ways. . . We'll discover talents we never dreamed we had and fervently wish for others at moments we feel we desperately need them. As time goes on, we'll probably discover that we have more to give and can give more than we ever imagined." --Fred "Mr." Rogers

What is it Like to Get an Epidural?

Before we discuss what it is like to get an epidural for labor, let's look at the basics about epidurals.

WHAT IS AN EPIDURAL?

An epidural is a form of regional anesthesia, which means it will numb a specific region, or area of your body, usually from the waist down. A tiny catheter is placed into a space between the vertebrae of the spinal column for the purpose of injecting local anesthetic and possibly narcotics. This tiny catheter does not go into the spinal column and you do not have to lie flat after the epidural is placed.

While the epidural causes a loss of pain sensation from the waist down, it does not block all sensation. You may still be able to feel pressure sensations. You may still feel touch, even though you may not feel pain. Many women can still move their legs, though some women feel as their legs have become too "heavy" to move.

WHEN IS AN EPIDURAL GIVEN?

When your epidural is given is primarily up to your health care provider. This is a good discussion to have with your care provider since their feelings on the matter will directly impact you. Some physicians will order an epidural once labor is well established, meaning the contractions are in a good pattern and there has been definite evidence of cervical change. Other physicians would like you to be a certain cervical dilation before receiving an epidural.

Prior to receiving your epidural, some preparations will have to be made. You will need an intravenous line and will need to have received a bolus of IV fluid. The most common side effect of an epidural is a drop in maternal blood pressure. This bolus of IV fluid will help prevent or minimize this side effect. You will also need certain lab tests to be completed to make certain it is safe for the epidural to be placed.

HOW IS THE EPIDURAL GIVEN?

An epidural is given by an anesthesiologist, a physician who specializes in anesthesiology. The anesthesiologist will ask you questions about your medical and surgical history. You may not feel like answering the questions, especially if you are in a lot of pain, but most of the questions are asked to provide for your safety. Once the preparations are completed you may be asked to sit on the side of the bed, or to lie on your side. The lower portion of your back will be cleaned with an antiseptic solution. The anesthesiologist may then numb the skin of your back with an injection of local anesthetic, similar to that used at the dentist. This would feel like a small stick and then a burn for only a few seconds. After that, you should feel pressure, and perhaps cramping in your back, but not pain.

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The anesthesiologist uses a needle to place the thin catheter into place in your back. One the catheter is in place, the needle is removed. A test dose of medication is injected into the catheter. This test dose is used to help verify the correct placement of the catheter. A nurse will be monitoring your pulse and blood pressure during this time. If there are no negative responses to the test dose, the actual dose is injected into the catheter. This may feel cold along your back.

It will take 10-30 minutes after the actual dose for you to become comfortable, depending upon which medication the anesthesiologist has decided to use. The epidural may be connected to a infusion pump which would give you medication continuously throughout your labor, or the anesthesiologist may return to re-inject the catheter whenever you need additional medication.

HOW DOES IT FEEL WHEN YOU HAVE AN EPIDURAL?

Epidurals feel differently to different women, but most women report that at first their legs feel warm and heavy, beginning with the feet and traveling toward the abdomen. Within 15-20 minutes you should become increasingly more comfortable. You may still be able to tell when you are having contractions, but not feel pain with them any longer. The awareness of the contractions will be beneficial to your pushing efforts when you reach the second stage of labor.

Once your epidural has completely set up, you can expect to feel numb. Your legs may be so numb that your movement is limited, or you may be able to move without difficulty. This may be partly determined by the particular medication the anesthesiologist used and partly by the dose that was given. You will be in bed for the rest of your labor. Even though you may be able to move about in bed, you will not have the muscular strength, or the feeling in your feet to walk safely.

WILL MY EPIDURAL WEAR OFF?

If your epidural is being dosed intermittently, you will begin to notice after a while that you are not as comfortable as you had been. At the point your contractions are uncomfortable to you, tell your nurse. Do not wait until your pain level is extremely high. The higher your pain level, the more difficult it is to bring it back down again. You may need another dose of medication.

If your epidural is on a continuous pump and you notice the sensations of your contractions have become stronger, this does not mean your epidural is wearing off. Even though you could not feel your contractions before, they have been progressing into a harder phase of labor. The continuous dose, set earlier in labor, is not effective now to deal with these contractions. In addition, the first dose you were given as been absorbed. At the point your contractions are uncomfortable to you, tell your nurse. The anesthesiologist can come and inject a re-dose into your catheter to increase your comfort level. It may be decided at that time to adjust the level on your pump, depending on your stage of labor.

WHEN IS THE EPIDURAL CATHETER REMOVED?

The epidural catheter is usually removed at the beginning of your recovery period if you have had a vaginal delivery. If you have had a Cesarean Section, your physician may choose to leave the epidural catheter in place and connect it to a Patient Controlled Epidural Anesthesia pump. This will infuse a narcotic into your epidural space continuously for pain management. If you need additional medication, you can give yourself more doses. This medication does not make you numb as the medication during labor. (See the post on Postpartum Pain relief after a Cesarean Section: After Delivery - The Postpartum Experience -- Pain.)

When the epidural catheter is removed, there is no pain. The only discomfort with the removal of the epidural catheter is the removal of the tape securing the catheter in place.

DOES AN EPIDURAL LENGTHEN LABOR?

While many people believe an epidural will lengthen labor, research does not support this. In fact, there is research, like that from Brigham and Women's Hospital (http://www.brighamandwomens.org/painfreebirthing/labor1.aspx) that shows an epidural only minimally lengthens labor, approximately 30-60 minutes. If your labor is well established, the contractions are in a good pattern and have been that way for at least an hour or so, it is not likely the epidural will slow down your labor.

DOES AN EPIDURAL INCREASE MY RISK OF A CESAREAN SECTION?

This is another one of those "old wives' tales" about epidurals. When given to women who are properly prepared (an adequate IV fluid bolus, and with a good labor pattern), an epidural does not increase your risk of a Cesarean Section (see the above data from Brigham and Women's Hospital)

DOES AN EPIDURAL HURT MY BABY?

Actually, an epidural is a very safe form of pain management for your baby, Unlike IV pain medication, which goes directly into your bloodstream and across the placenta into the baby's bloodstream, the epidural is a regional form of pain management. Very little of the medication, which is usually a local anesthetic and not usually a narcotic, gets to the baby. Studies show that babies born to mothers who have had epidurals have higher Apgar scores, a higher cord pH and less need for drugs to reverse the effects of narcotics immediately after delivery than mother's without epidurals who are given doses of IV pain medication during labor. The March of Dimes supports the fact that an epidural has little or no effect on a baby (http://www.marchofdimes.com/pnhec/240_12935.asp).

CAN IT PARALYZE ME?

We hear this question often, but an epidural cannot cause you to be paralyzed. The spinal column does not extend down as far as where the epidural is given, so there is no danger of it being damaged.

RISKS WITH THE EPIDURAL

With all invasive procedures, even getting an IV, there are potential risks. However, there are few risks associated with epidurals and they tend to be rare. Risks may include:

• Infection. Minor infections occur in 1%to 2%of all epidurals. Severe infections are rare, occurring in 0.1%to 0.01%of epidurals.

• Bleeding. Bleeding is a rare complication and is more common for patients with underlying bleeding disorders. This is one reason for the lab work prior to the placement of the epidural.

• Nerve damage.While extremely rare, nerve damage can occur from infection, bleeding or as a result of direct trauma from the needle. This will not cause paralysis.

• Dural puncture ("wet tap"). A dural puncture occurs in 0.5%of epidurals. It may cause a post-dural puncture headache (also called a spinal headache) that usually gets better within a few days. Although rare, a blood patch may be necessary to alleviate the headache.

Not specifically associated with epidural itself, women with epidurals are more likely to receive Pitocin augmentation during labor.


If you are concerned about whether or not an epidural is the right choice for you, discuss your concerns with your health care provider. It may even be possible for you to schedule a consultation visit with one of the anesthesiologist who provides services for the facility you will be attending. Write your questions down before you go, so you won't forget any of them as you are talking. Get the facts first hand from the experts.