Postpartum Mood & Anxiety Disorders (PMAD)

This is the updated term for postpartum depression (PPD).  PMAD is a form of clinical depression or mental illness that can begin at any time after childbirth, from days to even years after in some cases.  PPD is not something that is anyone’s fault or that necessarily be controlled.  Between 3-24% of new mothers are afflicted, and up to 50% of male partners of women with PPD also experience PPD (Clinical Rounds, MCU Oct 2011).  Although hormone drops are often blamed, no causation has been proven.  PPD is more serious than postpartum blues; if the blues last longer than 2 weeks and aren’t resolved by rest and support then seek help.

Symptoms of PMAD include any of the following:  crying for no reason, inability to cope, feeling overwhelmed, sadness, anger, hopelessness, impaired memory or concentration, loss of interests, nightmares, bizarre / strange / intrusive thoughts, perceived or actual difficulties bonding with baby, feelings of resentment or aggression toward baby or family members, apathy toward baby, thoughts of suicide.  Call your midwife or health practitioner in case of any of these symptoms.

Risk Factors of PMAD

Note:  PMAD can hit any woman at any time postpartum – for no apparent reason.  However the following increase the risk.

  • Personal or family history of depression, related to birth or not
  • Traumatic birth
  • Pain
  • Fatigue
  • Inflammation
  • Low blood-iron levels
  • Twins or multiples
  • Being “run-down” e.g. fatigue, low blood sugar
  • Stress e.g. such as social, economic, relationship, health concerns, child-care issues
  • Lack of social support
  • Perceived or actual isolation
  • Formula feeding in place of breastfeeding
  • Cigarette smoking
  • Infant temperament
  • An affected partner

“Baby-blues” is a normal, natural emotional reaction to birth that last hours or a few days.  Symptoms are mild and transient and occur in 50-80% of new mothers around day 3, when your milk comes in.  You may experience tears, exhaustion, worry, irritability, and lack of confidence.  Mothers experiencing baby-blues need support, rest and care to prevent it from progressing to depression.  If it lasts longer then it’s prudent to follow the measures listed under “Prevention and Treatment Strategies.”

Postpartum psychosis is a rare but severe and sudden mental illness that requires immediate 911 medical attention.  Symptoms include those for PPD, plus some or all of the following:  refusal to eat, fatigue, frantic excessive energy, confusion, delusions, loss of memory, failure to recognize familiar people, visual or auditory hallucinations, irrational statements, distorted thinking, suicidal or infanticidal thoughts and behaviours.  Seek 911 medical help immediately.

Prevention and Treatment Strategies

Although there may be factors that can’t be controlled, the best defence against PMAD is a well supported, healthy mother.  There seem to be higher rates of PMAD in Western cultures, likely due to stress and isolation.  In almost every other culture, new mothers are surrounded by women and family to take care of them.  All they’re expected to do is rest, recover, breastfeed and bond with baby for the first 40 days.  In North America most new mothers are expected to take care of themselves, their baby, and the household; and of course entertain a steady stream of visitors who want to check out the baby.

  • Prevention starts during pregnancy
    • Learn as much as possible about birth, breastfeeding and life after baby
    • Arrange postpartum support to allow for rest and bonding i.e. circle of friends or family, postpartum doula, community resources
    • Learn to say no
    • Plan to do nothing for 8 weeks; have freezer full of healthy tasty prepped food, kitchen stoked with non-perishables, household items stocked, major home chores done, hire house-keeper, dog-walker etc, get groceries delivered
  • Early intervention leads to shorted duration
  • Limit visitors and length of visits!!! Have a visitor rule: everyone has to bring a healthy meal – fresh or frozen – and do a chore from a “to-do” list on your fridge.  Set a time limit.
  • Take one day at a time
  • Ask for help
  • Manage pain, even if that means taking pain meds while breastfeeding
  • Have and use a simple schedule, allowing for the unpredictability of newborns
  • Take it slow; re-enter world gently if hibernating with new baby (40 days highly recommended)
  • Adequate sleep; sleep when the baby sleeps
  • Breastfeed
    • Hormones of breastfeeding, prolactin and oxytocin, help reduce PPD
    • Several studies find breastfeeding mothers actually get more sleep on average than formula feeders
    • Benefits of breastfeeding for both mother and baby far outweigh any risk of anti-depressant drugs effecting baby
  • Do something that brings joy daily
  • Find a way to have a little time alone daily, including time to relax (meditation, rest, praying, reading – whatever’s rejuvenating)
  • Self-care e.g. shower, get dressed, eat, get out for walk
  • Healthy foods (see Postpartum Nutrition handout)
  • Ingesting placenta e.g. dry and encapsulate
  • Craniosacral therapy, especially in case of lost consciousness during birth process
  • Community support programs such as Y’s Moms and LaLecheLeague groups
  • Mental health professional, ideally one who specializes in postpartum mental health
  • For mild PMAD, take supplements of a fish oil high in EPA and St John’s Wort; can be taken with antidepressant medication; safe with breastfeeding
  • Psychiatric care may be required including antidepressant drugs, many are safe for breastfeeding
  • Many antipsychotic drugs are not recommended with breastfeeding, but there may be alternative schedules available for some women (e.g., taking high dose at night and then not using breastmilk until 8-12 hours later – do this only upon advise from psychiatrist, who will help determine safe dosages and timing on a case-by case basis)

Support Measures to Consider

  • Support with housework, meals, daily tasks from one with whom mother feels comfortable
  • Postpartum doula
  • Call midwife or health practitioner with any concerns or questions regarding blues or depression
  • Families Matter Postpartum Support 1-888-545-5177
  • Sask Health Link 811
  • Online support at Mothering Magazine’s Forum: mothering.com/community

What Partner Can Do

Be there. Be present and involved.  While PMAD affects the mother directly, it’s a family issue.  Partners can’t “fix” this, but can be supportive.

  • Call midwife or health practitioner right away with any concerns
  • Don’t wait for mother to reach out – find help for her
  • Remind partner that she’s loved and partner is there for her
  • This is no one’s fault – remain non-judgemental
  • If she cries just hug and hold – allow the tears
  • Remind mother to get fresh air or do something for herself daily.  Make it happen.
  • Do something as a family – take a walk, cuddle by the fire
  • Self-care as this is a difficult time for partners too.  New parenthood is an adjustment for both parents even without challenges such as PMAD.  Eat well, rest when possible, and get fresh air.
  • Remember anything that takes care of mother (food, chores etc) is also taking care of baby
  • If partner can’t be there and take care of food / home then arrange for people who can
  • Listen attentively – partner may be the only person she opens up to
  • Remind her that she’s not alone, this will get better and you’ll all get through together
  • Ask “what can I do” or “what do you need” rather than “do you need anything”
  • Point out triumphs such as growing a healthy baby, meeting with a counsellor
  • Guard the door – only supportive helpful visitors are allowed and only if mom truly has energy
  • Be open with those closest family / friends about what’s happening
  • Observe, as health practitioner will ask about patterns and behaviours
  • Be wary of partners mental health; up to 50% of male partners of women with PPD also experience PPD (Clinical Rounds, MCU Oct 2011)

For mild issues some women find just getting out for fresh air daily, or having a bath, time with girlfriends, a nap, or whatever their thing is, helps.

Local Resources

  • Healthline Phone (part of public health care) as they have the training to screen and refer now and alert crisis if needed (811 is the new number)
  • Smiling Mask www.thesmilingmask.com and/or book by Carla O’Reilly & Tania Bird (this is a brilliant resource started by 3 local Regina women who suffered from PPD)
  • Edinborough screening tool – self assessment.  This is now part of the EPDS Screening, available at http://skprevention.ca/?s=EPDS .  There’s some other good info on that page too.  Take this to a qualified care provider if you score in a range that needs to be addressed.  Do this test at regular intervals.
  • Marlene Harper (Private therapist) 306-584-2731, Regina (note i don’t know her personally but she comes recommended by other mamas)
  • Online Therapy – cognitive behavior treatment program for maternal depression (Pilot program; may or may not continue long term)
    • Includes 7 interactive evidence based modules
      Therapist-assisted via email and telephone
      Provided at no cost
      Inclusion criteria:  SK resident, > 18 years, minor-major depressive symptoms, have a child <1 year
      For more information or to refer:
      –Website: www.onlinetherapyuser.ca
      –Email: Nicole Pugh: pugh…@uregina.ca
      –Phone: (306) 585-5369; (306) 337-3331

Holistic helpers who may be able to offer help, and could certainly compliment any medical care.
Dr. Vanessa DiCicco, ND – http://wellfamily.ca/meet-nds/vanessa-dicicco/
Cheryl Lloyd, hypnotherapist www.tranquiljourneys.ca

Psych Unit at RGH
Visitors are welcome!

 

References

Calgary Health Region. (2007). From Here Through Maternity. Calgary: Alberta Health Services.

Corwin, E., Murray-Kolb, L., & Beard, J. (2003). Low Hemoglobin Level Is a Risk Factor for Postpartum Depression. The Journal of Nutrition , 133, 4139-42.

Kendall-Tacket, K. P. (2005). The Hidden Feelings of Motherhood (2nd ed.). Amarillo, TX: Pharmasoft Publishing, L.P.

Kendall-Tackett, K. (2010, Aug). Nighttime Breastfeeding and Maternal Mental Health. Retrieved Sep 2011, from Science & Sensibility: http://www.scienceandsensibility.org/?p=1398

La Leche League Canada Health Professional Seminar, Calgary AB.  Preserving the Simplicity of Breastfeeding in a Complex World: a Paradigm for Depression, Stress and Postpartum Healing. 1 day seminar; Dr. Kathleen Kendall-Tackett.  2008.

Lim, R. (2001). After the Baby’s Birth – A Complete Guide for Postpartum Women (Revised). Toronto: Celestial Arts.

Sarah Breese McCoy,  J. Martin Beal, Stacia Miller-Shipman, Mark Payton, Gary Watson. (2006). Risk Factors for Postpartum Depression: A Retrospective Investigation at 4-Weeks Postnatal and a Review of the Literature. Journal of the American Osteopathic Association , 106 (4), 193-198.

The Mother Reach coalition . (n.d.). Postpartum Mood Disorder . Retrieved Sep 2011, from Mother Reach: http://www.helpformom.ca/

Varney, H., Kriebs, J. M., Gegor, C. L. (2004). Varney’s Midwifery, 4th Ed. Toronto: Jones and Bartlett Publishers.

 

Posterior Position – Turning Baby Prenatally

Fetal position at the onset of labour is one of the greatest determining factors of how the birth process will proceed.  During labour the fetus makes certain movements to descend through the pelvis.  The optimal fetal position is pictured below.  A good way to remember the best position is to think about giving your baby a back rub every time you rub your belly.

A spot near the back of the fetal head is used to determine fetal position.  The terms “posterior” or “sunny-side up” describe a baby who faces out, or is spine-to-spine with mother.   “OP” is the medical jargon.  The presenting part of the head is bigger in this position and the baby doesn’t flex and rotate as well as an anterior baby.

Problems Related to Posterior Position

  • More difficult for baby to drop into and through the pelvis
  • Pregnancy may last longer
  • Membranes are more likely to rupture before the onset of labour
  • Labour may progress slowly or not at all
  • Back-pain during labour that doesn’t disappear between contractions
  • Increased risk of tearing
  • Increased risk of instrumental or surgical birth
  • Increased stress on baby’s head and nervous system

However some women birth a posterior baby just fine.  Those include but are not limited to, women who’ve given birth without difficulty before, those with an average or smaller baby, a labouring woman who’s able to move about freely and allow her baby to rotate into an anterior position.

Fetus in WombBaby in optimal position:  head down and flexed, back out.

Signs of a Posterior Baby

  • Feeling kicks or flutters at your front
  • Frequent urination (more frequent than with anterior pregnancy)
  • Belly appears flat or lumpy
  • Your midwife or doctor can tell by palpating your abdomen, as is done at every prenatal visit
  • Fetal heart-tones may be difficult to hear
  • Head is not engaged or doesn’t drop into pelvis
  • Can be confirmed with ultrasound
  • During labour she can also tell during an internal examination

Factors Contributing to Posterior Position
Posterior-babies can occur with no risk factors, but the following increase the chances:

  • North American lifestyle – reclining in upholstered furniture, sedentary lifestyle, sitting in cars (it’s interesting to note this position is rare in cultures where women walk a lot or work bent-over, and lack Lazy-Boy style chairs and couches)
  • Sitting with legs crossed
  • Postural or anatomical issues
  • Issue of uterine / abdominal muscles (e.g. tight psoas)
  • First pregnancy
  • Epidural use early in labour (hinders rotation and descent of baby) is correlated with more than 3x the rate of posterior position at birth (Tully, 2008)
  • Labouring in bed or without adequate movement
  • Baby who was breech and turned to vertex
  • Mother with history of breech or posterior baby
  • Short or tight cord around baby
  • Emotional issues – fear of birth or parenting, not paying attention to pregnancy, family history of breech, relationship issues, financial concerns, stress (Frye, 1998)

Tricks for Turning a Posterior Baby to an Anterior Position
Sometimes there’s a reason (that we don’t know about) for baby to be posterior and nothing will turn her or him.  But in many cases a baby can be turned.  Please ask for details or referrals.

  • Visualization and “talking” to your baby. Focus on letting the baby know it’s easier to get out when facing the other way.  This works especially well if combined with changing your emotional environment e.g. dealing with fears, prepping for birth.
  • Look at a picture of baby in proper position (e.g. Fig. 1), or have it drawn on your belly!
  • Webster Technique with a chiropractor certified in its use. Pistolese (2002) cites an 82% rate of success in relieving the musculoskeletal causes of intrauterine constraint.  It’s beneficial to perform the Webster Technique starting at 35-36 weeks.
  • Sit with pelvis tilted forward – knees below pelvis with straight back. Instead of upholstered furniture, use a birth ball, the floor, a kneeling chair or a regular hard chair or stool
  • Hands and knees – read, crawl around, or child’s pose modified for pregnant belly
  • Pelvic rocking while on all 4’s – gentle cats and dogs yoga postures – several times daily
  • Swimming or floating – anything with belly down like a hammock for baby to drop into
  • Movement and exercise
  • Sleep on left side with a body pillow – left leg straight, right leg bent on pillow
  • Keep belly warm (babies may turn back to keep warm against mother’s back)
  • Homeopathic Pulsatilla 200CH, 1 dose every 3 days.
  • Acupuncture or moxibustion – see a Traditional Doctor of Chinese Medicine or an acupuncturist who specializes in women’s and pregnancy care.
  • Deal with fears around childbirth and parenting
  • Postural management – check out spinningbabies.com for some excellent postures and exercises that encourage babies to assume optimal positions for birth.

 

References

Frye, A. (1998). Holistic Midwifery, Vol 1, Care During Pregnancy. Portland, OR: Labrys Press.

Ohm, J. (2006). About the Webster Technique. Retrieved from icpa (International Chiroractic Pediatric Association): http://icpa4kids.com/about/webster_technique.htm

Pistolese, R. (2002). The Webster Technique: A chiropractic technique with obstetril implications. Journal of Manipulative and Physiological Therapeutics , 25 (6), E1-E9.

Tayler, R. (2000). Homeopathy for Pregnancy and Childbirth. Ottawa: Ottawa School of Homeopathy.

The Midwifery Group. (2008). Posterior Babies. Retrieved from The Midwifery Group: http://www.midwiferygroup.ca/downloads/position/Posterior%20Babies.pdf

Tully, G. (2008). Occiput Posterior – OP. Retrieved from Spinning Babies: http://www.spinningbabies.com/baby-positions/posterior

Delayed (Optimal) Cord Clamping

In spite of a mountain of evidence to support the benefits of leaving the newborn cord intact, immediate cord clamping is still routine care in many hospitals.  Updated obstetrical guidelines in the UK are to leave the cord intact for at least 1 minute and up to 5 minutes, and to leave it for longer than 5 minutes if requested by the mother (NICE, 2016). The Cochrane Review, considered the highest standard globally in evidence-based health care information, contains countless articles on the benefits of delayed cord clamping. 

The placental blood normally belongs to the infant, and his/her failure to get this blood is equivalent to submitting the newborn to a severe hemorrhage at birth.  (DeMarsh, 1941)

Yes, we’ve known since 1941!  Changing practise takes a long time indeed.

Immediate umbilical cord clamping after delivery is routine…  despite little evidence to support this practice. Numerous trials in both term and preterm neonates have demonstrated the safety and benefit of delayed cord clamping. The failure to more broadly implement delayed cord clamping in neonates ignores published benefits of increased placental blood transfusion at birth and may represent an unnecessary harm for vulnerable neonates.  (McAdams, 2014)

Basic newborn & cord physiology

  • The placenta is nature’s neonatal life-support system
  • Oxygenation continues until newborn lungs transition (30 to 90 seconds in a full-term infant)
  • Placental transfusion (blood moving from placenta to baby’s body) rate: 50% in 1 minute; nearly 100% over the next 2 to 5 minutes
  • “Delayed” in research ranges from 30sec – 3min, depending on the researcher and study
  • The newborn heart can beat and the brain can tolerate of lack of oxygen for up to 20 minutes (Resuscitation Council (UK), 2001; Frye, 2004; WHO, 1999) as long as the cord is intact.
  • Newborns cope well with lack of oxygen but struggle with low blood volume

At time of birth:

  • Blood volume of newborn at birth: 78ml/kg
  • Volume after 3min placental transfusion: 126ml/kg
  • g., 3.6kg (8lb) baby has 280ml – 450ml blood volume – a 40% difference!
  • Adults may go into shock and receive blood transfusions at 15 to 30% blood-loss.

6 umbilical cords   Intact cord – birth to 15minutes (Elphanie, 2011)

Benefits of DCC

Full-term newborns:

  • 40% more blood volume
  • 45-50% increased levels of red blood cell counts and blood iron levels
  • Benefits / effects last well past the newborn period
  • Protection from anaemia and iron deficiency for at least 6 months (Chaparro et al., 2006)

Preterm newborns:

  • Significantly lower rates and less severity of common, major newborn health issues
  • More stable vital signs and thrive better
  • Less likely to require blood transfusion, ventilation and oxygen therapy
  • Lower rates of anaemia at 6 months

Overall, the available evidence appears to suggest that DCC is likely to result in better neonatal outcomes in both term and preterm infants.   (Garafalo, 2012)

Issues related to immediate cord clamping:

  • Stem-cell banking: Alberta Health Services (2007) lists the maximum blood draw for an 8lb baby as 2.5-3.5ml in 24 hours, as more may lead to medical complications.  Green (2008) cites the same daily limit and 23-30ml total in 1 month.
  • The minimum amount of blood acceptable for collection is 45ml, maximum is 215ml; 100ml is optimal (Reed, 2011; CRYO-CELL International Inc., 2011).
  • Jaundice: Leaving the umbilical cord intact does not lead to pathological jaundice. The naturally occurring physiological newborn jaundice has no clinical significance.
  • Cord gases don’t change significantly even after 2 minutes of delayed clamping (De Paco et al., 2011).
  • Dysfunctional cord: If a baby is born flat with a limp, non-pulsing cord then the cord is no longer working.  In this case immediate clamping is warranted.

Does anything replace DCC?

  • Neither “milking”/“stripping” cord, nor gravity accomplish or speed-up full placental transfusion

Objections by your medical care provider?

Dr. Mark Sloan wrote an excellent article, Common Objections to Delayed Cord Clamping; What’s the Evidence Say? that addresses common misinformation and discusses the benefits of delayed cord clamping.

Even the American College of Obstetricians and Gynecologists now recommends a delay in umbilical cord clamping for all healthy infants for at least 30-60 seconds after birth, “given the numerous benefits to most newborns” (ACOG, 2017).  It’s not enough but is a big step forward for ACOG, notoriously interventionist.

 

References

ACOG American College of Obstetricians and Gynecologists. (2017).  Delayed Umbilical Cord Clamping After Birth. Obstet Gynecol 2017;129:e5–10. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Delayed-Umbilical-Cord-Clamping-After-Birth

Alberta Health Services. (2007). Maximum blood draw protocol for pediatric patients.

Asfour, V., & Bewley, S. (2011). Cord clamping practice could affect the ratio of placental weight to birthweight and perinatal outcomes. BJOG: An International Journal of Obstetrics & Gynaecology., 118 (12), 1539-40.

Buckley, D. S. (2005). Gentle Birth, Gentle Mothering. Brisbane: One Moon.

Chaparro, C. M., Neufeld, L. M., Alavez, G. T., Cedillo, R., & Dewey, K. G. (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. The Lancet, 367 (9527), 1997-2004.

Crews, C. (2007). Clamping of the umbilical cord – immediate or delayed. Is this really an issue? Retrieved from Midwifery Services of South Texas: http://www.midwiferyservices.org/umbilical_cord_clamping.htm

CRYO-CELL International Inc. (2011). Cord blood collection instructions. Florida.

De Paco, C., Florido, J., Garrido, M., Prados, S., Navarrete, L. (2011). Umbilical cord blood acid-base and gas analysis after early versus delayed cord clamping in neonates at term. Arch Gynecol Obstet , 283 (5), 1011-4.

De Marsh, Q. B., et al. (1941).”The Effect of Depriving the Infant of its Placental Blood.” Journal of the American Medical Association (J.A.M.A.), 116(23):2568-2573. doi:10.1001/jama.1941.02820230012004

Elphanie. (2011, Oct). Magical Umbilical Cords. Retrieved from Nurturing Hearts Birth Services: http://www.nurturingheartsbirthservices.com/blog/?p=1542

Fogelson, D. N. (2011). Delayed cord clamping grandrRounds. USC School of Medicine, A.P. Dept. Obstetrics and Gynecology. South Carolina: Palmetto Health Grand Rounds.

Frye, A. (2004). Holistic midwifery, vol 2, Care during labour and birth. Portland: Labrys.

Garofalo, Milena; Abenhaim, Haim A. (2012). Early Versus Delayed Cord Clamping in Term and Preterm Births: A Review.  J Obstet Gynaecol Can;34(6):525–531.  http://www.jogc.com/article/S1701-2163(16)35268-9/pdf

Greene, A. (2008). How much blood is too much guideline. Retrieved from Dr Greene: http://www.drgreene.com/article/how-much-blood-too-much-guideline

McAdams, R.M. (2014).  Obstet Gynecol. 123(3):549-52. doi: 10.1097/AOG.0000000000000122.

Mercer, J. S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M., & Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemmorhage and late onset sepsis; a randomized, controlled trial. Pediatrics, 117 (4), 1235-1242.

NICE National Institute for Health and Care Excellence (UK). (2016). Clinical guideline [CG190] Intrapartum care for healthy women and babiesPub Dec 2014, revised/updated Nov 2016.  https://www.nice.org.uk/guidance/cg190/ 

Intrapartum care for healthy women and babies

Reed, R. (2011). Cord blood collection: confessions of a vampire-midwife. Retrieved from Midwife Thinking: http://midwifethinking.com/2011/02/10/cord-blood-collection-confessions-of-a-vampire-midwife/

Resuscitation Council (UK). (2001). Resuscitation at birth, the newborn life support provider course manual (2nd ed.). London, UK: Resuscitation Council (UK).

Richmond, S., & Wyllie, J. (2010). European resuscitation council guidelines for resuscitation 2010. Section 7. Resuscitation of babies at birth. J. Resuscitation , 1389-1399.

Strange, K. (2009). NRP for midwives certification class. Seattle, WA.

Tolosa, J. N., Park, D.-H., Eve, D. J., Klasko, S. K., Borlongan, C. V., & Sanberg, P. R. (2010). Mankind’s first natural stem cell transplant. J. Cell. Mol. Med. , 14 (3), 488-95.

Usher, R., Shephard, M., & Lind, J. (1963). The Blood Volume of the Newborn Infant and Placental Transfusion. Acta Paediatrica – Nurturing the Child , 52 (5), 497-512.

WHO. (1999). Basic newborn resuscitation practical guide – revision. Geneva: World Health Organization Safe Motherhood Unit.

Yao, A., & Lind, J. (1969). Effect of gravity on placental transfusion. The Lancet.

Perineum Care

CALENDULA PADS – For swelling, pain, heat.  Make 5-10 pads 6 weeks before due date.
Calendula flowers promote healing and are soothing when applied topically.

  • Calendula Mixture: Make tea from dried calendula leaves (1 full tea ball per cup water steeped for 10 min) or use tincture (20-30 drops per cup water).  Add 1-2 drops of lavender essential oil or some lavender tea to mixture.
  • Partially dip maxi pads – preferably long, organic – in calendula mixture briefly, just to soak top layer. Another option is to use a sprayer to wet the tops.
  • Freeze pads in bowls so they’re curved like the female body. Store in Ziplocs (labeled with your name) in freezer.
  • Bring the pads to birth-place! Hospitals and birthing centers have freezers.
  • Apply immediately after birth.

PERINEUM RINSE
Soothing and healing for swelling, pain, abrasions, tears, bruising.  It’s safe to use with stitches.  This can be prepared during early labor or ahead of time and frozen/refrigerated.

  • Fill a peri- or spray-bottle with calendula mixture (above), a healing solution (below) or warm water.
  • Hospitals will provide a peri-bottle.  A spritz bottle works too.
  • Squirt solution on perineum after every washroom use, shower/bath, or in between if extra relief is needed. Do not rinse solution off.
  • If urination burns then squirt during urination or pee in the bath.
  • Allow the area to dry between applications. Air-time or even a cool blow drier can be helpful.
  • Note: if the rectum is sore or stitched, support the perineum with a cloth during bowel movements (like pooping into a cloth).

SITZ BATH

  • Soak your perineum in a bath for 15 minutes, 3 times daily. Shallow water is fine.
  • Add Epsom salt and if you wish to use herbs, add 1-2 cups raw herbs or healing herb tea, ¼ cup tincture, or up to 5 drops of pure essential oil. If you wish to use plain water then spray the healing solution after the bath.
  • Some women like cool water for inflammation while others find warm water soothing. Experiment with temperatures but avoid extremes during the initial postpartum days, and keep the rest of your body warm.
  • Do not sit on a donut-shaped vessel in the bath as it adds pressure.

HEALING HERBS
Calendula is healing, along with other herbs such as comfrey, lavender, witch hazel, tea-tree, yarrow.  Feel free to ask me about the various healing properties of the different herbs.  Nice sitz-bath blends can be purchased – look for an Epsom salts base with herbs or pure essential oils; no fragrance or additives.   There are some nice soothing perineum sprays on the market, such as Earth Mama Angel Baby New Mama Bottom Spray, sold in Regina at Head-to-Heal Wellness in Cathedral, or Hello Baby in East.

RECOVERY FROM DIFFICULT BIRTH
After a difficult birth follow the above recommendations plus:

  • Keep knees together as much as possible for the first 2 weeks, even while walking
  • Avoid stairs
  • Lift nothing heavier than the baby
  • Allow area to “breath” – air time or cotton panties (no synthetics)
  • Avoid sitting or standing for long periods of time
  • Avoid perfumes, chemicals
  • Avoid straining on the toilet – good nutrition and lots of water, support perineum with a cloth during bowel movements (like pooping into a cloth)
  • See a Physiotherapist who specializes in women’s pelvic floor to heal pelvic floor muscles; recover from perineum tears; avoid or heal incontinence, painful intercourse and pelvic pain
  • Consider seeing a complimentary practitioner who specializes in and is experienced with maternal postpartum recovery, such as a Webster certified chiropractor or an osteopath, to help ensure pelvic organs, bones, ligaments are healthy and aligned.

SPECIAL INFANT CARE FOLLOWING DIFFICULT BIRTH

  • Lots of frontal contact, skin-to-skin if possible; helps establish breastfeeding and is reassuring for baby. Babies who are held feed better, poop and pee more, and are therefore less prone to jaundice and other illnesses.
  • See a complimentary practitioner who specializes in and is very experienced with newborn care, especially if there was any trauma to baby’s head (vacuum, forceps, caesarean, malposition, and/or long “pushing stage”) e.g. chiropractor, cranio-sacral therapist, osteopath.

Labour Drinks

“Labouraid” and broths are excellent for hydration, energy and electrolytes.  They help keep the powerful forces of labour progressing.  Stock the ingredients at home and prepare at the first sign of labour.  Or make ahead (this is a great task for someone who wishes to help out) and freeze as cubes, popsicles, or in a bottle, to be thawed and consumed as labour progresses.  Most women prefer their labouraide chilled and their broths warm.

LABOURAID DRINK – version #1 (From many midwives and natural birth books)
1 L  water or Pregnancy Tea
1/3 C  raw honey or real maple syrup
1/3 C  juice, fresh-squeezed from a real lemon
1/2 t  salt, preferably Celtic or Himalayan
1/4 t  baking soda
2 crushed calcium tablets

These next two versions are from http://www.mommypotamus.com/how-to-make-a-labor-aid-electrolyte-drink/).  See site for details of ingredients.

LABOURAID DRINK – version #2 / Lemon Labor Aide
4 C  water
1/2 C  freshly squeezed lemon juice
1/4 t  salt, preferably Celtic or Himalayan
1/4 C  raw honey (or more to taste)
a few drops concentrated minerals (available at health stores, optional)
a few drops Rescue Remedy (optional)

LABOURAID DRINK – version #3 / Coconut & Lime Labor Aide
3 C  coconut water
1 C  water (or more)
1/2 C  freshly squeezed lime juice
1/4 t  salt, preferably Celtic or Himalayan
2 T  raw honey or maple syrup
a few drops concentrated minerals (available at health stores, optional)
a few drops Rescue Remedy (optional)

VEGGIE BROTH
Add fresh or dried veggies (e.g. carrots, celery, onion, garlic – anything) to boiling water
Simmer for 20-30 min
Add 1 T  apple-cider vinegar
Season with any herbs or spices you like
Add salt to taste, preferably Himilayan or Celtic (kelp powder can be used instead)
Blend to smooth consistency or strain veggie chunks out

BONE BROTH
Put bones and any left-over bits, including meat on bones in pot and cover with water.
Add 1-2 T  apple cider vinegar
Bring to boil then simmer (large bones such as beef for up to 24 hours; small animal bones such as chicken only need 3-4 hours)
Strain
Add salt to taste, preferably Himilayan or Celtic (kelp powder can be used instead)
Optional:  Add dried or finely chopped fresh veggies, herbs or spices and simmer for another 30min

 

Placenta Capsules FAQs

What qualifies you to provide this service?
Proper training and a lot of experience:  We’ve offered this service since 2009 and between us have done 500+ placentas, making us the most experienced encapsulators in Saskatchewan.  We are both OSHA certified and trained in Universal Precautions, food science and preservation.  We train placenta encapsulators through Birth Ways International.

How long does it take?  The capsules are ready in 1-2 days from when we get the placenta.

How many capsules will I get?
That depends on the size of your placenta.  Most women get over 100 capsules.  The average is around 115.  Bigger placentas can fill close to 140 capsules.

What’s the difference between gel and veg caps?
Gel caps are made from animal gelatin and veg caps are vegan, made from plant materials.  See a detailed ingredients list for our high quality capsules.

How do you clean and care for your equipment?
The processing is done using OSHA Blood Borne Pathogen Standards. All surfaces and equipment are cleaned, then disinfected, then twice-sterilized using chemical methods. (This is “over-kill” but is reassuring to us and our clients!)  We use high quality equipment that can be properly sterilized and is kept in like-new working order.

Can I keep my placenta if I have a caesarean birth?
Yes.  The steps are exactly the same.  Simply ensure your O.R. nurse knows you wish to keep it.

Am I “allowed” to keep my placenta?  Do I need permission from my doctor?
It’s yours to keep.  Simply write in your birth plan or tell your care-provider, “I’m keeping my placenta.”  Other details are for you to share or not as you choose.  Obstetrical staff at Regina General Hospital and nearby rural hospitals are quite used to women keeping their placenta.  If you’re at another hospital that has concerns, then you can sign their Release of Live Tissue waiver.  Remind the people attending your birth that you wish to keep it.

Can you make capsules from my placenta if I choose to use epidural or other medications in labour?  Yes.

Is my placenta safe to encapsulate if there’s meconium (baby poops inside) during the birth?
Yes.  The initial cleaning process takes care of this.

Are there any cases where my placenta can’t be encapsulated?
In the rare case of uterine or placental infection during labour, your placenta will be taken away to the pathology department for analysis.  We’ve processed well over 500 placentas and have never received one that was infected (we do watch for it though).  All placentas are inspected after birth by midwives/doctors, who do not send infected placentas (or anything else) home with patients.  Basically if your placenta is not taken away, it’s healthy for encapsulation.

Do you serve out-of-town clients?
Yes.  We have systems in place to make this easy for you.  We provide detailed, easy-to-follow instructions.

How do I package the placenta for you?
At Regina General Hospital, the placenta is usually put into a square plastic container; you can use that for storage and transport.  We provide detailed instructions to bring your own container as a back-up.  You can ask your nurse to get it ready.  While it’s not her “job”, most are happy to help.  At home births or other hospitals you’ll need to provide your own container (we provide detailed instructions).  If you have your baby at night or are shipping the placenta, then you’ll keep it cold (detailed instructions provided) until the morning when it’s picked up.

How do I get the placenta to you?
One of us picks it up at Regina General Hospital or at your home in Regina city limits, depending where you give birth.  If you have your baby out of town then you can have it delivered to us.  We provide detailed instructions.

How do you ensure the capsules are returned to the right person?
This is one of the most important parts of the process!  One of several advantages to working in partnership is that we can process two placentas at the same time in two separate locations. We have a triple labeling system in place to ensure 100% accuracy; your placenta is attached to a label at every stage of processing, from placenta pick-up through to delivery of capsules.  These are a matter of routine, and are followed with every client’s placenta, even though we rarely have 2 placentas in the same building at the same time.

How do I get the capsules back?
We deliver the capsules anywhere within Regina city limits.  If you live out of town then we can ship them or send them with someone going your way (we can drop the package off anywhere in Regina to that person).

How long do the capsules last?
They’re best used within 1 year, stored at room temperature in an airtight container (glass jar).  After that they don’t necessarily go “bad”, but the nutrients start to diminish.  If you wish to keep them longer, then the freezer can extend that for up to another year if they go in within the first few months.  (We don’t recommend this because we hear from so many women who put them in the freezer and promptly forgot about them.)

What is the Traditional Chinese Method?
Warming herbs are added to the placenta during processing.  It’s an extra step that adds 1 day and a small fee to the process.  Our placenta training includes a variety of methods of preservation and processing but encapsulation of pure placenta with no additives is by far the most requested method.

How do I store the capsules?
Just keep them in the glass jar.  There’s no need to refrigerate them.  They’re good for up to a year at room temperature in a cupboard.  If you wish to keep them longer, then store in a deep-freeze for up to two years.

Can you make capsules out of my frozen placenta?  Yes.

How do we proceed? 
Please contact me for next steps.  You will receive a contract via e-mail that you sign and return, and an instruction sheet for your birth-bag.  We need your estimated due date and contact info.  You can send an e-transfer, post-dated cheque or provide cash with the placenta.

What if I Haven’t Made Arrangements Yet?  We can usually accommodate you.  In an ideal world everything will be set up ahead of time.  However if you just decided to do this while you’re in labour – or even after your birth – and need to make quick arrangements, please text during normal “awake” hours.  (If you have your baby after 9am or before 8am, please put your placenta in fridge or on ice and get in touch in the morning.)

Birth Doula FAQs

What’s a doula?
A doula is a woman experienced in childbirth who provides continuous physical, emotional and informational support to the mother and partner during pregnancy, birth & early postpartum. In much of the world today and throughout history, women support women through labour & birth.

What’s the difference between a midwife and a doula?
Doulas work as part of a team with doctors or midwives, but not instead of. They provide non-medical support and comfort measures (e.g. encouragement, massage, positioning suggestions). They do not perform clinical tasks such as heart rate, blood pressure, or internal exams.

Midwives are highly trained in the medical aspects of birth. The carry oxygen, medicines, resuscitation equipment and other gear, and are known as primary care-givers during birth. In North America primary/medical birth care is offered by either a midwife or a physician.

Why choose a doula over simply using a friend or family member as support?
Doulas are trained and experienced in childbirth support. They know the sounds and behaviors of laboring women, and what that may indicate about progress. Doulas are trained in pain-reducing comfort measures, natural methods to keep labor progressing, and to support both the laboring woman and her partner. Doulas are familiar with local hospital policies & practices and have often built a rapport with the doctors, nurses and midwives. See http://evidencebasedbirth.com/2012/06/26/why-wouldnt-you-hire-a-doula/

In most Canadian hospitals, women are allowed 2 support persons – usually that’s her partner and a support person. Some hospitals accommodate a 3rd support person. Homebirths and birth centers encourage women to have all the support they wish.

How does the doula fit in with nursing staff?
Doulas do not replace nurses or other medical staff, but rather work as part of the team. They are there to comfort and support the mother & her partner. Nurses change shifts; doulas stay.

How does a doula assist with communication in hospitals during labor & birth?
During prenatal meetings doulas learn what’s important to a couple and discuss how to make informed decisions. A doula may remind or encourage a client to ask the questions necessary to understand a procedure and make informed decisions. Doulas do not speak on a client’s behalf nor intervene in their clinical care. They do not make decisions for clients, nor judge the decisions clients’ make, but are there to support those decisions.

What difference does the presence of a trained doula have on birth outcomes?
The presence of a doula tends to result in shorter labours with fewer complications and less interventions. When a doula is present during and after childbirth, women report greater satisfaction with their birth experience, make more positive assessments of their babies, have fewer caesareans and requests for medical intervention, and less postpartum depression. In case of unplanned circumstances, doula support helps reduce negative feelings about one’s childbirth experience. Studies [1],[2],[3],[4]   have shown that babies born with doulas present tend to have shorter hospital stays with fewer admissions to special care nurseries, breastfeed more easily and have more affectionate mothers in the postpartum period.

Analysis of six randomized trials1 demonstrates that lack of doula presence correlates with:

  • Double the overall caesarean rate
  • 33% increase in length of labour
  • 67% increase in oxytocin use
  • 2 ½ times more requests for epidurals

Will a doula make my partner feel unnecessary?
A responsible doula compliments and enhances the father/partner in their supportive role rather than acting as a replacement. (While I respect people’s individual circumstances, I will use “father” words for most of this paragraph.) The presence of a doula allows the father to support his partner emotionally during labor & birth without the pressure to remember everything he learned in childbirth class! The father typically has little-to-no actual experience with the birth process, yet is expected to act as a coach. Some partners feel (accurately) that this is a huge expectation. Many fathers experience the birth as an emotional journey of their own and find it hard to be objective. A doula is supportive to both the mother and her partner, and plays a crucial role in helping a partner become involved in the birth to the extent he/she feels comfortable. Studies have shown that fathers usually participate more actively during labor with the presence of a doula than without one.

When a couple works well together during the birth process they’re better able to handle the challenges of early parenthood. An incredible bond forms or is made stronger.

How often and when do we meet?
We’ll meet 2-3 times before the birth. The introductory meeting is any-time – it’s never too early. The prenatal meetings are best done between 24-36 weeks. After your baby is born there will be a minimum of one postpartum visit, more if needed or desired.

Are doulas only useful if planning an un-medicated birth?
The role of the doula is to help attain a safe and pleasant birth, not to choose the type of birth. The presence of a doula is beneficial no matter what type of birth you are planning. In fact, women who choose a medicated birth need as much support as those who choose a natural birth, but a different kind of support. For women who know they want a medicated birth, the doula still provides emotional support, informational support and comfort measures to help the women through labor and the administration of medications. Doulas can help a mom deal with possible side affects and by filling in the gap that medication may not cover; rarely does medication take all discomfort away.

For a mother who faces a cesarean, a doula provides comfort, support and encouragement. Often a cesarean is an unexpected situation and moms are left feeling unprepared, disappointed and lonely. In this case doula support is especially helpful during the early postpartum period.

What if I planned a drug-free birth then change my mind during labour?
Doulas don’t make decisions for clients or intervene in clinical care, nor do they judge women’s choices. They provide informational & emotional support while respecting a woman’s decisions.

What kind of comfort measures do you use during the labour & birth process?
While there are common comfort measures taught in doula training courses, each doula also brings her own tools and methods. Ours include the following:

  • Positioning suggestions
  • Massage & various touch methods
  • Homeopathy & Bach Flowers (optional; no extra charge)
  • Aromatherapy
  • Encouragement & reassurance
  • Heat or cold as desired
  • Hydrotherapy (water for comfort in labour, and/or water-birth)
  • Create space for partner, and recommendations to help partner to offer support
  • A calm, reassuring presence who trusts the birth process

When do we call you in labour?
Please call at the first signs of suspected labour. We’ll discuss what those are. From then on you’ll keep us posted on your progress and what’s happening.

When and where do you join us in labour?
When depends on the woman, her partner, and the labour. Early support often takes the form of checking in by phone and/or dropping by your place.  Your doula joins you either at your home or in hospital or birth center and remains with you until 1-2 hours after the birth.

How does shared-care work?
Doulas team up to provide enhanced service. Clients benefit from combined experience, education, and availability. Since doulas are on call for up to a month for each client, shared care allows them time for important life events and days off without having to turn clients away or rely on unfamiliar back-up. Clients meet both doulas prenatally so they’re familiar with whichever one attends birth.

What if you can’t be at the birth?
In the rare circumstance that one of your doulas can’t be there, you will be well supported. We work with reliable back-ups who offer excellent care. Fees remain the same. If the back-up is likely to be part of care, some clients wish to meet her prenatally, which can be arranged.

Do we pay more to work with 2 doulas?
No. Fees are outlined in the contract. The cost of working with both doulas is the same as hiring one of them individually.

What kind of postpartum support do you offer?
Your birth doula usually stays for 1-2 hours after the birth, until you’re ready to be on your own with your baby. We also visit in the first day or two postpartum, offering basic breastfeeding support, answering questions, and going over your birth. We are available for questions and can offer resources (educational and community). A second postpartum visit is offered.

What if I need extra help with breastfeeding or baby-care?
The information above describes our work as birth-doulas. Another kind of doula, a “postpartum doula”, specializes in extended care and breastfeeding support. There are also breastfeeding counselors and lactation consultants that can be arranged through public health or hired privately. We can provide resources and contact info. If you’re on the Mother-Baby Unit the nurses or unit Lactation Consultants can provide support.

Where’s that name from?
In ancient Greece “doula” meant the highest female servant who helped the lady of the house through child-bearing. Medical researchers Marshall Klaus and John Kennell, who conducted several randomized clinical trials on the medical outcomes of doula attended births, adopted the term to refer to labour support as well as prenatal and postpartum support.

 

[1] Klaus, M.H.; Kennel, J.H.; Berkowitz, G.; Klaus, P. “Maternal Assistance and Support in Labor: Father, Nurse, Midwife or Doula?” Clinical Consultations in Obstetrics and Gynecology 4 (December 1992).

[2] Sauls, DJ. Effects of labor support on mothers, babies, and birth outcomes. J Obstet Gynecol Neonatal Nurs. 2002 Nov-Dec; 31(6):733-41.

[3] O’Driscoll, K. and Meagher, D. Active Management of Labor. 2d ed. London: Bailliere Tindall, 1986.

[4] Klaus, M.H. and Kennel, J.H. Parent-Infant Bonding. St. Louis: C.V. Mosby, 1982.

Essential Herbal Tea for Pregnancy & Breastfeeding

Women have consumed infusions (tea) of Red Raspberry leaf and Nettle leaf through the ages for a healthy childbearing year, healthy reproductive organs at any stage of life, and to keep their skin soft and supple.  This blend is very high in easily absorbed minerals.  If no milk or sugar is added then this drink counts toward your daily water intake.

Drink 1-3 cups of Pregnancy Tea, hot or cold, daily through first 2 trimesters, and 3 cups during last trimester. 

Combine these teas in any ratio you wish, but the general recipe is:

  • 2 parts Red Raspberry Leaf
  • 2 parts Nettle Leaf
  • 1 part Horsetail Leaf (added for calcium & strong bones)
  • Optional: 1 bag or small scoop of lemon, berry/fruit teas (ensure no licorice), mint or lemongrass to change up the flavour.

A batch can be stored in the fridge for up to 3 days.

Red raspberry (Rubus idaeus)

  • Most commonly used and well-known pregnancy herb
  • Tones female reproductive system; also pelvic and uterine muscles
  • High amounts vitamin C, easily assimilated calcium and iron
  • Also vitamins E, A, B-complex, many minerals inc phosphorus and potassium
  • High mineral content helps tissues stretch, decreases stretch marks, helps prevent anemia
  • Lower rates of miscarriage and postpartum hemorrhage
  • Prepares body for labor. Therefore decreases pain and length of labor.  Doesn’t strengthen contractions but makes them more efficient.
  • Help expel placenta
  • Good for morning sickness

Nettle (Urtica dioica)

  • High amounts of virtually all mineral & vitamins needed for health
  • Especially high in A,C,E,D,K, calcium, potassium, phosphorus, iron, sulfur
  • High amounts of chlorophyll (for energy and nutrients, vitamin K)
  • Nourish and strengthen kidneys; gently dislodge and dissolve any mineral buildup
  • Relax leg cramps and muscle spasms
  • Prevent hemorrhage after birth due to high vitamin K
  • Strengthens blood vessels, therefore good for hemorrhoid prevention
  • Astringent for hemorrhoids
  • Increases quality of breast milk

Other herbs high in easily-assimilated vitamins and minerals (alone or added to the above teas) include Horsetail a.k.a. Shavegrass (very high in calcium), Alfalfa and Kelp.

Several other herbs are safe during pregnancy and are tasty e.g. mint.  Some aid pregnancy related issues such as nausea, heartburn, cramping, and constipation to name a few.  These include but are not limited to ginger, chamomile, slippery elm bark, and fennel.  Consult a qualified herbalist with knowledge of pregnancy herbs before taking any.

By the way, this tea is healthy for the males in your life too, and is safe for all ages from infancy on.  It’s a lovely, mildly flavoured drink for the whole family.

Prefer pre-packaged tea?  Health stores and quality Mama/Baby stores sell pregnancy tea, e.g. Earth Mama Angel Baby “Third Trimester Tea” (which you can take in any trimester).

Doula Fees

My fee is a fair reflection of my extensive experience, skills and knowledge.  Besides the often long and unpredictable hours, there are costs associated with being a professional doula. Some of these are monetary such as training, missing other work-shifts, association fees, parking and all the normal expenses related to self-employment.  Other costs are not measurable, such as missed family events, being on-call (700+ hours), and recovery time from long births.

If rates for full doula care seem too high, you can still access some services & wisdom to be more prepared and supported through your birth.

To understand doula fees, please see http://www.cordmama.com/blog/2015/3/23/why-doulas-are-expensive-and-why-youre-glad-they-are

If you have a partner who doesn’t understand paying for extra support, please see http://goodmenproject.com/families/new-dads-advice-just-hire-a-damn-doula-jrmk/

Other Options:

  • We can set up a payment plan.
  • Gift certificates for my services.
  • Raise funds e.g. a collection-box at your baby-shower or Motherblessing, or ask people to contribute to your doula rather than buying other gifts.
  • Find a less experienced doula, as they usually have lower fees.  See The Doulas of Regina for a listing of local doulas.
  • If there’s no way you can pay for birth support, check out the Doulas of Regina  Relief Fund.