Postpartum Mental Health Issues
Volume 11, Issue 8
Midwifery Today E-News
“Postpartum Mental Health Issues”
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In This Week’s Issue:

Quote of the Week

"Depression is a prison where you are both the suffering prisoner and the cruel jailer."

Dorothy Rowe

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The Art of Midwifery

Body and muscle tension are significant components of stress immediately postpartum. Due to strenuous pushing positions and contractions, a woman's body may need extra care and attention. Special postpartum massage can significantly reduce body tension by helping muscles to relax as well as facilitating hormone normalization. One such specialized massage is a component of India's Ayurveda therapy. Local massage therapists can come to a woman's home to support mom with daily therapeutic massage. Therapeutic massage can also be beneficial for the health of baby by stimulating liver function and normalizing baby's hormones.

Adarsa Antares
Excerpted from "Reducing the Risk of Postpartum Depression," Midwifery Today, Issue 76
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Editor's Note: You may also want to purchase Midwifery Today, Issue 89, which includes the article "The Influence of Birth Experience on Postpartum Depression."

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A small study of 38 women in Australia showed an association between depression and lower levels of omega-3 fatty acids during the third trimester of pregnancy.

A high intake of omega-3 fatty acids is already a recommendation for pregnant women because of the positive effect on brain development. The researchers noted that supplements are the best way to obtain these omega-3 fatty acids, because of the risk of mercury in fish.

— Six Minutes,

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Postpartum Anxiety Disorder

For many women, giving birth causes stress and anxiety. For women with generalized anxiety disorder (GAD), the stress of giving birth can trigger panic attacks. The National Institute of Mental Health estimates that about 6.8 million American adults are affected by GAD. Anxiety disorders affect women twice as frequently as men and usually are first diagnosed in early adulthood, which makes their effects relevant when caring for childbearing women.

Currently, we are unable to predict how pregnancy will affect symptoms of a panic disorder. For some women, pregnancy actually lessens the impact of anxiety disorders. In other women, pregnancy can worsen symptoms or cause a relapse. In one study, 43% of woman saw a decrease in their symptoms while 33% had their symptoms increase.

During a panic attack, physical symptoms such as chest pain, shortness of breath, heart palpitations, dizziness and tingling in the extremities are combined with feelings of terror and impending doom. Women who develop panic attacks postpartum report feeling out of control and consumed with worry over the panic and experience reduced self-esteem and concern that the symptoms will have a negative impact on their family.

Predicting panic attacks is difficult, but people affected by anxiety disorders can begin to understand the conditions that trigger their panic attacks by keeping a journal.

Midwives should be prepared for anxiety disorders during the postpartum period. Ninety percent of women with a panic disorder have symptoms that show up within the first three months postpartum, even when anxiety symptoms decreased during pregnancy. GAD occurs more frequently in postpartum women than in the general population. Symptoms of postpartum anxiety are more common than symptoms of postpartum depression and GAD often presents in combination with other depressive symptoms, so it may be easily misdiagnosed. For women who had a previous panic disorder, the postpartum period is a time of increased risk of relapse.

Jennifer Vanderlaan
Excerpted from "Pregnancy and Birth with Generalized Anxiety Disorder," Midwifery Today, Issue 88
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Question of the Week

Q: Is one dose of tetanus vaccine enough for mother and newborn, if the newborn was not delivered with sterile instruments? If the serum is unavailable, what is the solution?

— Anonymous

SEND YOUR RESPONSE to with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.

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Question of the Week Responses

Q: I am pregnant with my fourth child; the second child was a compound presentation and I had a T incision. During the c-section for my third child, the vertical extension of the T opened up after the baby was delivered, so my T has been stitched twice. I believe it is double-stitched; I know it was after the first c-section, and I'm assuming it was again with the second. Additionally, my vaginal delivery was at 41 weeks, and my second child also went 41 weeks gestation. I never went into spontaneous labor with either child, even after waters broke. I had Pitocin (no epidural) with the first, and no drug interference with the second prior to discovery of the baby's hand in the birth canal (the doctor had manipulated my uterus to expel waters and try to facilitate labor). Add to all this that I was diagnosed with gestational diabetes (GD) in December. So far my blood sugars are okay with diet. This baby will arrive almost two years to the date from my last cesarean.

Here's my problem: The recommended time for my cesarean is 39 weeks gestation, which falls on a Friday. The hospital doesn't usually do "elective" surgery on Friday, Saturday or Sunday, and my surgeon isn't available again until the following Tuesday, making me 4 days past my 39 week mark. The perinatologist is worried about rupture and suggests cesarean before 39 weeks, but then the hospital requires an amniocentesis to determine lung development. I do not like the idea of an amniocentesis, and if lung development is immature, I'd have to wait anyway.

My question is what to do? I feel an exception should be made to give me surgery at 39 weeks, rather than incurring risk to the baby from amniocentesis and respiratory problems, but I'm not sure they'll do this. What can you tell me, either about getting an exception to surgery dates and/or risk of rupture, or would you recommend doing the amnio and delivering before 39 weeks? I really do not want to deliver early, especially for the doctor/hospital scheduling policies. Any help you can give me is appreciated!

— Brigid Luzarraga

A: I have a couple of responses to Brigid's concerns. The standard of care in my community is to perform an amniocentesis prior to a scheduled cesarean at 39 weeks. This recommendation may hinge on the dating of the pregnancy (certain LMP, ultrasound timing, fundal growth). If the provider performing the procedure is experienced, the risks of complication to you or the baby are quite low. And asking the hospital to make an exception for you on that Friday doesn't seem to make much sense either. Women's bodies don't tend to suddenly turn into a hazardous place for a babe to grow from one day to the next. Your chances of laboring independently, which isn't recommended with a vertical incision, increase as you get closer to your "due date." But "due dates" are loose time frames for when we should expect a baby to come, not the rigid constructs that the medical community and our modern culture have latched onto. With that, I would encourage you to make a decision that is comfortable for you, not one based on fear and rigid adherence to an EDC. The vast majority of babes born after 35 weeks do beautifully, though some need more help with maintaining their temps and eating. So 39 weeks versus 39+4, versus 38+6 weeks…this just may be splitting hairs.

— Kari, CNM

Responses to any Question of the Week may be sent to E-News at any time. Write to Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


I have had the opportunity to live and to work in India for extended periods of time over the past 15 years. On a recent trip there, in November of 2008, I spent a few weeks in a very tiny rural village in Andra Pradesh state in South India.

Along with another nurse midwife from Hyderabad, who is now practicing in the US, and a documentary filmmaker with extensive experience working/filming in India, I am planning to live with/work with the village dai for a few weeks in November of 2009 and try to understand, through her eyes, the changing world of birth in India, and in her village. We hope to understand what seems to be the renewed interest of the Indian government in bringing "medical help" to these rural areas and in doing so seem to be ready to throw out the baby (the dai) with the bath water, as they say.

Rather than finding a way that the dai and the doctors can mutually support one another, what seems to be happening in this village (and possibly all over India) is that the doctors want to educate the dai (who has years more experience in birth than the doctors have) so that they can take over from her the tasks in birth that she has been carrying alone for so long.

We hope to make a short documentary film about the changing role of the dai, viewing the world from her perspective: how she has lived/worked/delivered and the changes that are coming to her from the outside world/government. The dai was very open to this, as were the doctors.

Given that this is a rural area of 30,000 people, it would seem there is enough work for a dai and the doctors and that it might not be necessary to phase out the dais from the work they have been doing for hundreds of years.

During these weeks in Jonnegiri, the two nurse-midwives would also make ourselves available to the dai, and to the doctors, or to whomever in whatever way we could. If they are open to it, we would like to introduce the Home Based Life Saving Skills Course (HBLSS). HBLSS training takes place over a 1- to 2-year time period and involves about three trips to an area for a time period of two to four weeks at a time. If we are to go further with this HBLSS course, funding would be needed at a later time, and a few additional visits.

We anticipate needing about $10,000 for three airfares, transportation costs to the village, and simple film costs for this initial visit and documentary filming project. Do you have any ideas, contacts, organizations that you are familiar with that might be open to sponsor such a project?

I will follow up on any lead that people suggest to me, as finding money at this time seems to be a huge challenge—nevertheless I think this is an important project and want to follow the doorway that seems to have opened for us at this time.

Julia Rasch

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I found "After Twin Birth" (E-News 11:5) to be a lovely story, but why the slam at the end of the article towards hospital births? "[T]win bonding would never have happened if the birth had occurred in a hospital because each baby would have had different receiving pediatric teams and separate warmers and routines to undergo." How closed minded to think there is only one way for twin bonding! And how demoralizing for women who either chose to deliver in the hospital or need the medical support! In addition, if those babies had been born in the hospital and a story written, I can't imagine the author saying anything so demeaning about a home delivery. It was rude.

Karen White, RN

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