What to Expect…AFTER you were Expecting

th_PregnancyWhile many women often saturate  themselves with extensive information about what they should expect while they are expecting a baby, for many new moms, they find that their research ended after they figured out how to write up their birth plan. Thus, there are a lot of unexpected realities that suddenly appear after they have the baby.

Retrieved from: http://collections.infocollections.org/ukedu/uk/d/Jh1436e/14.html

To start, I’d like to present the definition of postpartum: “(post-par-tum) adjective, occurring in or being the period following parturition [birth]” (Merriam-Webster Dictionary, 2012). I find that many people not in the medical profession practically shudder at this word, as if they thought every time we referred to “the postpartum period” that we were automatically assuming she would have postpartum depression when she got her period. Actually, a patient really told me that. And it is something many other people might also falsely believe. So for clarification, postpartum, and postpartum depression are entirely different concepts, are not ever used interchangeably and postpartum depression will never be shortened or nicknamed to postpartum just for the heck of it (you can’t make this up people). When health providers refer to the postpartum period, we referring to the period of time (not bleeding) that occurs from the time you give birth for six weeks thereafter. While postpartum depression can occur during this time, there are many, many other changes your body will experience that can also be overwhelming if you aren’t prepared.

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One of the most uncomfortable complaints associated with the postpartum period is breast engorgement. This occurs when the breasts fill with fluid from an accumulation of milk and fluid in the tissues, causing the breasts to become very swollen, heavy, firm, and extremely tender (think like the first day after breast augmentation). This can happen in both breastfeeding and formula feeding mothers, and is equally distressing for each.

However, treating breast engorgement is very different depending on if you are breast feeding or not, so pay attention. For breast-feeding women, they best remedy is to continue nursing every 1-2 hours, and use heat therapy with warm compresses, or let warm shower water to run over the breasts. This will increase the circulation to the breasts, and will help to facilitate drainage of fluid accumulation from around the tissue back into circulation, and nursing often will help to empty the breasts and will relieve some of the pressure. Frequent breastfeeding may also be beneficial in preventing breast engorgement, by providing a steady and consistent outflow of milk, decreasing the accumulation of milk in the tissues. Now, for the mother that is not breastfeeding, disregard the previous information. Your best action to treat breast engorgement is to focus on cold therapy NOT heat therapy. Using cold compresses on the breasts will help to decrease the circulation and swelling of the breast tissue. 1427051_f260As crazy as it may sound, cabbage leaves are highly recommended; they are cool, to draw the fluid away from the breasts, relieving some of the pain and swelling. They are also convenient, as the leaves take shape around the breast, and can be easily placed inside your bra, so you don’t have to worry about stuffing your bra full of ice. Additionally, because the breasts will become heavier, both breastfeeding and formula feeding women should wear good supportive bras to reduce the pull on your back and stretching of skin and breasts, and can help to reduce the overall pain and discomfort.

Amongst many other common complaints, many women complain of the achy, cramping feeling in their belly in the day or so following delivery. I feel like a full physiological explanation of the reason for their cramping is sometimes more helpful than the ibuprofen we give you, so try to follow along with all the gory details. During labor, the uterus intermittently contracts and relaxes in order to dilate the cervix and expel the baby from the womb. Very soon after the baby is born, the same thing occurs when the uterus expels the placenta (the afterbirth). Now, the placenta is actually attached to the inner lining of the uterus, and is kind of like a connection (or barrier, however you want to look at it) between the baby’s blood vessels and circulation and the mother’s. As such, you can imagine the high blood supply the is provided to the placenta, and when it separates from the uterus and is delivered, there is basically an open wound of open blood vessels. 6934W It is a rather complex process, but we’ll keep it as basic as possible here…In order to control the bleeding, the uterus again starts to contract down on itself, firm and constant, in order to constrict the blood vessels to reduce the bleeding. This doesn’t always happen on its own, and so a common practice is to stimulate the contractions further by infusing pitocin (the same drug used to make contractions stronger during labor), or by “massaging” the uterus down into a contraction.

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I was very fond of my instructor Jane, who always said “Ok darling, we’re just going to mash a bit on your belly now to stop the bleeding.” To me, this is a more accurate description than “massaging.” Over the next few hours to days, the mother may feel that cramping as the uterus tries to maintain a firm contraction. This may occur in several situations, one of them being while breastfeeding. As if breastfeeding wasn’t already the best thing to do for the baby, it is great for the mother too. Nipple stimulation by the baby suckling produces a hormone called Oxytocin. This probably reminds you of that medicine I mentioned earlier, called Pitocin, which is actually the synthetic version of Oxytocin. If you received Pitocin during labor, you can recall that the contractions started or got stronger after getting this med. Similarly, secretion of Oxytocin also stimulates uterine contractions. While this is also known as the “love hormone,” which is associated with feelings of motherly instinct and love towards the baby, this hormone plays a major role in keeping the uterus contracted to control bleeding, thus explaining why some women may feel somewhat crampy during or after breastfeeding.

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But rest assured, this discomfort is temporary, and will go away within a day or so,  and so please do not let this be a discouragement to breastfeeding! Another situation that may increase the cramping is when there is a full bladder. Think about the limited amount of space in the pelvis (I know, its hard to think of it as being anything but small after pushing out that baby). When there is a full bladder taking up space, it can push the uterus up and away from the pelvis, distorting the space needed for a contracted uterus, and thus, it may become soft, or “boggy.” In an attempt to compensate, the uterine contractions may become irritable and more uncomfortable. Additionally, there may be increased vaginal bleeding as a result of a soft uterus. This brings us to our next topic…

Retrieved from: http://www.thirdage.com/hc/c/what-is-postpartum-hemorrhage

Vaginal bleeding can understandable be a nuisance to the woman who has not had a period for the last 9-10 months. Bleeding is a result of a couple different factors including the process of involution (see above paragraph), as well as any lacerations or tears in the vaginal or cervix. Small tears in the vagina are common, and do not necessarily require stitches if they are not bleeding, though a midwife may throw a few stitches to enhance the healing process and prevent bleeding or infection later. The first day the bleeding is usually the heaviest, and should usually subside to a light period within the next day or 2, though the bleeding may increase if there is a full bladder (see above paragraph), so it is very important to be mindful of going to the bathroom and urinating every couple of hours to prevent the uterus from getting boggy, and reduce the amount of blood loss. Occasionally, I hear some concern from women that they start to bleed more or pass clots after they get up, especially in the morning. This then leads to the mindset that they should stay resting in bed to keep from bleeding more. While you should never ignore a noticeable increase in bleeding, it is common to notice more bleeding after getting up, especially after laying in bed for a few hours. This is because the vagina is basically a hollow vault, and when you are laying down, the pelvis is in a horizontal plane rather than vertical while standing, instead of dripping out, the blood tends to pool in some of the spaces and corners in the vagina and around the cervix. Then, when you change to a sitting or standing position, gravity works, and then the bleeding becomes evident. Additionally, blood tends to become clotted when it is still, so if you are laying for a few hours with pooled blood in the vagina, it may become somewhat thick or clotted, and come out when you stand or use the bathroom. As most other aspects of pregnancy, bleeding will eventually subside, most women will probably have at least some spotting for a couple of weeks after giving birth, and it may then become a whitish discharge before it stops completely. Now, for some women who are breastfeeding consistently, the bleeding (resuming your period) may not return for several months. images-4Aside from abstinence, lactational amenorrhea is one of the oldest and most natural methods of contraception, and is recognized by many cultures and religions around the world in which modern contraceptive alternatives are prohibited. Breast feeding is essentially Mother Nature’s way of naturally spacing out pregnancies (assuming ancient ancestors breastfed exclusively for the first many months to years of life). However, there is a catch! Do not foolishly assume that just because you are breastfeeding means that you won’t get pregnant. images-3In order to rely on the lactational amenorrhea method, breastfeeding should pretty much take place consistently, every 1-3 hours throughout the day. Pumping, formula supplementation, and prolonging time between feedings increase your chances of getting pregnant again, and if your feeding practice includes any pumping, use of formula, or you are only breastfeeding every few hours (such as when the baby starts to sleep through the night), you should consider yourself fertile, and at risk of getting pregnant again, even if you have not gotten your period yet. You should then consider using another form of contraception.

Generally, you are advised to avoid sex or anything in the vagina (tampons, fingers, douches) for six weeks after you give birth. If you are not nursing regularly, frequently, or formula feeding, you should consider some contraceptive alternatives, which should be discussed with you before you leave the hospital, and again at your 6 week follow-up appointment. As mentioned above, breastfeeding is an effective and easy way to prevent another pregnancy right away if the method is used properly, however, even then, it is reasonable to still use alternative methods for additional protection.images-2 If your last pregnancy didn’t occur because you forgot to take your birth control pill, you might be a good candidate for the birth control pill (just kidding!). Birth control pills are great forms of contraception for most women after having a baby (should not be used in women with history of or current blood clots, smokers over 35, breast cancer, conditions mentioned on all the commercials, etc). Depending on if you are breastfeeding or not however, will determine the kind of pill you can take. For women that are breastfeeding, pills containing estrogen may reduce the milk supply, and so it is recommended to use a progestin-only pill, also known as a mini-pill. These are considered to be safe to the breastfeeding baby, and are highly effective when used correctly (make sure you don’t miss a pill, take it at the same time every day, or you may get spotting, your period, or another pregnancy). If you are not breastfeeding your baby, either progestin-only or combination contraceptives (combination estrogen/progestin pills are the usual common pill) are appropriate. Additionally, breastfeeding or formula feeding women can also receive Depo Provera shots, we often encourage you to return to your clinic about 2 weeks after you deliver to get the shot. Another excellent method to consider at your 6 week appointment is the IUD, both the hormonal (Mirena) and non-hormonal IUD (Paraguard) are safe for breastfeeding and very effective for preventing pregnancy (see my blog ‘Got IUD?’ for info).

mch_postpartum_hair_lossAnother cause for concern brought by women after having a baby is that they notice their hair is falling out. While this can be very distressing, it is usually not a cause for concern. During pregnancy, hair and nails tend to grow faster, thicker, and seem healthier. Unfortunately, after pregnancy, hair and nail growth returns to normal, and women may shed the excess hair and fullness that grew during pregnancy. This may be very upsetting, thinking all of your hair is falling out, when in reality, the hair is just returning to the way it was before pregnancy.

Retrieved from: http://www.health.utah.gov/prl/factsheet.htm

As mentioned at the beginning of this blog, postpartum depression is another problem that may occur in the weeks to months after having a baby. It is not uncommon to initially have feelings of sadness, anxiety, and crying in the first few days after having your baby. This is usually temporary, and should normally reside within a few days. Postpartum depression on the other hand is a much more serious condition, which usually has symptoms occurring after a few weeks to months after having the baby. Signs of postpartum depression may be very generalized, such as feeling tired, sad, stressed, or loss of interest in activities and things you used to be interested in. These should be considered early warning signs of the possibility for postpartum depression, and you should contact your midwife or OB as soon as possible to discuss your feelings. Many women may feel hesitant to express concerns about such feelings, for fear of being judged, labeled “a bad mother,” getting their baby taken, or being locked away in a crazy house. It is so important to not let these fears cloud your own judgement of talking to your provider; we are not here to pass judgement or labels on your parenting, and pretty unlikely to lock you away or take your baby. But that’s why it is so important to seek help early on, so that we can help you from becoming a harm to yourself and your baby.

While I hope this blog is useful and informative to many women, please take all information carefully, and do not substitute this info for professional medical advice or diagnosis. This blog is merely a briefing of some common discomforts of the normal postpartum period, but sometimes these discomforts can prelude to serious complications, and should never be ignored. If you do have concerns especially heavy bleeding, severe cramping, breast pain, odorous vaginal discharge or fever (just to name a few!) notify your doctor as soon as possible to be evaluated. Thanks for reading!

This blog is in dedication to Cody, one of my best friends, who just gave birth to beautiful baby Kaya on January 3.

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New beginnings at the end of the road

Recently, I was moved by the successful start of a very special persons nursing career. In the short time working with her, I hope Laken was able to learn as much from me as I did from her. I always tell students that I enjoy them shadowing me because I remember the mental conflicts I often had as a nursing student, not just in applying the psychomotor skills we learn in lab, but also in the behind the scenes practical logic that they dont teach you in a class room, learning answers to questions you never thought of, and the confidence to know the right kind of short cuts, and when you should take them. I’ve been a personal cheerleader for Laken this summer, encouraging her self esteem and confidence with the best guidance, constructive criticism and positive support I knew how to offer. Now my baby bird has passed her boards, and about to start her first job as an RN, a real nurse. And it would not be beyond reason for her to have her own reservations and anxieties, being nervous about moving into this phase of her life and career. But she knows well that, as her mentor, I will always be a source of encouragement and support in her times of doubt. I have heard myself say many times “dont be scared, you are going to be great.” Strangely, this is encouragement that I have not only been giving, but receiving more and more myself recently. As my own impending graduation date grows frightfully close, I have found my own fears and reservations becoming more apparent in my plans leading up to, and after December 15 2012. The question crosses my path far too often; “where are you going to go after you graduate?” My generic response  is “I just want to graduate.” But as we move at high speed to that sanctioned date, I’m starting to find myself feeling it becoming less of an exciting milestone, and more of a sobering obligation. In undergrad, I used to say “for high school graduation you say ‘congratulations’; For college graduations, you say ‘my condolences'”. Without a doubt college is the best 4 years of our lives, you are a college kid, not a “real grown up.” Who would want that to end? For some, we continue on to grad school, telling ourselves that we are determined and ambitious, advancing our degrees and our education to improve our careers and professional opportunities. I dont doubt that this is the primary intention for everyone that goes straight into grad school. But recently, I have noticed additional characteristics that make me feel sadness over graduating. Its not so much a fear of the unknown, about not passing my boards or not getting a job (well yes, these are some fears), but it is also a fear of losing a part of my identity. I have always been a student, and the last 6 and a half years especially, I have been consistent, eager, and hardworking towards my degrees. I have learned ways to use my brain to learn in ways I never imagined. In grad school, studying often became a hobby (as evidenced by this blog). Its not that I believe that graduating is going to stop me from learning. I learn something new everyday, through academics or otherwise. But being a student was like having a security blanket from reality. A sort of limbo excusing you from the realities of life. Getting married, having kids, settling down, finding a permanent job, etc. (not that these things are something people dont do as students). But being a student, particularly going directly into grad school gives sort of an excuse to delay some of pressures of real life. There is always a goal, an objective, a reason to wait until after graduation to think of these things. After spending so much time and effort investing in this goal, how do you proceed once you have achieved it? Sure, getting my masters is by no means the end of the road for nursing. We had a great assignment for class where we describe where we see ourselves in 1, 5, 10, 20 years; the typical pregraduation assignment. I started with typical ambitious responses, but then it started beginning alot more sobering than I anticipated. There are so many paths to choose: DNP? PhD? Practice? Research? Legislation? With so many possibles, it is overwhelming to think of starting over with a new set of lifetime goals. Until now, my immediate goals of graduating allowed me to put these ideas off while I focused on the first step. But the pressure is on. Whats next? And my answer is not just to avoid further overwhelming discussion about my future, but Im also tring to convince my self that “I just want to graduate.”

Real or fake? The boob job dilemma

Whether breast augmentation may be seen by some as tacky taboo, others may marvel at the prospect, while still others just simply enjoy all the talk about boobs. While breast augmentation is by no means unheard of, understanding breast implants in relation to breast cancer and breast feeding is not the hottest topic. Regardless, of whether you are in favor of silicone, saline, or the good old fashioned all-natural, its  likely that either you or someone you know has breast implants. Please share the info.

About Breastfeeding…

ImageAs mentioned in one of my previous posts, “Breast is Best”. The American Academy of Pediatrics recommends that babies should be exclusively breast fed for the first year of life. This is not only beneficial to the nutritional intake of the infant, but breast feeding is also exceedingly beneficial to the mother as well (see my blog post for more info: https://g8rk8.wordpress.com/2011/03/26/breastfeeding-to-keep-kosher/). A common concern among women who have, or are considering breast implants, is the ability to breastfeed. ImageThe literature is varied, however, the review by Cruz and Korchin (2010) summarizes key investigations related to breast feeding success following augmentation. While there are a multitude of potential factors that could impede breastfeeding (in both augmented and non-augmented breasts), incision site remains to be a common denominator in nearly all studies. Though the differences between the periareolar and submammary approaches were minimal, these incision sites generally had the least success with breastfeeding when compared to transaxillary approaches. This is possibly due to a couple factors. First, the tissue surrounding the underside of the nipple is composed of many glands, ducts, and nerves that are involved in lactation. Damage to any of these structures can therefore interrupt the process of milk production, leading to absent or insufficient milk supply. Additionally, the periareolar incision involves severing many superficial nerves in the nipple, and is thus most often linked to decreased nipple sensation. Nipple sensation plays a crucial role in milk production; the suckling sensation produces a reflexive stimulation of the pituitary gland, with subsequent release of prolactin, an essential hormone needed for lactation (Cruz & Korchin, 2010). While it was thought that the transaxillary approach may have better breastfeeding outcomes due to reduced manipulation of breast tissue, this approach does, however, involve extensive trauma to the nerves and lymph nodes that are essential to proper mammary gland function. Another theory that has recently been suggestion for future investigation is the association of small “hypoplastic breasts,” and inadequate milk supply (Cruz & Korchin, 2010). ImageThis theory suggests that women who have difficulty breast feeding following breast augmentation are more likely to have had small, inadequately developed breast tissue prior to augmentation (thus inciting desire for surgical enhancement). Finally, placement of the breast implant is significantly related to breastfeeding ability. Typically, the implant is placed under the muscle (submuscular) or under the glands (subglandular). When the implants are placed under the glands, there is a greater chance of complications related to pressure from the implant against the glands, more discomfort during breastfeeding, and the possibility of capsular contraction (a long term complication of implants) that could potentially interfere with the breast anatomy and function of the glands.

Breast Cancer Screening…

While breast feeding with breast implants is an important topic that is left untouched by many women’s health providers, the primary intention of this blog was to discuss and bring awareness to the myths, risks, and screening tools for breast cancer in someone with breast implants. It is no secret in the health care field that breast implants pose substantial challenges to current breast cancer screening measures such as self-breast exams, clinical breast exams, and mammography. However, the greater majority of clinical investigations exploring the incidence of breast cancer following augmentation have shown little to no difference in statistics between augmented and non-augmented breast cancer patients3. In fact, some studies actually saw better cancer prognoses for patients with implants. There are several theories that have been elicited from this conclusion. This will be addressed after a review of the obstacles (booby traps?) imposed by implants on breast cancer screening. Chiefly, reduced imaging quality of mammograms is a primary concern with breast implants. Mammography provides detection of different densities in breast tissue, identifying possible tumors, which appear as radiopaque white masses  (pardon my lack of radiology expertise from that definition). This screening technique is a widely used and recommended method for the early detection of breast masses. Unfortunately, breast implants possess similar opacity to tumor masses, and can often lead to inconclusive and inaccurate results if a significant portion of breast tissue is obscured from the image.

Therefore, the more breast tissue that can be isolated from the implant, the better the likelihood of a more accurate mammogram. As mentioned previously, submuscular placement refers to implants that are placed under the muscles of the chest wall. This allows for more breast tissue to be dispersed away from the implant, and thus less opportunity for masses to be concealed. The same concept is true for self and clinical breast exams. The submuscular implant is well separated from the glandular breast tissue, and thus provides a firm “backdrop” with which to compress the breast tissue, providing greater ability to distinguish the different textures of tissue3. It is essential, however, to have an adequate knowledge of self-exam techniques, and the ability to distinguish between normal breast tissue, implant structures, and possible pathology.

Health care provider skepticism to breast implants may be related to challenges in reliable early detection of abnormal breast masses4.  However, as mentioned, several studies have had surprising results of breast cancer detection in augmented versus non-augmented breasts. Some studies found that women with breast implants often detected masses and were diagnosed at early stages of the disease, and frequently had smaller sized tumors than women without implants4.  Theories behind this concept are as follows:

  • Increased body awareness. Women who have undergone breast augmentation generally display a greater awareness of body image, identification of changes, and comfort with self assessment and examination3.
  • Increased implementation of self breast exams through the use of massage to prevent capsular contraction4.
  • Better educated about proper assessment, screening measures, and consistent follow-up.
    • Women with breast implants tend to have increased interaction and communication with surgeons and other health care providers about expectations, recommendations, and what to look out for3.
    • Women with breast implants are more likely than women without implants to have regular mammograms3.
    • Possible anatomical advantages: enhanced local immune response and surveillance due to the presence of a foreign body; compression of surrounding breast tissue leading to conservative blood distribution and reduced blood supply to growing tumors4.

In general, most of the research has shown very little other significant differences in either rate of detection, extent of metastasis, or disease prognosis amongst women with or without breast implants3. While these theories are simply just that, they do offer a firm foundation for consideration in a risk versus benefit analysis. I hope this blog has shed some light on a very unspoken issue in women’s health, and please pass on the information. I don’t feel breast implants are in any way better or worse than not having implants, but I respect and support the choice to do so if desired. As always, please take all information in this blog with a grain of salt. This is not professional medical advice, simply a casual discussion. Do not use this info as a substitute for professional medical attention.

 

References:

1Cruz, N., & Korchin, L., (2010). Breastfeeding After Augmentation Mammaplasty with Saline Implants. Annals of Plastic Surgery, 64(5): 530-533.

2Strom, S., Balwin, B., Sigurdson, A., Schusterman, M., (1997). Cosmetic saline breast implants: A survey of satisfaction, breast-feeding experience, cancer, and health. Plastic and Reconstructive Surgery, 100(6):1553-1557

3Smalley, S., (2003). Breast implants and breast cancer screening. Journal of Midwifery & Women’s Health, 48(5): 329-337.

4Deapen, D., (2007). Breast Implants and Breast Cancer: A Review of Incidence, Detection, Mortality, and Survival. Plastic and Reconstructive Surgery, 120(7):70S-80S

Infertility

Its ironic that so many young women spend the better part of our teenage years and early twenties worrying about getting pregnant, and then when their minds are finally ready to be pregnant, their bodies no longer are. ImageA couple weeks ago I was fortunate to have the opportunity to spend the day shadowing a nurse practitioner at an infertility and reproductive medicine clinic. I learned so much about the little things that are so frequently overlooked by most women (such as diet and exercise) and the significance it has on reproductive success. I hope this discussion provides insight and ideas for success when trying to plan for pregnancy.

The first topic that seems to have the greatest impact on fertility is diet and weight. Yes, it is those dreaded words that no woman ever wants to hear. While most of the women that came to the clinic were not necessarily obese, many of them could generally be considered at least mild to moderately overweight, and a small handful were slightly underweight. Image One of the first steps to improving fertility is to obtain a healthy weight. For the woman that needed to gain a few pounds, it wasn’t recommended that she consume all the Krispy Kreme donuts within a 10 mile radius, on the contrary, for both over and under weight women, they were advised to restrict the amount of carbohydrates in their diets, and eat foods high in protein and vitamin rich fats. While some of the providers admitted to being more carb-tolerant, some of the doctors are insistent about clients following a strict no-carb diet. While choosing between that bagel and getting pregnant might seem to be a no-brainer to the hopeful mother to be, it seemed that most women became more heartbroken learning some of the best fruits and “first line diet foods” were still off limits. As I mentioned earlier, women don’t want to hear that they need to go on a diet and lose weight. For the fluffy gal, its something she already knows, and doesn’t need to be told again. That being said, the explanation over WHY carbs are bad is brilliant, and it went something like this…

At the initial consultation, the nurse practitioner sat down to review lab results from their bloodwork. While most primary care labs check blood glucose, a less common lab is the amount of blood insulin. A very high majority of the women we saw at the clinic had high levels of insulin. ImageThe way this related to their fertility was explained as such: “When you eat meals that are high in carbohydrates, your body produces insulin, which is a hormone needed to transport the carbs into a usable form of energy in the cells. That is a normal response. However, insulin inhibits estrogen production, which is a major hormone of the reproductive system that is essential for fertility to help your eggs grow. When you eat a meal that is high in carbs, your insulin levels rise (which is a normal response), but while your insulin was up, you didn’t produce any estrogen that night.” This very cut-and-dry explanation was very enlightening, and made complete sense. While the actual physiology behind this concept is far more complex, coupling this diet with exercise to boost metabolism and lose weight is the first step women need to take to help in getting pregnant.

ImageAnother bright idea to improve chances of getting pregnant is to consider the type of lubricant used (if any), and how it may affects the quality of sperm. It might seem obvious to avoid a spermicidal lubricant if you are trying to conceive, but what about the rest of the commonly used lubes? In general, most of the water-based products are not beneficial to sperm quality, as they can decrease sperm motility and lifespan. ImageThey already have enough obstacles just trying to find that egg, why complicate things? Instead, some good alternatives to use (if needed) are natural oils such as mineral and cannola oil. Additionally, men should avoid wearing restrictive tight clothing, especially with excessive heat.

A very important concept to keep in mind is that there are only certain days that it is possible to conceive. While daily intercourse does seem to have s slight advantage (improved sperm quality), it is never the less essential to know the optimal time for intercourse (especially if you don’t have sex every day). The old school Natural Family Planning Method is one of the best ways to determine what days you are most likely to ovulate. Keep a menstrual diary. Record the first day you get your period. This is the single most important step to take to improve chances of getting pregnant. This is also very beneficial after you become pregnant, as it allows for accurate dating and gestational age of your baby. Most women have 28 day cycles, meaning from the first day of one bleeding period to the first day of the next. ImageKeeping a detailed diary month to month is very helpful to predict when you will ovulate, because in most normal cycles, ovulation takes place 14 days before menstrual bleeding occurs. It is a retrospective assessment that may not be apparent until a few cycles have been recorded. Additionally, you should make note of any irregular spotting in between periods, as this may indicate hormonal abnormalities and/or absence of ovulation.

Another good way to determine when you might be ovulating is by the quality of your cervical mucous. Most of us have noticed occasional differences in the color and consistency of the discharge on their underwear. Most of the time, during the infertile days of the cycle, the mucous is thicker, sticky, not as much, and may not always be apparent. Around the time of ovulation, the mucous becomes thinner, and more evident. The consistency is similar to that of an egg white. This is what you want to look for, as it usually changes within 1-2 days of ovulation. However, when evaluating vaginal discharge, know what is normal and what is not. Foul odor, green, yellow, or grayish color, or white, chunky consistency may be indicative of an infection. Being regularly screened for STD’s will help improve fertility, because STD’s such as chlamydia for example, can spread to the uterus, tubes, and ovaries, causing inflammation and structural abnormalities, that could contribute to problems with fertility later.

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Fertility is based on numerous complexities, that are beyond the depth of this discussion. That being said, infertility is also a complex issue that takes into account various disciplines, including age, medical history, hormones, male factors, STD’s, genetics, and much much more. Now I am by no means an expert in this subject; while I want to provide information learned from my experience at the infertility clinic, coupled with tid-bits of educational  information I’ve learned from class, I am only providing a non-formal discussion, and should not be substituted for a professional opinion =)

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STDs+PID=Salpingitis

Salpingitis is one of the complications caused by Pelvic Inflammatory Disease, a sexually transmitted infection whereby the causative agent, usually a Gonococcus or Chlamydial infection, ascends upwards throughout the female genital tract, starting in the vagina and spreading to the superior structures of the uterus, fallopian tubes, and ovaries. The resulting inflammation usually causes severe abdominopelvic pain and tenderness, with accompanying fever and vaginal discharge (Kumar, 2010).

Although Pelvic Inflammatory Disease is a treatable condition, the infection has the potential to produce long-term structural defects, that could cause infertility (Gibson, 1999). In the attempt to fight off the infection by the body’s immune response, many histological changes may result from the process, leading to scar tissue formation in place of normal endometrial tissue. In the organs where optimal functioning of the structures is essential for successful reproductivity, alterations resulting from cellular tissue repair may impede the ability for normal ovulation processes to occur. Some of the dysfunctions are the result of scarring of the tubes, and tuboovarian abscesses that permanently occlude the fallopian tube, inhibiting the passing of the ovum for fertilization (Bozoyan, 2006). Furthermore, the inflammation to the adnexa significantly increases the risk of ectopic pregnancies due to the resulting damages in tissue function induced by the infection and immune responses (Gibson, 1999).  In addition, acute salpingitis is often undiagnosed, or seen in later stages, due to a slow progression of symptoms that may be only mildly experienced.  When symptoms present as severe enough to seek treatment, the infection has often progressed to encompass the majority of the reproductive organs, and significant structural damage may have already occurred (Gibson, 1999).

As healthcare professionals, it is imperative to initiate aggressive treatment to eliminate the inflammation as soon as possible in order to prevent further damage and complications. Furthermore, early education on healthy and safe sexual practices should be initiated whenever possible to enhance understanding, and  prevent incidences of sexually transmitted infections.

References:

Bozoyan, M., (2006). Pelvic inflammatory disease; Sexually transmitted infections.

Armenian Medical Network. Retrieved from http://www.health.am/sex/more/pelvic_inflammatory_disease/

Gibson, M. (1999). Pelvic inflammatory disease: chronic sequelae of salpingitis.

Contemporary OB/GYN, 44(8) 123

Kumar, V. (2010).  The female genital tract. Robbins and Cotran; Pathologic basis of disease, pp 1009-1010. Philadelphia: Elsevier.

Traumatized: post-partum post traumatic stress disorder

The study that was conducted in this article was to recognize the prevalence of post traumatic stress disorder in post partum women. It is understood that in a period of about 4-6 months after childbirth, women may begin to experience symptoms of depression, that is linked with the hormonal and drastic environmental changes associated with bringing home a new baby. Recent research has questioned however, whether it is not only depression that these women are developing, but possible a form of post traumatic stress disorder following events involved during childbirth. This study looks to support this theory. Symptoms that are characteristic of PTSD are “persistent re-experiencing of the event, avoidance of stimuli associated with the traumatic event, numbing of general responsiveness and symptoms of increased arousal” (American Psychiatric Association, 1994). It has been seen that many women have had these symptoms following childbirth. The sample used was 102 women that anonymously completed and returned a questionnaire regarding the history and events of childbirth, as well as their current feelings and experiences on the topic. The method used to obtain the data was comparing the information given on the perinatal post-traumatic stress disorder questionnaire, to a screening of several evaluation tools: a history of traumatic events, a post traumatic stress disorder check list, a postnatal depression questionnaire, and a questionnaire on the perceptions of labor and delivery. What was found was that there were a significant number of differences in the results of women that experienced symptoms of PTSD and their childbirth experience. These women reported higher levels of distress during labor, with a greater fear of losing control and not being prepared, as well as higher levels of interventions by the obstetrician. Interestingly, there was no specific correlation with women experiencing PTSD symptoms and who had previously experienced a traumatic event. This article is very pertinent to nursing in labor and delivery, because as the nurses, we are supposed to be the rock that the woman can depend on as a source of support during childbirth. This study shows that labor is a very big experience to a woman, and without appropriate support and interventions, it is possible that women could suffer a range of psychological responses. This article also suggests the high rate of undetected PTSD in women, because it is not an expected finding. Reading this article, there are ways provided to detect PTSD in women, so it is not mistaken for postpartum depression, and does not go undetected, so that we can treat and help these women to the full capacity. References American Psychiatric Association (1987 and 1994). Diagnostic and statistical manual for mental disorders (3rd and 4th edns). Washington, DC: American Psychiatric Association. Leeds L, Hargreaves I; The psychological consequences of childbirth, Journal of reproductive and infant psychology (2008) 26(2): 108-22

Nursing School 101: Bed Baths

Previously in nursing history, performing bed baths on patients was a trivial, time-consuming task that not only has been seen to be cost inefficient due to the amount of time taken to prepare and perform the bed bath, but also poses several risks to the skin integrity of the patient in a number of circumstances, due to cross-contamination, drying out of skin from soap, and removal of critical natural substances essential to maintaining skin integrity. There have been many attempts to improve the effectiveness of the bed bath, in the form of inventions such as using soaked wash cloths, and various types of bath mitts, (U.S. Patent) that have decreased time consumption of the bed bath, but still posed challenges when maintaining skin integrity of the client. It wasn’t until 1995, that a team of nurses addressed each individual problem of the bed bath, and came up with a solution that not only decreased the workload for nurses, and improves cost effectiveness, but allows for cleansing and removal of dirt without drying of the skin or sacrificing the skin’s natural defenses.

A recent study in Japan showed that the workload of nursing care centers its highest percentage of time and cost in giving complete and partial bed baths. This survey, conducted using Conjoint Analysis, wanted to measure the value of hospital care and make an effort to estimate where the majority of the workload of nurses was being placed throughout daily tasks. The results were listed as bed baths holding the greatest workload, followed by giving intravenous medications in second, and assessing vital signs in third. In regards to cost, the survey concluded that, with the assumption that the average salary of a registered nurse in Japan was 25 thousand yen, a complete bed bath served a value of approximately 93.38 yen for a single unit (Anezaki, Aso, & Ohkusa, 2006). For a nurse that performs bed baths to several patients daily, it decreases the amount of time the nurse has to commit to more effective measures of care, such as administering medications on time, and adhering to the needs of more critical patients.

More importantly than the time consumed by the nurse in preparing and performing bed baths, is the lack in the overall quality of care a bed bath is really providing to the patients. Ideally, a bed bath would consist of numerous washcloths and water changes to prevent cross-contamination in different areas of the body being washed (Burke, 2002). In reality, there serves no time to complete such tasks, and the same water and washcloth is used to service the entire body. Because the skin is the body’s primary line of defense against the outside world, maintaining proper skin integrity is essential to many patients recovering in the hospital. The use of different kinds of soaps causes dryness to the skin of many individuals, especially the elderly, whose skin is at highest risk for breakdown due to a decrease in moisture and elasticity in the skin. These soaps also remove some of the essential acids and salts of the skin that help prevent growth of harmful bacteria (U.S. Patent). In an effort to decrease costs, washcloths that are used are of poor quality, and are coarse and harsh to the skin, increasing friction while cleaning. In combination with the skin drying action of the soap, the risk of skin breakdown increases dramatically, putting patients at higher risk of developing pressure ulcers and skin infections (U.S. Patent).

In attempts to improve washcloth quality by making softer texture cloths, there was a deficit in the ability to remove dirt and the cloths often would disintegrate after getting wet. Some of the solutions used as a substitute for soap did not prove to be effective in eliminating bacteria, nor did they leave the natural acid mantle of the skin intact (U.S. Patent). The solution of one problem often led to the deficit of another critical factor in developing a product that would not only be cost efficient and less time consuming for the nurse, but that would provide critically important quality of care to the patient’s skin in cleansing with effectiveness to reduce growth and transmission of bacterial organisms, and also provide safety to the integrity of the skin to prevent dryness and breakdown. Even better would be a way to produce bulk quantities of the product for efficient storage while maintaining proper sterile technique. Developing a product with all of these crucial characteristics seems impossible without sacrifice in another area. Originally thought up by Susan M. Skewes, RN, using a set of soft wash cloths soaked in cleanser and placed in sealed plastic bags until use, the “Bag Bath” took on a series of experiments, alterations and improvements to create the ultimate bathing tool (Skewes, 1994). After formulating this product, the question was if it was actually more efficient than the traditional bed bath. A study consisting of 30 patients and 21 nurses took place using the “Bag Bath” products, and a survey sought out questions to determine the level of satisfaction with the bathing technique. Overall, the survey showed that 81% of the nurses “stongly agreed” that the bag bath saved them a significant amount of time in bathing patients. The study showed that the average time to give the bed bath using the product was approximately 12 minutes (Skewes, 1994), compared to traditional bed baths requiring 20 minutes or more (Burke, 2002). Amongst other findings were the patient satisfaction rates. Skewes reports her findings in her article “No more bed baths” where approximately 80% of the patients strongly agreed that they felt cleaner, and their skin felt softer after receiving the ‘bag bath’. More importantly, nearly all the patients that received this bathing technique from admission to discharge had no findings of skin integrity break down or impairment, and those that had breakdown before use of the bag bath actually had improved skin integrity by discharge (Skewes, 1994).

Shortly after her debut with the “Bag Bath,” Skewes teamed up with fellow nurses and engineers John P. Martin, and Russell Raddatz to finding a more impressible form of the bag bath. After many long months of research and testing, the inventors finally developed the ideal product to performing the bed bath efficiently and cost friendly. The product, titled Cleanser-Impregnated Cloths for Cleansing the skin, was formulated with the idea of maintaining sterility until use, being kept in a sealed polyethylene bag for safe storage. The bags consist of a various number of disposable cloths in quantities of 2, 4, 6, 8, and 10 cloths, for a variety of complete, partial, pediatric, and facial cleansing techniques, that allows for disposal of each cloth after being used in a certain area. This technique prevents cross-contamination of the body parts, and risk of infections in greatly reduced. Each cloth consists of cotton and polyester fabrics, woven together with needle puncture to ensure the softness of the fabric, and maintaining the integrity of cloth. Each cloth is damp with a cleansing solution that does not need to be, and should not be rinsed from the skin. The solution will evaporate, leaving behind remnants of vitamin E and therapeutic skin formulas to render the skin feeling fresh and soft. Because the product is able to store indefinitely if unopened, it can be bought wholesale in large quantities to reduce cost. Because the cloths are disposable, and require almost no time for preparation, the workload is significantly reduced, and the nurses and patients are much happier with the use of the product in comparison to the traditional bed bath (U.S. Patent)

 

Anezaki, H., Aso, Y., & Ohkusa, Y. (2006). Evaluation of Nursing Care—Using

conjoint analysis. Journal of Japan ,Academy of Nursing Science 26(4): 102-109.

 

Burke, A. (2002). Personal Care II. Nursing Assistant Education. From

http://www.nursingassistanteducation.com/site/courses/eng/nae-pc2-eng.php

 

Skewes, S. (1994). No more bed baths! RN Magazine 57: pp 34