You are not eating for 2…

pastaOne of the most common phrases I hear amongst patients and in the media is “I’m eating for two,” when referring to pregnancy as an excuse for excessive food portions. This is just not true ladies. As I tell my patients, you are not, in fact, eating for two, but you are eating for yourself and a tiny baby. So that sandwich you are eating as an appetizer to your actual dinner? Completely unnecessary. I hate to break it to you ladies, but you only need about 200-300 extra calories A DAY. Unfortunately, excessive weight gain and/or obesity during pregnancy is a big deal. First, you run the risk of gestational diabetes, which turns your normal low-risk pregnancy into a high risk pregnancy, complete with food journals, blood sugar logs, and occasionally medications, frequent visits to the doctor, ect. We won’t even go into all that “fun stuff” in this post. Additionally, even without diabetes, we worry about the baby also gaining too much weight. cesarean incision with staples, caesarean.org.ukThis can lead to difficult, prolonged labors, complications during the delivery, and God forbid if you do need a c-section, don’t hold it against your doctor if she can’t make a very aesthetically pleasing incision/scar due to the inches of excessive fat tissue. In these situations, wound healing is at risk for dehiscence (opening of the incision), and risk of infection when the belly hangs low over the wound and creates a breeding ground for bacteria. Aside from the serious risks associated with excessive weight gain in pregnancy, your doctors also have to listen to your complaints about feeling tired, bloated, swollen, aches, stretch marks, “feeling like a whale,” and the list goes on and on. Don’t get me wrong, many of these complaints are inevitable parts of pregnancy, but can also be prevented or lessened in severity by simply watching what you eat.

So how do we prevent these unfortunate circumstances? First off, starting at a healthy prepregnancy weight and BMI is crucial to your overall health and well-being, whether you are planning pregnancy or not. Let’s not kid ourselves, we all love fast food, pizza, beer, and everything that might make you look pregnant when you arn’t.I for one have had an intimate love/hate relationship with pizza, pasta, and McDonalds forever. Recently, we have decided to go our separate ways, and now we are just friends. Trust me, I know your pain over eating right, exercising, and maintaining a healthy weight. weightgain pregBut seriously, its important. If you should find yourself trading that “food baby” belly for a real baby bump belly, a healthy lifestyle is not just crucial for you, but for the health of your baby also.

Every woman and pregnancy is different. That being said, some women may have a little more leeway in how much weight is appropriate during pregnancy. For example, a woman that is already starting out with a high BMI or is overweight has a much smaller window for weight gain than another woman who is underweight. Its not that we are picking on the heavy girls, I promise, we all know you just have more to love. weight-distribution-during-preg-picBut you are already starting out at a riskier weight, and therefore the weight that you do gain, should more or less only be attributed directly to the pregnancy (growing baby, placenta, uterus, blood volume, etc.). So first off, determine your BMI (we all know you’ve seen that app in your phone), and based on your BMI, look at the chart to determine the recommended weight gain for the total pregnancy. 7508_ideal_weight_gain_during_pregnancyLet me reiterate, this is how much weight you should be gaining by the END of your pregnancy, and the majority of that said weight should be happening towards the third trimester. If you find you have almost reached your total weight gain amount halfway through your second trimester, its time for an intervention. It’s not that we’re calling you out on your weight problems. OK maybe we are, but its because we care about you! There are times when excessive weight gain might have pathologic causes, and you might need some lab work and a little more investigation to figure out what’s going on. jessica-simpson-pregnancy-weight-gain-300x300But if it’s because your pregnancy cravings sent you to Olive Garden for bottomless pasta bowls, then we have a problem. But please, I ask that no woman takes offense if that touchy weight gain subject comes up at one of your prenatal appointments. I promise, there is no pregnant woman mold, and we know how everyone has their own shape and size. But it is important to not be careless with eating and overeating during pregnancy. Please, stay away from fatty foods, and foods high in sugar and salts. Go for high fiber foods, veggies, whole grains, proteins, etc. We want a controlled, healthy weight gain that can keep your baby safe, and hopefully help make the pregnancy as enjoyable as possible.

New Midwife on Duty

 

IMAG1906-1I know it has been a while since my last post, and since I have now been over a month working at my new job as a Nurse Midwife, I figure it is well past time to update my devoted blog readers on my life these past couple months.

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To start with, I think I have gathered a new philosophy for life. Avoid doing hair and make up before work for at least the first couple weeks when starting a new job. People will get used to you looking good and put together. Then when you happen to take a shower at work and don’t redo your hair and make up, people ask if you are feeling alright. And since lately I feel my day is generally filled with scrubbing in to assist on C-sections every day, I really question why I bother doing my hair at all before work, since I usually spend the entire day wearing my scrub cap.

A surprising aspect of my new job that I have found being in my new job is that my tolerance to submit to possibly unnecessary c-sections has become a lot lower. While still I’m a midwife very fond of promoting normal birth, I have started to find that so many of the women I care for are so high-risk for complications, that opting to side with doing a cesarean almost feels like the safer thing to do for this population. loadBinary.aspxSo many of my patients already that have seemed to be perfect candidates for normal birth seem to end up with difficult deliveries, dystocias, hemorrhages, strangely shaped placentas that won’t come out, and seriously their vaginas seem to basically explode pushing the baby, resulting so many large, painful lacerations requiring long and difficult repairs. While I have heard many times that this is a tough job to start with as a new midwife, I have found it  keeps me up with my critical thinking and practical skills that may not be used very much in a very “normal birth” kind of setting. While I don’t particularly enjoy those teeth grinding, sweating bullets situations, it definitely keeps me more aware and up on my little midwife toes.

While I was a little traumatized by many of the birthing practices I saw in Argentina, I do frequently find myself thinking “what would the Argentineans do?” when I am in a grind. For example, one practice we learn here in the States that I really loathe doing is clamping and cutting a tight umbilical cord around the neck. new-picture-4I have had a couple experiences in training and at work where after cutting the cord around the neck after the head is born, it is only to find the shoulders to be tight and difficult to deliver. Cutting the cord before the baby is born leaves the baby without a life line that is crucial during a tight shoulder scenario. These babies usually need more help than usual getting started breathing and reacting after birth, and it is terrifying. What I found in Argentina is that they rarely even check for a cord around the neck after the baby is born, and even when there is one, there is no worry, because there is never any unlooping or cutting the cord before the body is born. 1-s2.0-S1526952307000062-gr1Rather, they deliver every baby by what is referred to as the “somersault maneuver.”  This technique is accomplished by simply tilting the baby’s face downward to the mother’s thigh after the head is out, then the rest of the body is then delivered in something like a flip, or somersault fashion, keeping the neck (and cord) close to the vagina to prevent pulling. When I first had this explained to me, and even after seeing it and being taught to do it hands on, I never ever thought I would have the coordination to pull this stunt off. Not when I’m in the middle of a delivery and nervous enough as it is! Strangely enough, the first few vaginal births I had after coming back from Argentina, I found my hands automatically flipping the baby out every time without trying; it just seemed like the natural thing to do, especially with a cord around the neck.

images-5Another interesting fact is that I rarely have patients that speak English. And translators are not always readily available. While I am able to speak easily to my Spanish speaking patients, trying to communicate in Creole is a challenge I am not yet ready to face. I spent a day or so seriously studying the language, trying to memorize words and phrases, feeling ready to start learning Creole as my third language. “No gen pwoblem” right? Yeah, the next day I forgot everything, but felt a little more in touch with the broken French and clicking that I feel I will never able to reproduce.

Nonetheless, I am getting by. After a full 60-hour work week, I feel I can do [almost] anything. I can say I continue learning new thing every single day, and while I do miss my job as a nurse at times, I am glad to be in the profession I have come so far to do. I say my prayers daily, before and after work, and often during the day, because I know that “You Lord give perfect peace to those who keep their purpose firm and put their trust in You.” It was a verse that I kept with me all through midwifery school, and I will continue to live by it now as a professional.

If you have ever watched the show “Call the Midwife,” you will notice in the very beginning of the show, where the opening credits start, there is a visual of someone’s diary, and it says “Chapter 1: Why did I start this?” I highly recommend watching that show, its British but its phenomenal. And if you do watch Call the Midwife, this is an EXCELLENT parody to the show and a couple other, and it is absolutely hysterical. I know my fellow midwives will enjoy this one…

 

 

 

 

 

 

 

La Parterita en Mendoza Parte 2

Finishing my final weeks in Mendoza has undoubtedly been the experience of a lifetime, both personally and professionally.

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Not only did I get the opportunity to meet and work with an incredible group of people throughout the placement, but I also had the opportunity to travel to Buenos Aires, meet some “familia,” and learn a little bit more what it means to be Argentinean.

As I mentioned in Parte 1 of my trip, things are very different in Mendoza, everything from the slow, easy pace of life to the routine practice of episiotomies on primagravidas. And what an odd balance of conservative and liberal interventions there are!  One day, while sitting around with other parteras drinking maté, we came to the discussion of prenatal care and genetic screening.   Interestingly enough, they don’t typically do any of our routine blood work for genetic screening, but on the other hand, will do 3 ultrasounds instead, at least one ultrasound each semester, starting around 12 weeks. It is in this way that they screen for physical abnormalities, fetal anatomy, and an estimated fetal weight at the end of the last trimester.

As a very ambitious homework assignment from my Spanish teacher, I took my official State Midwifery practice protocol and translated it into Spanish. Took a lot of time and effort on my part, but I definitely feel it helped to enable the other midwives to have a better understanding of the role and practices of the Nurse-Midwife (“la Enfermera-Partera”) in the United States.

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Most things were more or less the same, and some very different. Parteras in Mendoza pretty much only work in the practice of birth. It was explained to me that very rarely are their midwives involved in prenatal or postpartum care, and almost never involved in non-obstetric gynecologic care.They are also unable to prescribe medications outside of Oxytocin or cervical relaxants during labor, not even antibiotics. They also do not First Assist or participate at all in cesarean deliveries. On the other hand, their midwives will often deliver twins and breech births, although, they did mention that breech births often are by cesarean delivery unless the woman has been laboring well prior to arrival at the hospital.

versusIt still strikes me in amazement at the conservative approach they use with fetal monitoring however. Even for the “high risk” patients and patients on oxytocin, they only use the doppler to listen for fetal heart rate “every 30 minutes,” or whenever they finish another round of maté. Although I can’t blame them, sitting around in waiting is a practice that comes with the labor and delivery territory, feast or famine. But in the US, I feel like we always are at least trying to “seem” busy, whether it is watching the fetal monitors, comforting patients, doing CEU’s. In my hospital in Mendoza, there is no sense of really going above and beyond, and no one seems to mind either way. As if their practice of FHR monitoring didn’t shock me enough, the method they use for timing contractions is even stranger to me. Although they document contraction rate every 30 minutes with the fetal heart rate, it was explained to me that they count how many contractions there are in 10 minutes, measured by manual palpation. However, I have to say I don’t honestly think I ever saw anyone stand there for 10 minutes straight feeling for contractions. It was more, asking the mother how many she thinks she had in the last 10 minutes and going by that, although there are not actually any clocks in the room. Or taking a guess based on how often you can hear them call out from down the hall. It is also interesting the way they document everything. While each patient does have an official “chart,” (a pile of papers paper clipped together, in no particular organization), they will write their initial assessment (in more or less a similar format to our SOAP notes), and then all additional progress notes are written where ever seems like a good place, on no particular page in the chart. On my first day, I was really confused when trying to read the charts. Whereas in the United States we typically document cervical exams with brackets (for example: dilation/effacement/station), in Mendoza, they don’t seem to have much specific attention to effacement and station, but they use the same format not to document cervical exams, but on contraction monitoring. For example, # contractions in 10 minutes/length of contraction/intensity. Imagine trying to figure that out. It was very striking to me also, that keeping track of FHR decelerations and timing with contractions is much harder, because there is no tracings to review later. In this sense, one would imagine, especially since almost all the patients receive Oxytocin, that there would be a greater attention to a specific assessment of FHR in relation to timing and frequency of contractions. But no, not really of a whole lot of concern there. Interestingly enough, there were very few times I saw (or rather heard) fetal bradycardia. In those instances, there were no heroic interventions like putting on maternal oxygen, internal fetal monitoring, or even stopping the Oxytocin. Occasionally I saw they might tighten the clamp on the IV to slow the Oxytocin a bit, but the extent of interventions they generally take is just changing maternal position. Once the heart rate comes up after, the doctors seem pretty satisfied and don’t push the issue any further. And the most amazing part of it all, is that nearly all of these babies come out screaming, hardly ever needing resuscitative efforts, not even bulb suctioning. Go figure. Bulb1While on the topic of resuscitation, you will recall in the first blog that I mentioned there are no baby warmers or resuscitative devices kept in the room. If the baby is having a slower time getting started crying, they simply poke their head out the door, shout “Neo!” down the hall, and just keep drying and stimulating till the Neo team arrives. It might be 10-15 seconds before anyone shows up, and usually the baby is already crying by then. But if the baby did need further resuscitation, the Neo team would grab the baby and run about 30-50 feet down the hall to the nursery. Incredible.

Another interesting concept is that there is no such thing as an “obstetric nurse” in Mendoza. All nurses have more or less only basic training, can give IV medication and start IV’s but none are allowed to do vaginal exams or push with patients, only midwives and doctors.

Also very interesting and rare sight to see in the US: a patient was pushing in the dilation room, and the baby was not descending as expected, despite her pushing efforts. I have seen very often in the US sitting the patient up in order to implement the natural force of gravity, and letting the patient “labor down.” Occasionally they would do this in Mendoza, but for this patient, when the FHR started slowing, instead of having the patient just sit up and rest rather than push, the midwives instead had her stand and squat to push. They then said they will know how she is progressing based on the amount of bloody show dripping on the floor. What?!

IMAG1792As a midwife, we are taught to embrace women in their experience of childbirth. However, labor coaching is not a common practice for the midwives of Mendoza. Rather than sitting with a patient and massaging or coaching her (as I felt a need to do), the other midwives/docs sit around in their on-call room drinking maté and chatting until someone started pushing or until it was time to check FHR again. To me, I felt torn between the desire to help and be with these women during their pain, while other part of me also felt a need to establish myself in discussions with the other providers and participate with them, whether be it checking cervixes or discussing the weather. It was a struggle to keep a balance between both obligations, because its so uncommon to be actively engaged in the patient’s labor outside of routine monitoring and pushing etc. Despite my best efforts to teach and show them labor coaching techniques, my teaching often seemed in vain. After only a few minutes, the midwives would stop and encourage me to go with them to talk instead.

IMAG1786-1In professional sense, the experience in Mendoza has left me with a combination of feelings: intrigued,  terrified, enlightened, humbled, and thankful. When leaving for this trip, I had different plans about my participation as a Midwife in Mendoza, seeing it as being a sort of residency, an extention of my education of sorts. Boy was I in for a surprise. After all I saw from the first day onward, I certainly held myself with caution about what practices and routines I allowed myself to participate with. Taking everything with a grain of salt. Allowing myself to see and understand their practices, but not immerse myself enough to make habits or adopt them. Having a short and flexible schedule every day was helpful, knowing when things were becoming too overwhelming, and when I needed to take a step back.

I am beyond grateful for the experience, and recommend to anyone considering. Step out of the comfort zone, learn the unthinkable, appreciate what you do and what you have. From my time in Mendoza, I am taking back with me both the good and the bad, and ready to step into my new career with a new outlook for my profession. IMAG1794

La Parterita en Mendoza- Parte 1

 

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For those they haven’t been in the loop, I have spent the last week and a half living and working in beautiful Mendoza, Argentina. I have been working with midwives here in a very busy public hospital, in a high risk obstetric unit.  While I always knew from the beginning that things were going to be really different here, I had no idea the extent of how much I would be surprised by. Also, the language barrier caught me quite off guard on my first day. I have had pretty good knowledge of the Spanish language before coming here, being able to translate and speak with patients at work etc. I knew how to ask questions, take a 

medical history, instruct someone through child birth, and give discharge education. ImageBut it never occured to me that it wouldn’t be the patients I would have difficulty talking to, but rather the staff. Being able to have normal everyday discussions became the biggest obstacle. Also, I never realized until being here how much of my knowledge of Spanish was quite dependent on “Spanglish,” and being able to throw in a word or two in English if I didn’t know how to say them. Here at the hospital NO ONE knows ANY English. Nada. So it was definitely a bit of a struggle my first couple days to be able to keep my mind in constant focus every minute to what’s being said, and training myself to stop translating in my head, but rather to simply think in Spanish. Fortunately, we have a really great Spanish teacher at the house who comes a couple hours twice a week to do lessons. I am happy to say I can finally speak outside of the present tense at last! This has definitely opened the field for conversation in the hospital, and I am becoming quite confident in my ability to talk with other people in the hospital about the differences between their practices and ours in the States, the things that quite literally blew my mind. ImageFor starters, when women come in labor, they are taken into a “dilation room,” which has about 6 or 7 “beds,” which are more like a table with a paperthin mattress, and they are required to basically lay there and suffer until they are complete. No epidurals, no pain medicine, no visitors with them, just sitting or laying on the beds sobbing and moaning for hours. There is absolutely no privacy, they do vaginal exams in front of everyone else, and the door of the room wide open, but no one seems to mind it nonetheless. What really surprised me however, is  when they do get to completely dilated, the woman holds her bag of IV fluid and Pitocin, and walk down the hall to the delivery room, dripping amniotic fluid and bloody show on the floor like nothing.Then they go into the delivery room which is basically a metal table with stirrups (if they are lucky) otherwise there is just 2 metal poles they have to prop their feet against. No pillows, no adjustable bed, nada. Not even a baby warmer, no oxygen or resuscitation supplies, nothing. 

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And because I understand we in America are probably a bit overly aggressive about 

continuous fetal monitoring, I was not surprised that they only listen for heart tones every 30 minutes. Even the patients on Pitocin. 

But I was quite surprised that, even after the long walk down the hall with the baby basically crowing, they really don’t monitor the baby while she’s pushing, except when they were using forceps to deliver. And might I add no pain medication is given. The patients are draped with this “sterile” white cloth and instructed to push right away, the doors of the room wide open and everything.Image What really astonished me, one of the midwives told me that for primagravidas, it is routine to just go ahead and cut a mediolateral episiotomy before they start pushing. They do give some lidocaine first, but I couldn’t help but feel the pain of it for the patient.

ImageAs if that wasn’t enough torture for this sheltered little midwife, they have a tech or one of the other nurses or doctors stand or straddle the head of the bed, and apply fundal pressure. Knowing that just the mention of fundal pressure could cost you your license, I felt mortified at the site. After all is said and done, the patient and her baby are put on a stretcher to cuddle and bond in the hallway for a few hours until they are taken to the postpartum unit. ImageAfter a first impression like that, it was hard to get the courage to go back. But the following day, it was a little better in the hospital, as there was a class of medical students there, and they invited me to join in their class for the day. I still mostly was just observing things, helping to get some heart tones and check a cervix here and there, but I felt more confident in communicating with the others, and the professor there was very helpful and very easy to understand. But after a few hours of paying super close attention to every word around you, it gets quite mentally exhausting. After a beautiful walk home in the Mendoza sunshine, it was time for Spanish class and “social activities” with the roommates.  

The end of the first week definitely wrapped up on a good note. There are different midwives every day, and where as the midwives there on the other days were not unfriendly, they were not able to slow down and interact with me as much as the midwives there on Friday, which was a guy midwife and a woman midwife. After having seen the work flow from the previous days, I had a little bit better idea of how everything works, who is who, etc., and so there was less need for them to explain all that, and we were able to have really good conversations (in Spanish), drink Mate, and they were very facilitating to me, letting me check dilation and they even let me assist to deliver 3 babies today, which was really great.  

This past week was a bit funky in terms of the work week, because Monday and Tuesday there were problems with the buses working, and the bus never showed up. So I spent the day being productive with my Spanish studies. Wednesday I went in, but it seemed like it was “C-section day.” When I arrived, there were about 7 patients all gowned and prepped for surgery. ImagePossibly a day for the residents to practice their surgical skills I suppose. There were a couple midwife students from Mendoza there with me that day, so it was nice to be able to bond and work with them, as I still basically see myself in the student role. However, the same way I needed to do so many deliveries in order to graduate, they also do, and we did have one vaginal birth we did do. The patient came in contracting every 1-2 minutes, and before they even checked her in the dilation room, I could already see the head presenting. Thinking were just going to have a baby in the bed, I went ahead and grabbed my gloves, and to my surprise, they actually had her get up and walk down to the delivery room. By the time the patient was on the table the head was crowning, and the student still had not got her gloves on. I went ahead and kept my hands supporting the perineum, and basically told her to get her gloves on or I’m going to deliver this baby myself. Like any ambitious midwife student, she made the sacrifice of trying to get the other glove on, and delivered the rest of the baby with only one glove. Priceless. ImageAnd, ironically, as much as I am not a fan of doing routine episiotomy for first pregnancy births, this was the first one that they didn’t cut (obviously there was no time), and go figure, she gets a third degree tear. 

While a lot of the practices here have reason behind it, some of their habits will never fail to surprise me. Particularly, the common use of open toed sandals, flip flops, and even heels. One day, after a resident put a foley catheter in for a c-section patient, there weren’t any foley bags, so she just tied a glove around the end of the catheter and taped it instead. I also don’t ever think I will understand the “sterile technique” here either. A doctor might put on sterile gloves to do a cervical exam, and then dip her sterile gloved fingers into the jar of KY jelly they use for the fetal heart monitor. What?!

Nonetheless, I am having a really great experience out here. I am so much better able to appreciate not only the quality of the healthcare back home, but also the philosophy behind it, driven by empathy, compassion, and lawsuits. It is so strange to see these high risk women, no prenatal care, minimal fetal monitoring, and strangely aggressive birth interventions have babies that always come out screaming, with no need for oxygen, suction, or calculating Apgar scores. Yet back home, we practice with such strict protocol, doing everything by the book, and still seem to have more problems with babies needing some resuscitative efforts. It is both very humbling and enlightening to acknowledge such a concept. I feel like in comparing the conservative/aggressive nature of birth interventions here versus the US, I don’t really find  that one medical culture necessarily has does or doesn’t do more than the other, but they almost sort of compliment each other like a Yin and Yang, by being more aggressive in some practices, and more conservative with others. And its not that they do these interventions just because thats what they were told, but they just take a position on the other side of the controversy than we do for that specific intervention. Between learning the language and learning their practices and philosophies, it has definitely been a very mind stimulating process thus far. And as such, makes a perfect welcome for a doing some wine tasting after work. Image

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.

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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