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Depression in Pregnancy

Depression, suffering and anger are all part of being human. – Janet Fitch

Depression is the inability to construct a future. – Rollo May

SYNOPSIS

Depression is a mood disorder, a biological illness, which affects 14-23% of women during pregnancy. Depression makes a woman feel sad, bleak, helpless, anxious, irritable, fatigued and lacking in energy.

Depression can be treated. Left untreated, it can lead the woman to poor nutrition, drinking and smoking causing the babies to be born premature, less active, and have developmental problems. Antenatal depression is a strong precursor to Postpartum Depression.

Depression treatment is psychotherapy, medication, and self-care. Cognitive behavioural therapy (CBT) is the often used psychotherapy. A woman can do it herself after suitable instructions. Medication is antidepressants. These pose a very small risk to fetus. A few supplements are also claimed to help. But these should not be taken without doctor’s advice. Self-care involves proper diet, adequate sleep, exercise, and pregnancy-yoga.

Several women have depression during pregnancy. So, you are not alone. Do not therefore hesitate to speak to your doctor at the first appearance of the symptoms of depression.

INTRODUCTION

Pregnancy is a joyous period for women. But for a few the joy is clouded by mood swings. We all have transitory mood swings. But if these last a few weeks or a few months, then these signal depression.

DEPRESSION

Depressions are biological illnesses caused by changes in brain chemistry. Such changes may be triggered by the hormonal changes during pregnancy. This is called antenatal depression. But except in name, it is similar to clinical depression.

SYMPTONS

Symptoms of depression vary from person to person. But if you have one or more (usually five) of the following symptoms for most of the day, nearly every day, for two weeks or more, it signals depression:
• feelings of sadness, bleakness, hopelessness, and anxiety;
• lack of interest or pleasure in doing anything;
• feeling tired or having little energy;
• difficulty concentrating;
• difficulty remembering.
• feeling emotionally numb.
• extreme irritability.
• sense of dread about everything, including the pregnancy.
• feelings of failure, or guilt.
• trouble getting to sleep, waking up in the night or sleeping too much;
• overeating or decreased appetite.
• weight loss/gain unrelated to pregnancy
• low self-esteem, or feelings of guilt or failure
• fidgeting a lot, or moving and speaking very slowly
• loss of interest in sex.
• thoughts of suicide or self-harm may occur.
• inability to get excited about the pregnancy, and/or baby
• feeling of disconnection with the baby, and an inability to form/feel a bond with the developing baby.

RISK

Anyone can have depression. But the following factors, or a combination of these, increases the risk of getting depression:

• Family history of depression. Risk of suicide also goes up.
• Personal history of depression or anxiety in the past – like during an earlier pregnancy or after the birth of a previous child. Also the risk of postpartum psychosis, a rare but very serious condition that involves hallucinations, increases.
• Life stress events, such as financial problems, the end of a relationship, the death of a close friend or family member, or a job loss.
• Lack of support like having relationship problems or an unsupportive partner or having your baby on your own, or if you feel isolated from friends or family
• Unplanned pregnancy finding out you’re pregnant when you didn’t plan to be.
• Domestic violence and emotional abuse that tend to get worse when you’re pregnant.
• Infertility treatments
• Complications in pregnancy

TREATMENT

Antenatal depression is treatable with psychotherapy, medication and self-care.

Psychotherapy

• Cognitive behavioural therapy (CBT) is the often used psychotherapy. It helps the mother recognise her emotions and counter her negative thoughts. She is encouraged to do CBT herself after step by step instructions in CBT through books and talks; or she may be advised do it in sessions with a therapist.

Medication

• She may also need antidepressants. Not enough evidence is available that these are completely safe to take in pregnancy. A few of these pose a very small risk of birth defects that include fetal heart and skull abnormalities. Doctor weighs the risks and benefits to the mother and to the baby to decide on antidepressants. If the mother was on mental health medication before pregnancy, she should not stop these without asking the doctor. Also, she should not start any medication, including herbal medication, without asking the doctor.
• Supplements. Several supplements such as St. John’s wort, SAMe, Saffron extract, 5-HTP and DHEA are being marketed as being helpful in depression. These seem to help some people but sufficient evidence is not available for their efficacy. A few of these can interfere with prescription medications or cause dangerous interactions and may be unsafe. Consult your doctor before taking any supplements or herbal medication.

Acupuncture

Acupuncture is claimed to help relieve depression. But the evidence for its effectiveness is ambiguous or outright contradictory. The World Health Organization has recognized acupuncture as effective in treating mild to moderate depression. – Dr Andrew Weil in ‘Depression, Health, World, Organization.’

Self-care

Diet, sleep, and physical activity are just as important as medication and therapy — sometimes more so.

Diet and nutrition.

Diet is so important to mental health that a new field of medicine called nutritional psychiatry has grown around it. Many foods have been linked to mood changes, the ability to handle stress and mental clarity.

• Foods to avoid are:

o Alcohol: it depletes serotonin, which makes people prone to anxiety, depression and panic attack.
o Caffeine: It lowers serotonin and increases the risk for anxiety, depression, and poor sleep. Reduce intake of coffee, tea, and hot cocoa.

• Foods to take are those rich in:

o B12 and folate. These prevent mood disorders and dementias. Sources: beetroot, lentils, almonds, spinach, liver (folate); liver, chicken, fish (B12)
o Vitamin D. Its deficiency is associated with different mood disorders. Sources: sun exposure; breakfast cereals, breads, juices, milk; high-quality supplements.
o Selenium. It decreases depression. Sources: cod, Brazil nuts, walnuts, poultry.
o Omega-3 fatty acids. These improve cognitive and behavioral function. Low levels of omega-3 fats leads to mood swings and depression. Sources: cod, haddock, salmon, halibut, nut oils, seeds, walnuts, and algae; high-quality supplements
o Endorphins. These enhance mood and promote a sense of well-being. Source: dark chocolate

Sleep

Lack of sleep (insomnia), or disturbed/obstructive sleep (apnea) are linked to depression. People with insomnia are 10 times more likely to have clinical depression and 17 times more likely to have clinical anxiety, and people with apnea are five times more likely to have clinical depression, than people who sleep normally. To help get sleep, lower room temperature, follow a schedule, avoid naps during the day, listen to relaxing music, try a low carb/high fat diet and eat 3-4 hours before sleep time, exercise, and practice yoga and meditation.

Exercise

Exercise releases endorphins, natural cannabis-like brain chemicals, and other natural brain chemicals, that enhance your sense of well-being. Depression causes tiredness and lack of energy. It may therefore be difficult to begin exercising. So begin with a walk for five or ten minutes and gradually increase to 30-45 minutes a day for three to five days a week. Results will appear after a few weeks because exercise is a long term treatment. Therefore pick up an exercise – walking, cycling, swimming – that you enjoy.so you will continue to do it

YOGA

Yoga focuses on the balance between your mind, body and breath. This balance is created through:

• physical exercises and postures (asanas)
• breathing exercises (pranayama)
• relaxation
• meditation

Yoga improves your physical, mental and emotional wellbeing. It helps you to:

• Improve your circulation, muscle tone and flexibility; to keep the body supple and relieve tension around the cervix by opening up the pelvic region. This prepares to-be-mothers for labor and delivery.
• Alleviate the effect of common symptoms such as morning sickness, painful leg cramps, swollen ankles, lower-back pain and constipation.
• Stay mentally agile through relaxation, breathing and meditation.
• Train you to breathe deeply and relax consciously, helping you to face the demands of labor and childbirth.
• Feel calm, and ease muscle tension.
• Recover faster post-delivery.

If you are already doing Yoga, you may continue to do pregnancy yoga during pregnancy. Since most miscarriages happen during the first trimester, you may, as a precaution, decide not to do Yoga during that period. Although there is no evidence that doing yoga, or any other exercise, during the first trimester will harm your pregnancy.

If you have never before done Yoga, then do not begin it in the first trimester. Begin in the second trimester, after 14 weeks of pregnancy. Join a pregnancy Yoga class. Your instructor will start you gently and slowly and modify the posture to suit the stage of your pregnancy.

Avoid these:

• Lying on your back after 16 weeks.
• Breathing exercises that involve holding your breath or taking short, forceful breaths.
• Strong stretches or difficult positions that put you under strain.
• Lying on your tummy (prone).
• Upside-down postures (inversions).
• Back bends.
• Strong twists.

A study published in Obstetrics & Gynecology in December 2015 found no evidence of fetal distress in any of the 26 postures attempted. These included downward facing dog and savasana. But avoid any poses that feel uncomfortable.

The Art of Living recommends only nine asanas (postures) for pregnancy Yoga. These include Shavasana (Corpse Pose) and Yoga Nidra (Yogic sleep).

You may restart postpartum yoga six weeks after a vaginal delivery; and a longer period after a Caesarean section as advised by your doctor. The postpartum asanas help combat back and neck aches and also help breastfeeding mothers.

ADDITIONAL

To help yourself handle depression:

• Talk about your concerns with your partner, family and friends. They may offer you a proper perspective or practical help. And simply talking about your problems makes these seem more manageable.
• Take time to relax. Give yourself some “me time.” Read, take a calming bath, lunch out with friends, watch an entertaining movie or play. In short do anything that takes your mind away from your concerns and gives you physical and mental relaxation.

DOWNSIDE

Untreated depression can lead to poor nutrition, drinking and smoking. These can cause premature birth, low birth weight, and developmental problems. Babies of ‘depressed’ mothers may be less active, have lower attention span, be more agitated, have behavioral problems and delayed cognitive and language development as compared to babies born to normal mothers.

Antenatal depression is a strong precursor to Postpartum Depression: a major depression in the weeks and months after childbirth. It affects mother’s health and quality of life and also the well-being of the baby. It can cause bonding issues with the baby and can contribute to sleeping and feeding problems for the baby.

CONCLUSION

If you have symptoms of depression, remember, you are not alone. Between 14-23% of women struggle with some symptoms of depression during pregnancy. Antenatal depression can be treated and managed. Most women recover with a few weeks, or a few months, of treatment.

So do not feel shy. Speak to your doctor at the first appearance of the symptoms of depression.

REFERENCES

1. Depression During pregnancy
https://www.babycenter.com/0_depression-during-pregnancy_9179.bc#articlesection1
2. Depression In pregnancy

Depression in Pregnancy


3. Facing Depression During Pregnancy
https://www.webmd.com/baby/features/facing-depression-during-pregnancy#1
4. Depression during pregnancy: You’re not alone
https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by- Antenatal depression
5. Antenatal depression
https://en.wikipedia.org/wiki/Antenatal_depression
6. Prenatal Yoga for women to do during pregnancy | The Art of Living …https://www.artofliving.org/in-en/yoga/yoga-for-women/yoga-and-pregnancy
7. Introduction to Pregnancy Yoga – Verywell Fit
https://www.verywellfit.com › Fitness › Yoga › Yoga and Your Health
8. Pregnancy yoga for beginners – BabyCentre UK
https://www.babycentre.co.uk/a1033238/pregnancy-yoga-for-beginners
9. The Complex Relationship Between Sleep, Depression & Anxiety …
https://sleepfoundation.org/excessivesleepiness/…/the-complex-relationship-between-sl…
10. Depression & Sleep – National Sleep Foundation
https://sleepfoundation.org/sleep-disorders-problems/depression-and-sleep
11. Can Acupuncture Treat Depression? – Scientific American
https://www.scientificamerican.com/article/can-acupuncture-treat-depression/
12. Natural remedies for depression: Are they effective? – Mayo Clinic
https://www.mayoclinic.org/…/depression/…/natural-remedies-for-depression/faq-200.
13. Depression and anxiety: Exercise eases symptoms – Mayo Clinic
https://www.mayoclinic.org/diseases…/depression/in…/depression…exercise/art-20046.
14. Exercise is an all-natural treatment to fight depression – Harvard Health
https://www.health.harvard.edu/…/exercise-is-an-all-natural-treatment-to-fight-depress..
15. 20 Simple Ways to Fall Asleep as Fast as Possible – Healthline
https://www.healthline.com/nutrition/ways-to-fall-asleep

Painless Childbirth

The pain of childbirth is not remembered. It’s the child that’s remembered.

Words cannot express the joy of new life.

SYNOPSIS

Labor pain can be excruciating. Many women have low pain thresholds and are unable to bear such pain. For them, painless delivery may be a need. In this procedure, once the active labor begins, an injection of epidural is given. Epidural makes the delivery almost painless. But epidural has certain side effects. Also, it often results in forceps or vacuum delivery. And both these pose risks of injury to the mother and the baby. But natural birth is also not without risks. For example, unrelieved labor-pain is associated with postpartum depression, post-traumatic stress disorder, and chronic pain. Your gynecologist in Delhi looks at many factors, including the health and emotional well-being of the mother, and then recommends the optimum childbirth procedure for you. Follow her advice.

Labor Pains

Childbirth is a joyous but painful experience for women. Labor pain is the mother of all pains, it is said. But labor pain is different for each woman; and different for each pregnancy of the same woman. And no one can predict what your labor will be like. It can range from mild to extreme. For some women, labor may be almost painless, or mild, or just irritating, or a dull or mild hurt. For others, pain may be excruciating, all-encompassing, cramps going from the top of the stomach down to pubic area, radiating to lower back and rectum, each contraction like a punch in the stomach that knocks all the air out; pain may be burning, and in stabs; pain may be in legs and hips.

Keeping fit during pregnancy and learning relaxation techniques – rhythmic breathing, visualization, meditation, and self-hypnosis – can help handle the pain. HypnoBirthing – practice, and use of a combination of music, visualization, positive thinking and words to relax the body and control sensations during labor – may help keep you keep calm and keep the muscles loose. Changing positions may help reduce the pain. Massage and walking may also help.

Total natural Birth

Many women believe that pain cements the bond between them and the baby. They also fear the side effects of medicated births and epidurals and decline even the painkiller injections that are usually given during labor. That is, they opt for ‘total natural birth (tnb).’ It, ‘tnb,’ is the worldwide trend these days.

But unrelieved childbirth pain is associated with postpartum depression, post-traumatic stress disorder, and chronic pain. Women should be aware of this when opting for tnb. And if during tnb, or natural birth, the pain becomes unbearable, they should not hesitate to opt for pain relief medication. They should ‘differentiate between pain and suffering. Pain can be managed, but if it becomes overwhelming, medication may prevent suffering.’

The stages in childbirth are:

  • Early labor (up to eight hours or longer): cervix dilates, or opens to 3 to 4 centimeters, and begins to efface (thin). Mild-to-moderate contractions, 30 to 60 seconds long, occur every five to 20 minutes and progressively become stronger and more frequent.
  • Active labor (approximately two to eight hours): Contractions continue to become longer, stronger and closer together; the cervix dilates to 7 centimeters. This is when most women request pain medication, though sometimes it’s given earlier.
  • Transition (up to an hour): Cervix dilates to about 10 centimeters, pain is strongest, contractions are intense and closely spaced, you may feel pain in your back, groin, even your sides or thighs, as well as nausea.
  • Pushing (a few minutes to three hours). Intense pain is eclipsed by major pressure as you feel a great urge to bear down and push your baby out—some women describe it as “like pooping a watermelon or bowling ball.” Although pain continues, many women say it’s a relief to push because it helps relieve the pressure. When the baby’s head crowns, or becomes visible, you may experience a burning, stinging sensation around the vaginal opening as it stretches.
  • Placenta delivery (up to 30 minutes): This stage tends to be relatively easy, as mild, crampy contractions ease the placenta out. At this point, you’re focused on your new-born anyway.’

Painless Delivery

Several women have low pain-threshold. And in a few women, anticipated pain and discomfort may cause anxiety. These women may opt for ‘painless delivery.’ A few others may opt for it because it is the flavor of the month.

In painless delivery, the woman has to bear the ‘early labor’ pain which can be mild to acute depending on the individual. These ‘early labor’ pains can be managed with warm showers, massages, and exercises.

When labor reaches the ‘Active labor’ stage, an injection of epidural is given in the spinal cord by the anesthetist. He tops up the epidural from time to time as the labor progresses. Epidural takes 10 minutes to place and another 10 to 15 minutes to begin to work. Epidural greatly reduces the pain during the ‘Transition’ and ‘Pushing’ stages and makes ‘Placenta delivery’ nearly painless.

Disadvantages of Epidural

The disadvantages of epidural are that labor is prolonged, the woman is unable to self-help, and the chances of delivery through forceps or vacuum increase. In one study, these chances increased from 16.4% in non-epidural to 37.9% in epidural delivery. Forceps or vacuum delivery has certain risks of injury. These are explained to the patient at length before she opts for natural or painless delivery.

Common side effects of epidural are:

  • Itching
  • Nausea and vomiting
  • Fever
  • Soreness
  • Low blood pressure
  • Difficulty urinating

A few rare side effects of epidural are:

  • Breathing problems
  • Severe headache (1%)
  • Infection
  • Seizure
  • Nerve damage (extremely rare, 1 in 4,000 to 1 in 200,000)

But gynecologist in South Delhi says that ‘there’s lots of misinformation [about epidural etc] — the risks and complications are overblown, and women suffer unnecessarily.’ And that epidurals and other pain-relief drugs are quite safe.

Forceps Delivery Risks

The risks to the baby from forceps delivery, though rare, are:

  • Minor facial injuries due to the pressure of the forceps
  • Temporary weakness in the facial muscles (facial palsy)
  • Minor external eye trauma
  • Skull fracture
  • Bleeding within the skull
  • Seizures

Forceps delivery risks to mother are:

  • Pain in the perineum — the tissue between your vagina and your anus — after delivery
  • Lower genital tract tears
  • Difficulty urinating or emptying your bladder
  • Short-term or long-term urinary or fecal incontinence (involuntary urination or defecation) if a severe tear occurs
  • Injuries to the bladder or urethra — the tube that connects the bladder to the outside of the body
  • Uterine rupture — when the uterine wall is torn, which could allow the baby or placenta to be pushed into the mother’s abdominal cavity
  • The weakening of the muscles and ligaments supporting your pelvic organs, causing pelvic organs to drop lower in the pelvis (pelvic organ prolapse)

Most of these risks are also associated with vaginal deliveries, but these are more likely with forceps delivery.

Vacuum Extraction Risks

The risks of vacuum extraction to the mother are:

  • Tears and damage to the tissue in the lower genital tract
  • Pain after labor and delivery
  • Blood loss and subsequent anemia
  • Muscle and ligament weakness around the pelvic organs
  • Urinary or fecal incontinence, which may be temporary or permanent

Risks to the baby are:

  • Bleeding and wounds on the scalp.
  • Stretching of the nerves along the neck, which can cause Erb’s palsy or a brachial plexus injury.
  • Bleeding under the skin or in the brain.
  • Bleeding in the eyes.
  • A skull fracture.
  • Neonatal jaundice.
  • Brain damage, which may lead to permanent disability.

Natural Birth Risks

Natural births have risks too. Especially if the mother has a medical problem, or if an issue prevents the baby from naturally moving through the birth canal. Other concerns are:

  • tears in the perineum (area behind the vaginal wall)
  • increased pain
  • hemorrhoids
  • bowel issues
  • urinary incontinence
  • psychological trauma

Labor and delivery during natural birth can be eased with:

  • massages
  • acupressure
  • taking a warm bath or using a hot pack
  • breathing techniques
  • frequent changes in position to compensate for changes in the pelvis

The optimum method of childbirth for You

When advising you about the optimum method of labor and delivery for you, the Obstetrician will consider:

  • overall health and emotional well-being of the mother
  • the size of the mother’s pelvis
  • the mother’s pain tolerance level
  • the intensity level of contractions
  • size or position of the baby

Conclusion

Hopefully, the information in this write-up will help you make an informed decision, in consultation with your obstetrician, about the optimum method of childbirth for you:  total natural birth, natural delivery, painless delivery, or a caesarean section.

References:

  1. Natural vs. Epidural: What to Expect

https://www.healthline.com/health/pregnancy/natural-birth-vs-epidural

2. Pros and Cons of Painless Delivery

https://medium.com/health-care-for-women/pros-and-cons-of-painless-delivery-2c25e5d82e11

3. 8 Ways to Manage Labor Pain

https://www.parents.com/pregnancy/giving-birth/pain-relief/manage-labor-pain/

4. Painless Normal Delivery: Watch You Tube https://www.youtube.com/watch?v=zgcUvdEOMb

5. Pregnancy and birth: Epidurals and painkillers for labor pain relief

https://www.ncbi.nlm.nih.gov/books/NBK279567

6. Using Epidural Anesthesia During Labor: Benefits and Risks

https://americanpregnancy.org/labor-and-birth/epidural/

7. Side effects – Epidural

https://www.nhs.uk/conditions/epidural/side-effects/

8. Risks of Epidurals During Delivery

https://www.healthline.com/health/pregnancy/pain-risks-epidurals

9. Natural Childbirth V: Epidural Side Effects and Risks

https://chriskresser.com/natural-childbirth-v-epidural-side-effects-and-risks/

10. Labor Pain Explained: Stages, Symptoms and Pain Relief

https://www.parents.com/pregnancy/giving-birth/labor-and-delivery/understanding-labor-pain/

11.Women’s experience of pain during childbirth

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093177/

12. Methods of Childbirth

https://www.webmd.com/baby/guide/delivery-method

13. Forceps delivery

https://www.mayoclinic.org/tests-procedures/forceps-delivery/about/pac-20394207

14. What moms should know about forceps and vacuum deliveries

https://utswmed.org/medblog/forceps-vacuum-delivery/

15. The long term effects of forceps delivery on a baby

https://www.teeslaw.com/article/long-term-effects-forceps-delivery-baby

15. Forceps or vacuum delivery

https://www.nhs.uk/conditions/pregnancy-and-baby/ventouse-forceps-delivery/

16. Does Pain After Childbirth Increase Postpartum Depression Risk?

https://www.healthline.com/health-news/does-painful-childbirth-increase-post-partum-depression-risk

17. Less Labor Pain, Lower Postpartum Depression Risk?

https://www.webmd.com/depression/postpartum-depression/news/20161026/less-labor-pain-lower-postpartum-depression-risk#1

18. Feeling depressed after childbirth

https://www.nhs.uk/conditions/pregnancy-and-baby/feeling-depressed-after-birth/

19. Vacuum extraction

https://www.mayoclinic.org/tests-procedures/vacuum-extraction/about/pac-20395232

20. Vacuum-Assisted Vaginal Delivery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672989/

21. Vacuum-Assisted Delivery: Do You Know the Risks?

https://www.healthline.com/health/pregnancy/risks-vacuum-assisted-delivery

22. Vacuum Extractor Injuries

https://www.cerebralpalsyguidance.com/cerebral-palsy/causes/vacuum-extractor-injuries/

23. Benefits and Risks of Water Birth

https://momlovesbest.com/water-births-benefits-risks