Tag Archives: pregnancy

Resources on Hazards in Pregnancy

substancesDuring pregnancy, some women worry a lot about the potential harms they might expose their developing baby to – medications, smoking, environmental pollutants, workplace hazards and more. Others feel like they’re continuously bombarded with messages that ‘nothing is safe’ and ‘you can’t do / eat/ drink anything you want to do / eat / drink because you’re pregnant.’

If parents look in the popular media, they see a wide range of information: some accurate and research-based but hard to read, some easy to read but not so accurate. It helps to have good resources to point expectant parents to. These are in order from the ones that I think are most broad / helpful to parents to those which are less broad or less helpful.

The Mother to Baby website from OTIS (Organization of Teratology Information Specialists) has a large collection of fact sheets on specific hazards that are research-based and consumer friendly (though not for a low reading level). Topics include medications, herbal products, infectious diseases, illicit substances, and maternal medical conditions. http://www.mothertobaby.org/otis-fact-sheets-s13037

The March of Dimes http://www.marchofdimes.org/pregnancy/staying-safe.aspx is a very consumer friendly site with good summaries on lots of topics.

Center for Disease Control (CDC). Lots of helpful information and links on infectious diseases, medication, workplace hazards, and more. http://www.cdc.gov/pregnancy

LactMed – Drugs and Lactation Database. For info on medications and breastfeeding. “Information on the levels of such substances in breast milk and infant blood, and the possible adverse effects in the nursing infant. Suggested therapeutic alternatives to those drugs are provided.” http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

FDA information for Expectant and New Parents. Info on food safety, breast pumps, ultrasounds, and more. http://www.fda.gov/ForConsumers/ByAudience/ForWomen/WomensHealthTopics/ucm117976.htm

The Environmental Working Group offers Consumer Guides on choosing healthier (for humans and the planet) products: pesticides in produce, cleaning products, cosmetics, genetically engineered foods, and lots more. http://www.ewg.org/consumer-guides

MotherRisk. The website includes a few fact sheets, plus links to research studies on medications, herbs, and infectious diseases. For Canadians, they offer phone hotlines for questions about medications exposures, nausea and vomiting in pregnancy, exercise in pregnancy, and HIV and pregnancy. http://www.motherisk.org/prof/index.jsp

Reproductive Health in the Workplace has info about workplace exposures and breastfeeding and on how not to take your workplace hazards home with you. http://www.cdc.gov/niosh/topics/repro/pregnancy.html

OSHA (Occupational Safety and Health Administration) Standards related to reproductive hazards in the workplace: https://www.osha.gov/SLTC/reproductivehazards/standards.html

The Environmental Protection Agency (EPA) lists hotlines consumers can call with questions on particular hazardous substances: http://www2.epa.gov/home/epa-hotlines

Safety and International Travel: http://wwwnc.cdc.gov/travel

How Expectant Parents Can Help

Part of the reason there is limited information on the safety of substances during pregnancy is because of limited research on pregnant women. Expectant parents can volunteer to be in a pregnancy registry. These studies just collect information from pregnancy parents who take medications and vaccines, and collect information on the baby. Outcomes are compared to those of parents who did not take that medication during pregnancy.

Participating parents are NOT taking experimental drugs or anything they wouldn’t otherwise take!! These registries are an opportunity for parents who are already taking medication or need to take a medication to share their experience with researchers. It might especially appeal to parents who are frustrated at how little information is available to them about their meds. This helps them help others moving forward.

Participating would typically involve a few phone calls (or possibly even online surveys): one or two during pregnancy, and one after the birth. I

Learn more here: http://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm251314.htm and here: http://www.pregnancystudies.org/participate-in-a-study/participate-in-a-study/

If you are a professional who would like to encourage your clients to participate in registries, there are outreach materials (brochures, etc.) available here: http://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm256789.htm

photo credit: G. J. Charlet III via photopin cc

Talking about Prenatal Mood Disorders in Birth classes

pregnancydepressionMost childbirth educators are covering postpartum depression in their classes. Some are also covering other postpartum mood disorders such as anxiety and obsessive compulsive disorder which are quite common. (Depression affects 10 – 20% of new moms, Anxiety or panic disorder affects ~10% and OCD affects 3 – 5%). And hopefully they’re also pointing out that a person can experience multiple disorders at once – for example, she can have depression AND anxiety.

A few educators are remembering to include partners – about 5% of new dads have a postpartum mood disorder.

But I wonder how many of us are talking about mood disorders in pregnancy?

Incidence of Mood Disorders in Pregnancy

Of women who experience depression after birth, a third say it started during pregnancy. (Source) Sometimes, depression is missed because symptoms can be mistaken for the fatigue or appetite disturbances associated with pregnancy. Estimates of incidence of depression in pregnancy range:

Rates determined by structured interview have ranged from 2 to 21% and up to 38% for women of low SES. Estimates derived from self-report questionnaires have ranged from 8 to 31% and 20 to 51%, respectively. Source.

Almost one third of women with manic depression (aka Bipolar disorder) report onset during pregnancy. OCD often begins in pregnancy (pre-existing OCD is usually exacerbated by pregnancy). Interestingly, pre-existing anxiety / panic disorder  may actually decrease in pregnancy due to hormonal effects. Source

How do we talk about this in childbirth classes?

I see multiple places we could address this:

1) when talking about discomforts of pregnancy and the physical changes of pregnancy, you could also address emotional changes and challenges

2) when discussing self-care in pregnancy, could include emotional self care and talk about mood disorders there

3) when talking about postpartum mood disorders.

I find it works well for me to cover it when talking about postpartum mood disorders.When I’m almost done with that topic I say “Although you may hear a lot of talk these days about postpartum mood disorders, we know that they begin in pregnancy for a third of the women who experience them. If you were just listening to my description of symptoms and thinking ‘I feel that way now’, then you may be experiencing a prenatal mood disorder. All the resources for support and techniques for self care I just talked about can also help with pregnancy mood disorders. I would encourage you to reach out for support now – the sooner someone gets support, the sooner they start feeling better. If you have concerns or questions, you can talk to me after class or by email.”

So, it works well for me to cover it near the end of the series when I’m talking postpartum. But, I could also make an argument that it would be better to cover it as early in the series as possible so that parents who are experiencing it get support as early as possible.

When do you (could you) cover it in your classes?

For more resources on perinatal mood disorders, see http://ppmdsupport.com/index.html
photo credit: Maria & Michal P. via photopin cc

Update on Transgender Families

[Note: this post was originally written in 2015, updated in 2019.]

In 2015, we did an updated edition of Pregnancy, Childbirth, and the Newborn: The Complete Guide. We added a few paragraphs on transgender people who identify as men and are pregnant, and other expectant families who are genderqueer, gender non-binary, and so on. We switched most of the language in the book to be gender neutral, but it is not perfectly so. In the process of making those changes and many other things I have learned since then, I’ve found several resources that are helpful for birth educators and doulas.

To any transgender or genderqueer folks who read this… I am still learning. If I mis-state anything here, feel free to comment on how I could do better.

Understanding Gender Identity

First, if you know your knowledge of transgender issues is limited, a great place to begin is “Guide to Being a Trans Ally“. It’s long, but well worth the read. (Many people also find the Genderbread Person to be a helpful tool for understanding these ideas.) For example, it defines sex, sexual orientation, gender, gender identity and gender expression, and all the ways terms are used. It also talks about how all these things can be a spectrum. (A side note: If you think biological sex is totally binary, not a spectrum, you’ll find this a fascinating post about in-utero development of sexual characteristics.)

For example, I am a cisgender woman, because I was assigned female at birth, and I identify as female, and my gender expression is female though not exactly “extremely feminine” (you’ll never see me in high heels or makeup!) And I am heterosexual.

A transgender man is someone who was assigned female at birth because of their biological sex characteristics, but internally identifies as male. Some transgender men are not “out of the closet” and don’t disclose their transgender status in their public life – they think of themselves as male and may ask those close to them to refer to them as male, but their gender expression in public is female or sometimes androgynous. Some transgender men express themselves as male – they dress in “male” clothing, may use mannerisms and speech patterns associated with men, and may have a male name but will openly define themselves as trans-male. Some express themselves as completely male and will never disclose any other identity – as the Guide says, they “just want to be seen as their gender-affirmed selves.” In your practice, although you wouldn’t have known it, you may have encountered these men as partners to a female-identified expectant mother.

Estimates on what percentage of the popular is gender variant range widely. The Williams Institute says 0.6% of Americans are transgender. The Transgender Law and Policy Institute says 2 – 5% of the population experience some gender dysphoria (an emotional / mental health condition that arises when someone’s gender expression and how other people refer to them and react to them does not align with their internal sense of who they are.)

It is very likely that younger people are more likely to identify as transgender than older people. When asked whether they identify as lesbian, gay, bi or transgender, 1.4% of those over 75 say yes, but 8.2% of those 20 – 39 do. (Source) This is likely not due to a change in actual incidence of homosexual orientation or transgender identity but more on social attitudes that make it more acceptable to acknowledge those feelings. This will mean that in the future, you will be more likely to knowingly encounter gender variant families than you were in the past.

Transgender people in America (especially transgender women of color) experience very high rates of harassment, discrimination, and assault. They have high rates of homelessness, unemployment, and lack of health insurance. (see http://www.transgenderlaw.org/resources/transfactsheet.pdf and Gender Not Listed Here.)

Transgender Men and Pregnancy

A pregnant father would be someone who was assigned female at birth (and has a uterus, ovaries, and so on) but his internal sense of gender identity is male. There are also non-binary people and other people across the gender spectrum who carry and birth babies.

Some of those expectant parents will have an outward gender expression that is obvious to birth professionals, and they may also have a conversation with the professional about their gender identity, pronouns, and preferred terms (e.g. “I am the baby’s father, and you should refer to me as he / him”). Other transgender people may be more hesitant to reveal their gender identity to their caregivers, and may be cautious in how they dress and present themselves when coming for appointments – such as presenting more feminine than they otherwise might and not correcting the caregiver if they use female pronouns. However, this may increase their gender dysphoria. Dysphoria is often intense during pregnancy, and having your caregiver use ‘she’, ‘her’, ‘mother’ and other gendered terms frequently can increase that.

When birth professionals encounter clients who express themselves as gender variant, we  need to know how to treat them with respect and honor their identity. And, because we will also quite possibly encounter other gender non-conforming people without knowing it, we should work on adapting our language at all times to welcome them in. And even if everyone in the room is cisgender, using gender-inclusive language helps to increase the visibility of transgender people and their rights for respectful language. And that includes language on websites and advertising where potential clients may look before coming in to determine whether they would be welcomed by your practice.

Health Care Experiences of Transgender People

Many transgender people have a history of bad encounters with health care providers: As many as one-fourth of gender variant people avoid health care services due to concerns about discrimination and harassment. (Source)  “FTM youth said they frequently encountered verbal abuse and condescension from frontline health care staff such as receptionists: ‘I can’t even make it through the front door without staff staring at me, laughing at me, or whispering about my gender presentation.’ In the FTM youth group, all participants agreed that they did not feel safe receiving health care.” (Source) “One FTM youth found experiences with gynecological care especially upsetting:’There is a lack of sensitivity… The doctor was not sensitive to the fact that I experience myself as male and that this experience was overwhelming for me.’ Said one FTM adult,“I think for me it is respect and a willingness to respect your pronoun. I found that to be a huge problem. As somebody that hasn’t done any body alterations,it’s hard for people to switch pronouns and accept the pronoun [that I prefer].” (Source)

This page http://transequality.org/Issues/health.html offers brief, but helpful, recommendations for trans* people about accessing effective health care in general, and things they should consider, and talk to a supportive caregiver about.

Health Professionals Advancing LGBT Equality (previously known as the Gay & Lesbian Medical Association) has an excellent resource for health care providers on Guidelines for Care of LGBT Patients. It talks about how LGBT clients might “scan” a practice to see how friendly it is: they might look for gender-neutral language (pregnant parent, partner, and so on – not mother and father), non-discrimination statements, gender-neutral restroom signs, pride flags, intake forms that ask for relationship status not marital status, offer a check box for transgender, a line for preferred pronoun, and so on. Check it out for ideas that might apply to your practice.

Birth Professionals and Gender Variant Families

The Science and Sensibility blog hosted a post by Simon Adriane Ellis on Working with Gender Variant (Transgendered) Families which is an excellent summary for birth professionals (OB’s, midwives, doulas, childbirth educators, and so on) about how to work with gender variant people successfully. Some tips are:

  • Offer accommodations such as one-on-one classes, appointments at the beginning or end of the day, if you need to refer to another provider, you call ahead to provide the patient’s background.
  • Plan to offer additional emotional support – they may feel very isolated and may be struggling with gender dysphoria. [Note: Ellis also co-authored a journal article titled “Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family” which explores this parenting experience and says the over-arching theme was loneliness.]
  • Use sensitive language. It’s important to ask them what name, pronoun, and parenting term they would like to be addressed by.
  • “Don’t let your curiosity get the best of you” – it may be tempting to ask the whole history of their gender identity… only ask what you need to know to care for them
  • I think a really important sentence from the article is “The urge to refer clients/patients to “someone who has more experience” is strong; often, it is grounded in sincere concern for the client’s well-being. But the truth is: with very few exceptions, there is no one with more experience.”

ACNM has a position statement on Transgender/Transsexual/Gender Variant Health Care which includes some pointers to additional research.

Inclusive Language in Childbirth Classes

I attended an in-service by Kristin Kali, from Maia Midwifery on how language matters for LGBT students in childbirth classes. Here are some of my takeaway notes from that:

  • Using very gendered language like “mom” and “dad” can be very alienating for many families: single parents, gay or lesbian couples, surrogates, donor fathers, polyamorous families where there will be more than two parents, or a transgendered dad who is carrying the baby.
  • On intros, could ask “who is in this baby’s family?” Or “who will support you in birth and in the early weeks as a parent?” “Who is in your family? You and your child? You and a partner and child? Uncles and aunties?”
  • In class, refer to pregnant parent rather than “mom”, people in labor rather than “women in labor”, the uterus rather than “her uterus”, parents instead of “mothers.”
  • Don’t wait till you have someone in class who you know is transgender before you adapt your language. It’s hard to remember it in that one class! Consider just changing your language  long-term for ALL classes to be as inclusive as possible so that it flows naturally when you do have that parent

You can also talk about chest-feeding as well as breastfeeding. Kelly Mom has a great collection of information on transgender parents and chestfeeding.

If you have single stall bathrooms, instead of having “men” and “women” signs, have signs that just say “restroom” or “all gender restroom”.

Science and Sensibility features a blog post by Sharon Muza on Using Gender Neutral Language in Birth Classes.

Resources for Finding Supportive Caregivers

Here are some directories that may aid a gender variant expectant parent in finding a caregiver:

Updates on Cesarean Birth

As we update Pregnancy, Childbirth and the Newborn, I will post here about major updates in each section since our 2010 edition. Here’s what’s new in thoughts about cesarean.

Key resources to be aware of

Barber, et al. Indications Contributing to the Increasing Cesarean Delivery Rate. OBGYN VOL. 118, NO. 1, JULY 2011. Reviews records of over 32,000 births at Yale-New Haven hospital between 2003 and 2009, when the cesarean rate increased from 26% to 36.5%. Factors that contributed the most to the increase were, in order:

  • An increase in the diagnosis of nonreassuring fetal heart rates and failure to progress in labor. [Note: These are somewhat subjective diagnoses. It is possible that the rates of problems did not change much, but that caregivers began to lower the threshold at which they would decide cesarean was indicated.]
  • Multiple gestation. The rate of twins increased slightly, but it also became more common to do a cesarean for multiples rather than attempting a vaginal delivery.
  • Suspected macrosomia. Although more cesareans were done because it was thought the baby was too big, the actual size of babies delivered did not increase.
  • Preeclampsia. The average age of mothers has increased, and more women are obese prior to pregnancy, and this has led to an increase in gestational hypertension. Also, caregivers are becoming more likely to use cesarean rather than induction for women with preeclampsia.
  • Maternal request. A very small (less than 1%), but increasing, percentage of women requested a cesarean.

A 2011 journal article by Zhang, et al for the Consortium on Safe Labor, titled Contemporary Cesarean Delivery Practice in the US summarizes current trends. Some of the data from this article figured strongly in the ACOG / SMFM statement discussed below.

ACOG Committee Opinion on Cesarean Delivery on Maternal Request, 2013. They estimate 2.5% of all U.S. births are elective cesareans without medical indication. Their summary recommendation was: ” in the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended to patients. In cases in which cesarean delivery on maternal request is planned, delivery should not be performed before a gestational age of 39 weeks. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.”

Consensus statement from ACOG and Society for Maternal-Fetal Medicine. Safe Prevention of the Primary Cesarean Delivery. 2014. This statement has the potential of a huge impact on maternity care practices and should be read by all childbirth educators and other birth professionals. From the abstract, with my emphasis added: “The rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women’s access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.

Read a response to this statement on Lamaze’s blog, Science and Sensibility. And Penny Simkin’s presentation on the statement and its implications. Or my reflections on it.

What does this all mean?

It can take a long time for practice recommendations to become wide-spread practice in the “real world” of obstetrics. They will likely be adopted more quickly in university teaching hospitals in major urban areas than in rural hospitals.

I think these are the messages we give our students about cesarean:

For a parent who has not had a previous cesarean, your chance of having a cesarean with this birth is about 23%. It is much higher if you are carrying twins (47%), if you are older, obese (44% at BMI of 35+), or if your labor is induced (about twice as likely). Rates vary greatly by hospital, so it’s good to research your options.

If you are carrying multiples, and the first baby is head-down when it is time for the birth, vaginal birth is better than cesarean.

If your baby is breech at 35 weeks, try chiropractic, acupuncture / moxibustion and other techniques to turn baby. Ask for a version at week 37.

If a care provider tells you your baby is looking big, and recommends an ultrasound in late pregnancy to assess size, or recommends induction / cesarean to treat: know that a) late-term ultrasounds are not a precise way to measure size, b) macrosomia is not considered a reason for induction, and c) macrosomia should only be considered an indication for cesarean if baby is believed to be at least 5000 grams (11 pounds) in a woman without diabetes, and at least 4500 grams (9 pounds, 14.7 ounces) in a woman with diabetes.

The most common reasons for cesarean are repeat cesareans, failure to progress in labor and concerns about baby’s heart rate that arise during labor.

For most women with prior cesareans, VBAC is a safe option and should be pursued.

Failure to progress in labor. See my post on what should be considered prolonged labor. Also, talk to your clients about all the ways that we promote labor progress.

For baby’s heart rate: If there are concerns, ask how concerning it is – does it warrant immediate intervention, or is it possible to try other things. Some options are: changing mom’s position, IV fluids or oxygen for mom, amnioinfusion for baby, turning down Pitocin, letting narcotics wear off, giving tocolytics to gentle the contractions. She can also request that they use fetal scalp stimulation to check baby’s response.

 

 

 

 

Nutrition Update

We are working on a medical update to Pregnancy, Childbirth and the Newborn. We are reviewing current maternity care trends and updated recommendations. I will post key changes here. Here’s what’s new in recommendations for nutrition during pregnancy:

Calcium: Past recommendations were 1200 mg/day for pregnant women. New recommendations (as of 2010) are: 1000 milligrams of calcium each day (1300 if you are under 18 years old) for non-pregnant, pregnant, and lactating women. Source: IOM.

Vitamin D: in 2010, many doctors were testing vitamin D levels, and prescribing supplements based on the result of the testing. However, there was lack of consensus on what levels were adequate and what were considered deficiencies. New recommendations are to skip the testing, but recommend supplementation for all. Non-pregnant, 400 IU per day. During pregnancy, women should take 600 IU (equal to 15 micrograms). This is more than she would likely get from supplemented foods (a cup of milk typically has 100 IU) so supplements are often needed.Some research indicates that 4000 IU is beneficial but that is not yet the recommendation. Breastfed babies should be given 400 IU daily, or up to 800 IU in winter/northern climates. Sources: Institute of Medicine, Canadian Paediatric Society

Vitamin D3 supplements are more effective, and should be used by most. Vegans may choose vitamin D2, since D3 is animal-based.

Iodine: In the past, women got the required iodine through intake of table salt, which is iodized. As consumption of processed foods has increased, most of their salt consumption is from processed foods, whose salt is not often iodized. One third of women  may be deficient, which can cause hypothyroidism, which harms baby’s cognitive development, ad makes mother and baby more vulnerable to environmental pollutants. Pregnant and breastfeeding women should take in 290 – 1100 micrograms per day, and a good way to ensure that is a daily supplement of 150 micrograms. (Source.)

Saturated Fat and Dairy: The views have changed significantly over recent years. A major review concluded: “there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of [coronary heart disease, stroke, or cardiovascular disease],” Source. Also, people who eat high fat dairy, butter and cheese seem to be less likely to be obese than those who stick strictly to non-fat dairy. Source. Possible reasons: higher satiety after eating high-fat foods may mean they eat less total calories, and/or many non-fat products are supplemented with added sugars to boost the taste. Organic whole-milk dairy foods may be a better choice in pregnancy than low-fat.

Stevia: Stevia is a natural sweetener and sugar substitute. The FDA has approved the purified form, stevioside and rebaudioside A (aka Rebiana) found in products like Truvia and Pepsi True. However, whole stevia leaves and stevia extracts have not been tested and approved for safety.