Transcription
Media File Name: Postpartum Care.mp3
Media File ID: 2450011
Media Duration: 58:09
Order Number:
Date Ordered: 2016-02-16
Transcription by Speechpad
www.speechpad.com
Support questions: [email protected]
Sales questions: [email protected]
Transcription by www.speechpad.com
Megan: Hello, everyone and welcome to the Postpartum Care webinar. I'm
Megan Hiltner with the Healthy Start EPIC Center. We have approximately 60
minutes set aside for the webinar. It is being recorded and the recording along
with the transcript and slides will be posted to the EPIC Center's website
following the event. Before I turn it over to Dr. Janet Shepherd who'll be your
speaker for today, I have a couple of quick housekeeping announcements.
We really want your participation and your questions and your comments. So at
any point during the webinar, please chat them in at the bottom left corner of
your screen. We will only be taking questions through the chat box and if there
is...if we do get too many questions to get to by the end of the webinar, we will
be including them in the Frequently Asked Questions document that will post
along with the other webinar materials on the EPIC Center's website. Also, we
want your feedback. So at the end of the webinar, you will be presented with a
survey that will pop right up on your screen afterwards, so please complete it
and give us your feedback.
Now, let me introduce your presenter for today. Dr. Janet Shepherd is the
maternal health technical adviser for the Healthy Start EPIC Center. She's a
board certified OBGYN. She is a continuing appointment as adjunct professor
for Florida State University College of Medicine where she was the founding
education director for obstetrics and gynecology, and in that role she
participated regularly in the Panhandle Fetal and Infant Mortality Review
sponsored by the Healthy Pregnancy Network at Capital Area Healthy Start
Coalition. She has significant experience in insight into the Healthy Start
Program.
This is the third in a series of four webinars that are covering the four perinatal
periods. The other two webinars coming before this, preconception care and
prenatal care, are posted to the EPIC Center's website. So if you haven't had a
chance to view or listen to those, please go check those out. Without further
adieu then, I'm going to turn it over to you Dr. Shepherd to begin the webinar.
Transcription by www.speechpad.com
Dr. Shepherd: Thank you, Megan, and welcome everybody. Thanks for tuning
in today. I do think this is an important webinar, our third of the four P's
looking at postpartum care. These are my objectives. I'm hoping that by the end
of this webinar you'll be able to explain why postpartum care is so important,
you'll be able to describe common emotional and physical issues that affect
women after having a baby, and we'll also discuss the essential components of
postpartum care.
I thought it would be a good idea to start out by looking at our postpartum
benchmark in Healthy Start. I imagine you're all familiar with this, but I think
it's a good thing to review before we get started. The goal of Healthy Start right
now is to increase the proportion of Healthy Start participants to receive a
postpartum visit to 80%. I know that sounds like a lot and I'm pretty sure that
many of you are looking at that and wondering how you will even get close to
that.
But I want to tell you that we need to be working on this because this is very
important and it wouldn't, of course, be a benchmark if it wasn't. But just to
show you, it's not just Healthy Start that's saying this. In fact many other
maternal child health organizations have adopted the benchmark as well. It's
even one of the goals for Healthy People 2020, just to show you how significant
this is.
So what are we talking about with these postpartum visits? Basically we're
talking about a visit with the healthcare provider. The healthcare provider could
be an obstetrician, it could be a nurse midwife, it could be a family practice
doctor, it could be a family practice nurse practitioner, or it could even be a
well-trained home visiting nurse or at least some of these visits. Many different
healthcare providers can be participating in this and it should occur at four to
six weeks postpartum ideally. Of course, there's some flexibilities with that.
One of the flexibilities is that if a woman has had a complicated pregnancy and
ended up with a C-section or a severe preeclampsia, if she was depressed during
Transcription by www.speechpad.com
pregnancy, then she probably should get this visit early in fact at 7 to 14 days
and then another one at four to six weeks. This doesn't have to be a one-time
thing.
Why is postpartum care so important? I will start out by just saying that as we
all know, having a baby is a big deal. Well, being pregnant is a big deal, but if a
mom is pregnant, hopefully she's getting some prenatal care, and so she's
getting the chance to get medical care and to get some support from healthcare
personnel throughout her pregnancy. Of course, when she delivers the baby,
she'd get support and then in the hospital, but afterwards, things aren't all that
easy and she doesn't get postpartum care, she's kind of on her own and she
lacked that support that she had ahead of time.
Why does a mother need that support? Well, I think we all are aware that
becoming a mother, especially for the first time, is a major adjustment. A
woman might want this baby, be excited about this baby, but still there are often
unexpected challenges. Most of us can imagine the 24-hour demand of infant
care, but it's kind of the concept of surprise, that first time.
The lost of personal time and space. And then even if this is the second or third
or fourth baby, it still changes the relationship in a woman's life with her
partner, with her other children, with her relatives end to end. There's a lot of
adjustment going on. And then in addition, of course, there are the physical and
emotional ramifications of just having had that delivery. So this woman is in
need of support just as much as she was during the pregnancy and the birth.
The postpartum visit is intended to meet these needs. It's intended to provide us
moral support and reassurance to the new mother, but also with a physical exam
to ensure that her body is feeling normally and that she doesn't have any
significant health risk. It's there to provide support for breastfeeding, very
important as we know, and it also presents us an opportunity to screen for
postpartum depression and refer if needed.
Transcription by www.speechpad.com
But that's actually not all. There's even more. This is an opportunity to provide
preventive care. This is an opportunity to look at what other support is available
to this woman. What other social support does she have and do we need to help
her get some more? And how is she doing with the baby's father? What's the
baby's father's role? Can we encourage more involvement of the father or
partner?
It's a chance for that, and then it's also a chance to catch up on and follow-up on
medical and other issues that may have risen during pregnancy. For example, if
she hit with diabetes during pregnancy, she needs to be followed up for that.
Finally, it's the chance to think about future pregnancy whether the woman
wants them, how many she wants, reproductive life explaining as we call it, and
then helping her achieve the contraception to achieve that goal.
Let's go through each one of those components of postpartum care and what it
might look like. As far as support and reassurance, this is a chance for the
healthcare provider and the mom to discuss the stresses of new motherhood, the
chance to reassure the mom that it's normal to feel overwhelmed sometimes,
and provide suggestions, comments, good suggestions or things like 'Don't try
to be a supermom.
When the baby is sleeping, sleep. Don't think about everything else that needs
to be done, accept help, ask for help especially from your mom,' if she's in the
picture with some relatives and friends, and then giving women permission to
have a little time for themselves and time with their partner. So those kinds of
support can be really helpful. Now, of course, what else can be helpful is if the
father participates in these visits, the father or partner.
Now, of course the father has got a lot of adopting and adapting to these new
situations with you too, so this can help, the father or partner, but it can also
help the father or partner understand what's going on with the mom. Because
Transcription by www.speechpad.com
sometimes it's hard. Fathers scratch their head. You were excited about this
baby, you wanted this baby, and now sometimes I feel how stressed you are. I
don't understand it. Being part of this visit can help the father understand and
help the father or partner understand how they can help support the mom.
We said we also want to address the physical issues after delivery. So we want
to check the normal things and reassure the woman that they're normal and then
be sure that she doesn't have any danger signs rather than normal physical issue.
For example, it's normal for women after delivery to have high pressure. Don't
expect that, but it's a big hormone change, kind of like the change of life.
When you get high pressure, they need to be reassured that's normal. It's clearly
they get tired, tired from having a baby and then taking care of the baby. But it
certainly is not normal for the high pressure to turn into a fever or chill or for
the tiredness to feel like the flu with aches and things. We'd want to know about
that. We're going to evaluate for that.
It's normal for women to have cramps like a period for several weeks after
having a baby because the uterus is going back to its normal size, but it's not
normal to have severe abdominal pain, and an exam can help reassure a woman
that what she's feeling is normal or tell us it's the problem. It's normal to bleed
for four to six weeks after women have a baby. A lot of women don't expect
that, they can be reassured, but if the bleeding is heavier, lasts longer, that is a
problem.
And it's normal, of course, to be sore around the vagina. Some women have
stitches to deal with. If she's had a C-section, she's got stitches and her scar. It's
normal that that will be sore, but those scars and those stitches need to be
checked to be sure that they're not too sore, too red, swollen or draining. Breasts
become swollen and tender normally. When the milk comes in, nipples can be
sore initially breastfeeding, but if the woman had a hot red sore spot on one
breast, that's, of course, a sign of an infection on that side. So the physical exam
is very important.
Transcription by www.speechpad.com
Now, there is this one other thing on that list, and that's not likely to be
evaluated to postpartum visit, but anybody who is in touch with women who are
postpartum needs to understand that these are danger signs. A woman that has a
painful leg, particularly painful calf, one leg, chest pain, trouble breathing, these
can be the signs of blood clot. One of the biggest times women are at risk for
blood clot is postpartum. Anybody dealing with postpartum women, be on the
alert. If she brings up symptoms like this, she needs to go to the emergency
room.
Those are some of the physical symptoms women have, some of the things we
might worry about. Women used to have a lot of other physical concerns too.
And if you work for Healthy Start, and particularly those of healthcare
providers, we have to be prepared too and to these questions as well. One of the
questions that women often have in their mind is, "When can I have sex again?"
Now, they may not bring that up.
They maybe shy to bring that up, and also it may not really be them that's
wanting to have sex again but maybe their partner. But still they have a
question about, "When can we?" One of the concerns women have in fact is
that often their partner is interested, but they're not at this time. It's really
normal for women to have low sexual desire after they have a baby. That's
about the hormones again, but a lot of women get really scared about that.
They're like, "Oh, I wonder if I'm ever going to come back."
Of course we want to reassure that that will come back. And the other thing we
need to realize is part of why she's probably having low desire is because she
know it's going to hurt and she's had stitches and it tears or anything. Well,
maybe it is and she really should be examined before she goes back to having
sex so that we can be sure that it isn't going to hurt her or even damage anything
in any way.
Transcription by www.speechpad.com
Another symptom that women frequently have after they have a baby is that the
vagina is dry when they first try to have intercourse. This happens especially in
women who are breastfeeding. It's good to be able to talk to women about this
too and reassure them that that's normal and what they had before is going to
come back, but meanwhile it's really a good idea to plan on using lubricants,
like some from the drugstore when they begin to have sex again.
Hopefully we encourage women to wait until they had their postpartum check
before they become sexually active again because we want to be sure
everything is fueled up and nothing gets injured. But studies show us, and I
think it's probably not a surprise, that many women do not wait that long. And
so if you see somebody before her postpartum visit and she talks about having
sex again or you get a feeling that that might be in the offing, it's really good to
warn women that they could get pregnant even this early.
Now that's especially if they're not breastfeeding. But women that are not
breastfeeding have been shown to ovulate as early as 25 days after delivery.
That's three and a half weeks. Considerably this woman could get pregnant
again three and a half weeks after she had a baby and now it's obviously be
really hard on her body and hard on her new baby as well. So if a woman does
plan to have sex before her postpartum visit, before six weeks, be sure that she
understands that she should use something, maybe a condom to prevent such a
quick pregnancy again.
The other question a lot of women have is, "How am I going to lose all this
weight?" That's really an important question and we need to take that question
very, very seriously. Because what we know is women in a country have a
higher rate of obesity than men and part of why they do is because they hold on
to their baby weight sometime. We really want to help them remove their baby
weight so that they don't end up with long term obesity and all of the health
concerns that raises. This is even true. Even women who were normal weight
before pregnancy, gained a normal amount of weight in pregnancy or maybe a
little more, even they, if they don't lose that pregnancy weight, they are set up
for long term obesity.
Transcription by www.speechpad.com
So we really want to encourage women to think about losing this weight. We
want to help them do it. And of course, one of the really good ways to begin to
lose the weight is to breastfeed because breastfeeding requires an extra 500
calories a day, stuff like walking five miles, that certainly makes losing weight
easier. We also, of course, once talked about those diet and exercise. This is a
slide some of you have seen before if you're on the prenatal webinar. Because
really, especially if a woman is breastfeeding but really most women after
pregnancy, they need to build themselves up again and they need to continue
that very healthy diet that they ate during pregnancy, all those things on the
what-to-eat list.
But if they want to lose the weight and we want to encourage them to do that,
they need to minimize sweets, sugar-sweetened beverages and fried foods. Just
as on the side, most women should continue their prenatal vitamins at least six
weeks postpartum, and if a woman is breastfeeding, she should continue them
as long as she's breastfeeding. But the other piece of losing weight is exercise.
This is interesting in that some women not only don't lose their baby weight,
they actually gain more weight after pregnancy, and the reason is because
they're indoors with their child kind of taking care of things in the house, they're
not getting exercise at all, and they actually gain more than their baby weight.
So we really want to encourage women to get out of the house if they can and
get some exercise. Women can begin exercise as soon as they're medically
recovered. Now, obviously she's got stitches around her vagina. She wants to
make sure that's healed first. She's got a C-section. It's going to probably be six
weeks before she can do real exercise. But our goal is 20 to 30 minutes of
moderate activity most day and that will help a woman lose that baby weight.
What I like to think about is just taking a walk, that counts, that's exercise, and
that's something, if the weather cooperates and she wrapped the baby up real
warm, you can take the baby out for that walk with you.
Transcription by www.speechpad.com
Okay. Our next goal with that postpartum check is to support breastfeeding. I
think we all know, speaking of benchmark that some of our Healthy Start
benchmark are to increase the number of women who begin breastfeeding to
81%, 82% I believe it is, and 61% still to continue for six months. In our
country right now, 79% of women begin breastfeeding in the hospital, but only
49% continue for six months. We've got work to do, and one of the times that
we can do that work is in the postpartum check. If a woman has been
breastfeeding until she comes in for this check, we can give her positive
reinforcement for that.
Then we can also talk about repeat all of those benefits of exclusive
breastfeeding for the first six months in the baby's life. Of course it's good for
the mom, it's good for the baby, it's good for their bonding. The sixth week
check or the postpartum check, whatever it is, allows us also to address any
questions and concerns the mom may have so that hopefully that will also
encourage for the continued breastfeeding. Now, we don't want to judge women
who choose not to breastfeed.
If the woman is using formula, this is our chance also at the postpartum visit to
be sure that she is following the guidelines as far as safe preparation of formula
and other feeding practices. So let's look at a case regarding breastfeeding. I
love this beautiful picture of Malia. Of course these are made-up cases, but
Malia comes in for her sixth week checkup and she has been successfully
exclusively breastfeeding her baby for the first six weeks of his life and she's
really enjoyed it.
But at her postpartum check, she asked how to wean him because she says,
"I've got to go back to work, so I have to wean him now. I wish I didn't but I do,
plus my mother and my grandmother are both telling me that six weeks was
more than enough. I've done what I needed to do so now I should wean him."
Let's talk a little more about breastfeeding and how we might counsel Malia.
Transcription by www.speechpad.com
One thing that we have to think about with our Healthy Start participants,
because many of them are African-Americans, is to realize that breastfeeding is
historically lower in African-Americans, especially low income AfricanAmericans. Currently the numbers on African-Americans breastfeeding are that
59% ever breastfed, that's versus 79% of the general population and 30%
continuing at six months. So we'll just look at that with 49% in the general
population. It is lower in this community and we surely would like for it to
increase.
Why is it low? People have asked that question. Sociologists have a lot of
publications about it and they believe that maybe a legacy of slavery actually
that African-Americans were asked to be the wet nurses for other babies and it
led to a negative attitude understandably about breastfeeding. This may be
something cultural, at least according to our sociologist colleague, that leads to
that African-Americans often lack support of social networks, like we saw with
Malia. Her mom and her grandmother think she's breastfed just plenty already.
But there's more to it than that also and there are things in our current
environment that can and should be changed for African-Americans particularly
low income women. In fact it turns out that very often low income women are
working in environments that are not baby friendly at all. In fact they may have
to be back to work in two to four weeks. They didn't have time even to establish
a pattern of breastfeeding.
And then their work environments are not as likely to be breastfeeding friendly
as some other women would be. Another thing that I have come upon just in the
last couple of weeks regarding this is that the hospitals that low income
African-Americans deliver in tend to be those big city hospitals, which do not
meet all those baby friendly, breastfeeding friendly criteria many times. There's
a lot, for African-American low income women, to deal with, to try to
overcome some of this, and again to get the benefits of breastfeeding.
Transcription by www.speechpad.com
How can we help Malia out? How can we encourage her to continue
breastfeeding? In fact she really even wants to. Well, we want to give her
positive reinforcement for what she's done so far, that's for sure, although we
want to encourage her to continue breastfeeding for at least six months. Now
there have been studies actually particularly in African-American women, what
can we do to help them, to support them to continue breastfeeding?
There are two sets of studies that have shown us some helpful things. One of
them is to at the postpartum check rather than talking about weaning the baby,
talking about and referring Malia to some peer counselors in her community,
some other young women her situation that have continued successfully
breastfeeding for six months. Community health workers and doulas can also be
people that you can refer to to help support Malia in her choice.
The other thing that's interesting studies on is mobile technology. By this, I'm
just talking about cellphones. Cellphones have tons of apps regarding
breastfeeding that can support a woman and have been shown to support young
African-American women very well. This can be accessed just Googling it.
You can find some that are approved by the American Academy of Pediatrics,
you can find some that are designed just for African-American women.
Facebook has support groups for breastfeeding and support groups for
breastfeeding particularly for African-American women. They could be shown
to lead to continuation of breastfeeding in women like Malia. We can suggest
all these things to her. And then the good thing is that when she gets these
supportive structures in place like her cellphone and her peer counselor, she
learns things and she shares it with her mom, with her grandmother, teaching
them and her partner, and hopefully more women in the future will be able to
breastfeed as well.
Now of course why Malia was concerned partly that she had to stop
breastfeeding was because she has to go back to work. We have to think about
that with her as well and we have to encourage her to explore her option, where
Transcription by www.speechpad.com
she worked. Is there time to pump her breast? Is there lactation? We hope there
is. In fact there is a law about this. As you may be aware, there is a Federal law
that jobs that are full time, hourly wage need to provide these things.
She's got that kind of weapon if she needs it, if she's got that kind of job. If she
doesn't, then it may not be so easy to get those things but she should at least try.
If she can get those things, the time to pump, the lactation, then the good news
is if she's got to employ health insurance, it should cover the cost of the breast
pump and the cost of a lactation counselor to teach her how to use it and how to
fit into her and the baby's life.
Hopefully we can end up encouraging Malia to continue to breastfeed for six
months and she will be very happy to find out that there are ways and there are
supports and that she can do this. Okay, moving along to our next element of
postpartum care, and that is looking for and managing postpartum depression.
What do we mean by postpartum depression? We're talking about major
depression, begins six weeks of giving birth. And look at those numbers, it's
now thought to affect 15% to 20% of postpartum women.
If we're seeing postpartum women, we are seeing this. Now we want to
differentiate this from the baby's mood. I'm sure many of you are familiar with
that, this is in fact most women actually, and this is beginning a few days after
having a baby when the mom tends to get kind of over emotional and weeping,
this is a hard time, lot to adjust to it. But she really responds to rest and support
and respond, result spontaneously in two to four weeks.
Postpartum depression, on the other end, does not get better at six weeks. It's
still there and the woman's depression is bad enough that she really can't enjoy
anything, including her baby, and she really doesn't have much interest in
anything including her baby. She is pretty much depressed all the time, severely
depressed and can't really function in life with that all.
Transcription by www.speechpad.com
Who gets postpartum depression? Well, here are some risk factors. Interestingly
enough, we think that some of postpartum depression is physiologic and
genetic. And why we think that is because women who get severe postpartum
depression tend to be women who already did get sever PMS or premenstrual
syndrome in the past or who have had postpartum depression with their last
pregnancy or who had a history of major depression.
Also we know that if a woman's mom had postpartum depression, she is more
likely to get it as well. That's why we think it's little bit genetic, little bit
physiologic. But of course there are environmental contributors and we have
looked at these environmental contributors. You can see why postpartum
depression would be so common in our Healthy Start participants. I mean they
are probably up around that 20% in the ranking we just looked at.
Because one of the big stresses that's shown to be associated is low income,
then we have teens, very high risk, and inadequate emotional and social
support. We know there's a lot of women in all or some of these situations.
Another environmental contributor is women who have had previous problems
with pregnancy, for example lost pregnancy or has babies with birth defects and
then it's just can be very traumatic for them, and to examine to postpartum
depression.
How do we manage postpartum depression? Well, we screen all moms
postpartum and we even screen...as we've said on the prenatal webinar, we
screen women pregnancy as well because we now know that this depression
often begins in pregnancy or exists in pregnancy as well. But even if we're
screening pregnancy, hopefully we have, we screen again postpartum and even
later on it because it seems like we should. And why do we do the screening?
We do it because it turns out that only 20% of women with significant
postpartum depression mentioned it to their healthcare provider. Why is that?
Well, they're not feeling so good about this. They're feeling embarrassed. They
should be happy with this new baby, they don't want to talk about this, they
Transcription by www.speechpad.com
don't want to admit to this, but if we do a screen, it's somewhat anonymous, it's
somewhat objective, and it's easier for them to let us know by how they answer
the question.
This is why we do the screening on all mothers two to six weeks postpartum.
And then of course if the screen is positive, this will need to be referred for
treatment. It's not just enough to know this is going on and it needs to be
aggressive treatment. Because what we know is if postpartum depression isn't
treated, the woman can remain depressed for a year or two or more. The infant
is going to be affected certainly by his mom's depression and withdrawal and
certainly the bonding in their relationship.
So very important to treat these women. Usually they are treated with
antidepressant medication and that has have to do with what I said. It's just this
something largely physiologic. And so if we correct the hormonal imbalance in
the brain, we help treat that woman. Sometimes in fact, if a woman was
depressed during pregnancy or if she had postpartum depression with her last
pregnancy, these medications are begun as soon as the baby is born to prevent
her from getting be at postpartum depression. Psychotherapy can also be helpful
for a lot of these moms.
Let's look at another case. Here we have Christina. She is just kind of staring
off into space there with her baby. She's 16 years old and she just had this first
baby and she didn't want to come in for this postpartum visit, but her mom kind
of made her. Mom insisted she go and finally brought her in because her mom
was worried about Christina. She says that when she was pregnant, she was
excited about the baby, but now she leaves most of the care to her mother and
she doesn't seem interested in the baby at all. How do we help Christina?
Well, I'll start out by first trying to talk with Christina without...and everyone is
just hand and body [SP] that screen. We want to talk to her and see what clues
we can get from that. And of course when I ask her how she feels she will
answer me with like one word, "Fine" or something. But if I ask a little more
Transcription by www.speechpad.com
about her life, I might find out that the baby's father broke up with her right
before she had the baby. So that's clearly adding to the other stresses going on
for her.
After we talk, then we'll administer the depression screen. The Edinburgh is
probably the best one. And she fills it out, and as you may know, it scores from
0 to 30. Hers was 28. Whoa! That's really high and I'm really concerned about
Christina. I'm glad her mom's there with her. We can share the results. But good
thing about these screens is that you can share the results. It's objective. It's in
black and white. I'll give you a test and here's what it shows. It shows that
you're depressed, but really that's not uncommon with the stress that you've had
and with the hormone changes.
So I want you to get in some care right away. When somebody with a score that
high, I would really need right away to refer her for mental healthcare. But
she'll then hopefully begin on medication and begin to engage with and enjoy
her baby. It may take a few weeks. She's going to need a lot of support from her
mom and maybe some therapies also, but eventually hopefully she will come
back and enjoy that little baby.
Okay. Moving down the list, we said that the postpartum visit is also important
for preventive care. One of the important elements of preventive care is
following up on medical problems that began in pregnancy. We all know that
women who were never diabetic before can become diabetic during pregnancy,
we call that gestational diabetes, and what we also know is that if a woman has
had gestational diabetes, she has seven times the risk of developing type 2
diabetes later in life.
It can even be there right after delivery. Anybody who's had gestational
diabetes needs to be tested again after the pregnancy to be sure that they still are
not diabetic. It's very, very important. Then we've got preeclampsia, the high
blood pressure of pregnancy. Four times increased risk of chronic high blood
Transcription by www.speechpad.com
pressure in women who have preeclampsia. So those women too, they need to
be seen, they need to be see how their blood pressure is doing.
And then we know that women who have had preeclampsia are at greater risk
of heart disease and stroke later in life. We need to make them aware of that
and make them aware of healthy heart practices like diet, exercise, getting
regular blood pressure checked, etcetera. Of course other medical issues might
have come up in pregnancy too and we want to be sure those are stable as well.
One of the reasons we want to do this is if she plans another pregnancy, we
want her to go into that pregnancy as healthy as she can. We want to have the
diabetes or high blood pressure under control before she gets pregnant. We call
that, of course, pre and interconception care. We want us to be really looking at
all of these medical pregnancy problems, and then we want to help this woman
transition to well women care. Once she comes for her postpartum visit after six
weeks, she's about done with that maternity care, and if she's got a family
doctor, that's great, she can continue there.
But if she's getting care from an obstetrician or a midwife, she is going to need
to be transferred to another site to continue her care. One of the advantages of
postpartum care is that we have the opportunity to get women involved in well
women care after the pregnancy. Sometimes if we don't see a woman for
postpartum care, we don't see her again until she's pregnant again, and we
would have so loved the opportunity to help her keep healthy in an interim.
We want to go not just follow up on medical problems during pregnancy, we
also want to follow up on social issues. One of them is smoking. A lot of
women are able to stop smoking in pregnancy because they are so concerned
about the health of their baby. Not all, that's for sure, but a lot of women can
manage it with our help. But then once they have the baby and all the stresses
we've talked about of new motherhood, 70% are previous smokers who were
just smoking.
Transcription by www.speechpad.com
So postpartum visit, perfect time to see how you're doing with that smoking,
perfect time to remind her that that smoking is not good for her baby either, and
that what can we do to help you stay away from tobacco? Alcohol use in
moderation but mood altering drugs is another very important social issue to
deal with. It turns out that women who are using either illegal drugs, like
heroine or prescription pain pills that are not prescribed for her, or even
methadone, the requirements for them to get the feeling that they expect are
higher in pregnancy, and especially at the end of pregnancy because the woman
is bigger.
She has a bigger bloodstream, she has a bigger weight. Once she loses the baby,
her requirement decreases and there's a danger of drug overdose in postpartum
women that we want to be aware of. Finally intimate partner violence in
pregnancy. We know that if that had gone on during pregnancy, there's a higher
risk of continued abuse. This is another type of women that are at big risk for
postpartum depression, post-traumatic stress disorder, and their babies are at
risk too for anxiety and depression.
So I want to be aware of following up on all these things as well. Finally and
very importantly, we need to think about reproductive life planning. We want to
ask these questions as you know to every woman of reproductive age every
year, whether she plans to have children or more children, how many and when,
but the postpartum visit is the perfect time to bring it up.
You want more, how many and when? Then when we talk about when, of
course, pointing out the optimal spacing of at least 18 months from delivering
one baby to conceiving the next. This is probably done with a famous study that
shows that this is very important, and what it shows us is that babies that are
conceived less than 18 months after a delivery have a higher risk of preterm
birth, low birth weight, and small for gestational age. So that is certainly
basically the mom's body has not yet time to recover.
Transcription by www.speechpad.com
It's not yet time to restore all of it, what it gives to the baby, and so these babies
turned out smaller, maybe early. A subsequent study to this has shown that
there's also an increase in infant mortality in that first year of life in woman
who conceive before 18 months. So it's very important to counsel our
participants about this and help them choose the contraceptions that will help
them wait that long if that's okay with them.
Here is another case. This is Shonda and she feels her little baby and she says,
"Well, I got pregnant by accident last time because I missed the birth control
pill, but actually me and my boyfriend are very happy with the baby now.
Things are good but..." she says she won't be ready for another one for at least
three years. You don't have to tell her about 18 months. She's talking three
years.
She says she would like something more effective for contraception than the
birth control pills, but she's breastfeeding. We're happily here and we want to be
sure she gets something that won't interfere with that. She says, "I need
something I don't forget to remember all the time because I am really busy with
the baby." How do we counsel Shonda? Well, I like this chart from the World
Health Organization. I've shown it in the sessions before.
This is available in the CDC website if you ever want to download it, but what
it shows you is basically everything that's available to women and the most
effective are on the top. Shonda can see that the there are some that are more
effective than pills and she may want to move to either the implant or the IUD,
which are what we call our LARC method, Long Acting Reversible
Contraceptive, but they are the most effective things we have.
She ends up choosing the implant. She says, "Well, it was three years, that's
how long it lasts, nothing to remember." It doesn't affect breastfeeding and can
be removed any time if she changes her mind. Eighteen months, she might be
ready for another one even though she doesn't think so now and any of these
methods can be removed and she can get pregnant again whenever she likes.
Transcription by www.speechpad.com
We talked all about the mom here, and of course what about the baby? It has to
be a question. It kind of depends on where this woman is getting her care,
whether the baby might get it with her if it's with his family doctor or a family
nurse practitioner or even a home visiting nurse or she's with an obstetrician or
midwife, it might have to be somewhere else. The main thing is finding out
where the baby will get care. Does the baby have insurance and a medical
home?
And then visits for the baby are recommended as early as two to five days after
going home from the hospital, and again at one, two, four, and six months.
What happens at those visits? Well, they'll be examined, history is taken, and
see how the baby is doing. Blood tests are done, very important immunization,
first one happens at one month. Baby is weighed and measured, get vision and
hearing checked, developmental milestones that you're doing as much as you
should be doing if there's time, and what about if it's responding to its mom and
dad? Is it healthy psycho-socially doing?
But one of the big advantages of postpartum care for the baby is a chance for
moms to have questions and dad too if he's along. Lots of questions about this
new baby and this provides the opportunity. But the counseling goes at the well
child visits also. Pediatricians call that anticipatory guidance.
Basically really important early on is to remember, remind the parents about the
ABCs of safe sleep which you see right there, make sure they're using a car seat
and know how to do so, make sure they know it's important to start reading
even to infants and encourage father involvement, and I love that picture
because it shows you that number three and number four can be combined.
That's a lot of things we do in a postpartum visit and maybe more than we even
thought. Let's keep track of, that's for sure and that's why the coin has been
working on a postpartum screen tool. I think they've all seen by now the six
Transcription by www.speechpad.com
screening tools that the coin has developed, and since they're all going to be
very beautiful, first of all though the coin is working on incorporating all the
comments that they got from all of you and then hopefully these will appear and
be useful to you by the end of the year.
The useful big...for example with the postpartum screening tool to be sure that
you are covering everything that we've mentioned. Make sure that everything
here has been covered and everything that we've talked about is on that
postpartum screening tool. I have one last case here. I love this picture. I just
think this is the basic new mom here. This is Glenda. Glenda's baby is clearly
older than six weeks and that's because she didn't go for her sixth week
postpartum check.
She says, "You know, I had a normal pregnancy, normal delivery, why do I
have to go?" A lot of women say this if they did have a normal pregnancy and a
normal delivery. They don't understand why they should get checked, but I
think we've seen a lot of good reasons already here today and I wish you would
have done. But we understand because she also said she was just too tired to go.
This baby is so active during the day and keeps her up at night and she's just too
tired. Not only does she thinks she doesn't need it, she's too tired to go, but she
brought her baby in for her three months check.
Now of course, women do this too, and I think we all recognize this. Women
take care of the baby before they take care of themselves. She brought her baby
in, but she didn't go for her check. Luckily in her situation, she was seeing a
pediatrician, and the pediatrician said, "You know, right in this same building,
down the hall, there are some midwives and you need to get your sixth week
check. How about going over there and getting a check while you're here?"
So Glenda did. Glenda goes down there. It's now at least three months since she
had her baby. But she says, "Well, since it turned out to be really helpful, I wish
I would have gone at six weeks." Because they did with a depression screen and
it was negative, but she sure was stressed as you could see in that picture. She
Transcription by www.speechpad.com
says the practitioner was just very understanding about the difficulties of being
a new mom.
Just talking about it made her feel better, but the practitioner also gave her some
suggestions on how she'd get more rest, referred her to a new mom support
group at the community center, and while she was there, Glenda had mentioned
that she already decided she didn't want another baby any time soon and this
gave her the opportunity to get started back on birth control pill. So you gave
her the opportunity to space her pregnancy. Glenda in the end did benefit from
that visit even though she had no real problem.
We see that postpartum care can be a wonderful thing and I think we saw four
examples where it helped the woman out. But it needs to be good postpartum
care too and I'm sure many of you listen to this thing. Yeah, this all sounds
good but is this really what our participants get? Another part of our initiative
as far as increasing the number of women who get postpartum care to make
sure that it's beneficial to them, to make sure that it is accessible and
convenient.
It's somewhere a woman can get to easily, it's a time the woman can get to
easily, or maybe it's a home visit. It needs to be accessible and convenient.
Ideally it's from one person, from both the mom and the baby, and if isn't
maybe they're connected in the same building like that ideal situation we just
talked about. And then it needs to be mother-centered. It has to be what women
really needs, not just looking to see how her stitches are doing.
It needs to be asking women what help and support they need and responding to
that and being sure that the content is culturally appropriate, helpful, and
meaningful for the woman. If, of course, we can achieve this then postpartum
care can be so important and really vital to the future health of the mom, the
baby, and the family. But thank you. I think we're ready for some questions.
Transcription by www.speechpad.com
Megan: Thank you so much Dr. Shepherd. We do have a few questions that
have come in already. And folks just a reminder, if you have any questions or
comments, please chat them in the bottom left corner of your screen. The first
question is related to breastfeeding and depression. "Is there a risk on
depression medication and breastfeeding?"
Dr. Shepherd: That's a really good question and some others are very concerned
about that. What we know is that a little bit of the medication gets in breast
milk. Some antidepressants more than others though. Ordinarily if a woman is
breastfeeding, the person who prescribes it will prescribe one of those that goes
across in very small amounts.
The general feelings from our pediatric colleagues is that the benefit of being
treated for the depression even with just little amount of medicine that goes to
the baby, the benefit of that and the benefit of breastfeeding together are worth
it. The breastfeeding, of course, does help with the maternal depression and
baby's development, and so that little bit antidepressant in the breast milk is not
considered significant.
Megan: Right. This question is about spacing. "After a stillbirth or a
miscarriage, is optimal spacing still recommended and how long should she
wait?"
Dr. Shepherd: Yeah, that's another good question. And interestingly since we
gave the last webinar, there is a new study that just came out and it talked about
how long you should wait after a miscarriage. We used to tell people that they
should wait a little while for their body and mind and emotions to recover, but
the study showed that women who got pregnant immediately actually did better
than women who waited. This is for women with a history of miscarriage.
Now with stillbirth, I have not seen similar data and I still would urge waiting at
least a little bit longer because that would have gone further in the pregnancy.
Transcription by www.speechpad.com
Your body has got to recover from, as well as that is of course a very traumatic
experience, but you probably don't need to wait 18 months.
Megan: Great. Okay. The next question that came in is about LARC. "Are
LARCs covered under all insurance plans? Or it might be inaccessible with
certain health insurance plans?"
Dr. Shepherd: Yeah, they are supposedly, the LARC method, basically all
methods of contraception are supposed to be covered by all insurances under
the Affordable Care Act. But as you may know there are some exceptions to
that. That is if women work for a religious organization that doesn't believe in
contraception or an organization like hobby lobby where the owners are
religious and they don't believe in contraception. So there are some people that
don't have that access but most people do because the access that they
need...what needs to be covered is one in every category of contraception.
Affordable Care Act guarantees that at least one kind of birth control pill is
covered, but the implant is always covered because there's only one implant,
and with the IUD that depends on the insurance plan. Many will cover both the
hormonal one and the non-hormonal one. We wish it was covered for everyone,
but it is covered for most people. Medicaid covers all this method and many of
our participants has nowhere on Medicaid, so it's much more accessible than it
used to be.
Megan: A little bit of this is in your presentation, Dr. Shepherd, but this
question did come up. "What do you say to a participant who says they don't
need to worry about birth control because they are breastfeeding?"
Dr. Shepherd: That's another good and important question and we see that come
up. Now, breastfeeding does help delay ovulation and does help delay that first
period. Like I said, the women who ovulate at 25 days after having a baby, they
are women who don't breastfeed. But it doesn't delay it completely and it
Transcription by www.speechpad.com
doesn't delay it for long. In order for breastfeeding, the work for contraception,
the women needs to breastfeed every three hours, and not only that. If the
woman has good nutrition, even that can wear off after a short time.
I've done some work overseas in countries that are developing countries. And
there, they use breastfeeding for contraception quite a bit. But of course they
can because they're often carrying their baby in a sling and their baby nurses
almost constantly, certainly every three hours. And these women also have a
lower nutritional status.
For those women for about six months it can work, but in our country because
we're healthier, even if you breastfeed every three hours, you can only
guarantee that as a work for about 10 weeks. So not a good choice for spacing
pregnancy. It's really good to add something else to that as a postpartum check.
Megan: "Is there a recommendation or is there any appropriate ages that's been
documented or stated to stop breastfeeding a baby?" I think the person is asking
about is there an age of a baby that is there's recommendations out there today?
Dr. Shepherd: I don't think that there really are. Our pediatric colleagues, they
encourage breastfeeding as long as it can be done. I mean, it has served its point
[SP], it becomes a little bit impractical, but I don't think there's any known
cutoff that I've heard of.
Megan: Another breastfeeding question, "What are natural ways to increase the
supply of a woman's milk when it begins to slow down?"
Dr. Shepherd: Well, usually if it begins to slow down, it's because the woman is
breastfeeding less. The more you breastfeed, the more the breast will make
milk. You have to right away think about that. And if you have gone back to
work and are not able to pump quite as the amount that you breastfed before,
Transcription by www.speechpad.com
then maybe you're not stimulating that breast enough to make enough milk. So I
think that's the first that you have to look at is the breastfeeding stimulated
enough and certainly is the mom getting enough fluids also?
Megan: Great. There's a comment here and a question Dr. Shepherd, and I'll
read the comment first. The person said, "Thank you for a great overview of
postpartum care. You mentioned throughout that we need to keep remembering
the importance of involving male partners and their needs. Do you know of any
successful strategies involving male partners to encourage breastfeeding when
baby and mom are at home from the hospital?"
Dr. Shepherd: Yeah, that is so important if we can do that. I think that one of
the most important ways we can do this is to involve the male from the get-go.
Because we start talking these days about breastfeeding during the pregnancy.
We talk about it all through the pregnancy, and then at the hospital, and then at
the postpartum check. I think the more the father can be included from the getgo, the more the father is going to buy in. I think that's probably the easiest
thing. And of course there's lots of other benefits to having the father involved
from the beginning also, but I think with breastfeeding, especially that's
important.
Megan: Okay. So another question, "What do you tell participants when they
ask you about urinating when they, say, cough, sneeze, or go for a walk?"
Dr. Shepherd: That's a question that we get frequently postpartum. And if we
don't get it, I think the woman is often wondering about it because many
women after they have a baby, the muscles have been stretched out, the muscles
down in the pelvis where the baby has come out, and they're not quite as strong,
and when we can make urine, yes, in all of these situations.
Now there's something called Kegel exercise that you can't emphasize enough.
These are exercises that strengthen those muscles. They can actually...they
Transcription by www.speechpad.com
began in pregnancy to prevent this from even being a problem, but they can
certainly begin afterwards to get those pelvic muscles back in shape. What this
involves is tightening those muscles. One way to help women understand what
we're mostly talking about is to tell them that when they urinate, they should try
to let a little urine out and stop, little urine out then stop. That's the muscle that
we're talking about.
Now, you don't want to exercise always by doing that because you can end up a
bladder infection, but that teaches you what muscles we're talking about. Then
we encourage women to tighten those muscles, hold for five seconds, release
for five seconds, hold for five seconds, like three times a day, and you can do
this any time. While you're doing the dishes, while you're waiting at stoplight,
any time, but exercising those muscles can help relieve any loss of urine and
other issues as well.
Megan: Well, thank you so much. Everyone, you have a moment or two to
submit a question if you have any other final questions, but I'll take a quick
moment to let you know we're in the process of setting up registration for the
March webinars and those will be sent out on the Healthy Start Lister of
announcing those webinars and registration for those webinars in the first week
of March. If you're not already, sign up for the Healthy Start Lister and get
those e-mails. We encourage you to sign up and stay tuned for that information.
It's not only do webinars and trainings get posted to that lister but other relevant
Healthy Start information.
Stay tuned for those upcoming webinars. As I've mentioned early on, this is the
third in the series of webinars going over the four perinatal periods. The last
webinar on parenting is scheduled for April the 12th, so it will cover the fourth
of the perinatal period. We don't have any more questions today, so I do want to
say one more thank you to you Dr. Shepherd for another great presentation. Do
you have any final closing remarks that you'd like to make?
Transcription by www.speechpad.com
Dr. Shepherd: I don't. Just thank you very much for having me and thank you
all for coming out to our call.
Megan: Okay, everyone. Thanks so much. These webinar materials will be
posted to the EPIC Center's website. So if you want to download the slides or
anything like that, you can find them on Healthy Start website, EPIC Center
website soon. That concludes our webinar. Thanks for your participation.
Transcription by www.speechpad.com