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THURSDAY 31 JANUARY 2013

CRYOPRESERVATION

Cryopreservation 6Oocyte cryopreservationIndicationsMethodSuccess rates

egg donation 8

Egg donationEmbryo transferEmbryo profilingPreimplantation genetic diagnosis

Live birth rate 10BiomarkersOther factors

non pharmaCeutiCaL 11Maternal complicationsFetal complicationsIntrapartum asphyxia

Caesarean seCtion 13Types Indications risks 13 Risks for the motherRisks for the child

Infographic types of caesaren section

sCreening 7Weeks development

antimüLLerian hormone 9bLastoCyst differentiation 10ImplantationSusceptibility inner CeLL mass differentiation 9Cavity formationSusceptibilityInfographic of age difference

neonatoLogy 15Spectrum of careNursing and neonatal populations

LeveLs of Care 17Infographic of new born

equipment 17IncubatorQualifications and requirementsPatient populations

PRENATAL DIAGNOSIS

PAIN CONTROL NEONATOLOGY


CRYOPRESERVATION

Cryopreservation

The Rand Consulting Group has estimated there to be 400,000 frozen embryos in the United States. The advantage is that pa-tients who fail to conceive may become pregnant using such embryos without hav-ing to go through a full IVF cycle. Or, if pregnancy occurred, they could return later for another pregnancy. Spare oocytes or embryos resulting from fertility treatments may be used for oocyte donation or embryo donation to another woman or couple, and embryos may be created, frozen and stored specifically for transfer and donation by us-ing donor eggs and sperm. Also, oocyte cry-opreservation can be used for women who are likely to lose their ovarian reserve due to undergoing chemotherapy.The outcome from using cryopreserved em-bryos has uniformly been positive with no increase in birth defects or development ab-normalities.Other expansionsIntracytoplasmic sperm injection (ICSI) is where a single sperm is injected directly into an egg. Its main usage as an expansion of IVF is to overcome male infertility prob-lems, although it may also be used where eggs cannot easily be penetrated by sperm, and occasionally in conjunction with sperm donation. It can be used in teratozoosperm-ia, since once the egg is fertilised abnormal sperm morphology does not appear to in-fluence blastocyst development or blasto-

cyst morphology.Assisted zona hatching (AZH) can be performed shortly be-fore the embryo is transferred to the uterus. A small opening is made in the outer layer sur-rounding the egg in order to help the embryo hatch out and aid in the implantation process of the growing embryo.Luteal support is the administration of medication, generally progesterone, pro-gestins or GnRH agonists, to increase the success rate of implantation and early em-bryogenesis, thereby complementing and/or supporting the function of the corpus luteum.In egg donation and embryo donation, the resultant embryo after fertilisation is in-serted in another woman than the one pro-viding the eggs. These are resources for women with no eggs due to surgery, chemo-therapy, or genetic causes; or with poor egg quality, previously unsuccessful IVF cycles or advanced maternal age. In the egg donor process, eggs are retrieved from a donor’s ovaries, fertilised in the laboratory with the sperm from the recipient’s partner, and the resulting healthy embryos are returned to the recipient’s uterus.Embryo splitting can be used for twinning to increase the number of available.

Human oocyte cryopreservation (egg freez-ing) is a novel technology in which a wom-an’s eggs (oocytes) are extracted, frozen and

stored. Later, when she is ready to become pregnant, the eggs can be thawed, fertilized, and transferred to the uterus as embryos.

Oocyte cryopreservation is aimed at three particular groups of women: those diag-nosed with cancer who have not yet begun

chemotherapy or radiotherapy; those undergoing treatment with assisted re-

productive technologies who do not consider embryo freezing an option; and those who would like to pre-serve their future ability to have children, either because they do not yet have a partner, or for other personal or medical rea-sons.Over 80,000 reproductive-age women are diagnosed with cancer each year. Chemother-apy and radiotherapy are toxic for oocytes, leaving few, if any, viable eggs. Egg freezing offers women with cancer the chance to preserve their eggs so that

they can have children in the fu-ture.

Oocyte cryopreservation is an important option for individuals undergoing IVF who object, either for religious or ethical rea-sons, to the practice of freezing embryos. Having the option to fertilize only as many eggs as will be utilized in the IVF process, and then freeze any remaining unfertilized eggs can be a positive solution. In this way, there are no excess embryos created, and there need be no disposition of unused fro-zen embryos, a practice which can create complex choices for certain individuals.Egg freezing can also be beneficial for women who, for the purpose of education, career or other reasons, desire to postpone childbearing. Freezing eggs at an early age may ensure a chance for a future pregnancy.Additionally, women with a family history of early menopause have an interest in fer-tility preservation. With egg freezing, they will have a frozen store of eggs, in the likeli-hood that their eggs are depleted at an early age.

The egg retrieval process for oocyte cryo-preservation is the same as that for in vitro

fertilization. This includes one to several weeks of hormone injections that stimulate ovaries to ripen multiple eggs. When the eggs are mature, a medication to trigger ovulation is given and the eggs are removed from the body using an ultrasound-guided needle through the vagina. The procedure is usually conducted under sedation. The eggs are immediately frozen.The egg is the largest cell in the human body and contains a great amount of water. When the egg is frozen, the ice crystals that form can destroy the integrity of the cell. To prevent this, the egg must be dehydrated prior to freezing. This is done using cryo-protectants which replace the water within the cell and inhibit the formation of ice crystals.Eggs (oocytes) are frozen using either a

controlled-rate, slow-cooling method or a newer flash-freezing process known as vit-rification. Vitrification is much faster but requires higher concentrations of cryopro-tectants to be added. The result of vitrifica-tion is a solid glass-like cell, free of ice crys-tals. Vitrification is associated with higher survival rates and better development com-pared to slow-cooling when applied to oo-cytes in metaphase II (MII). Vitrification has also become the method of choice for pronuclear oocytes, although prospective randomized controlled trials are still lack-ing.Once frozen, the zona pellucida, or shell of the egg hardens. Fetal versus maternalSome screening tests performed on the woman are intended to detect traits or char-acteristics of the fetus. Others conditions in the woman that may have an adverse effect on the fetus, or that threaten the pregnancy.


The percentage of transferred cycles is somewhat lower in frozen cycles compared with fresh cycles (approx. 80% and 90%, re-spectively).Two recent studies showed that the rate of birth defects and chromosomal defects when using cryopreserved oocytes is con-sistent with that of natural conception.Recent modifications in protocol regarding cryoprotectant composition, temperature and storage methods have had a large im-pact on the technology, and while it is still considered an experimental procedure, it is quickly becoming an option for women. Slow freezing traditionally has been the most commonly used method to cryopre-serve oocytes, and is the method that has resulted in the most babies born from fro-zen oocytes worldwide. Ultra-rapid freezing or vitrification represents a potential alter-native freezing method.In the fall of 2009, The American Society for Reproductive Medicine (ASRM) issued an opinion on oocyte cryopreservation concluding that the science holds “great promise for applications in oocyte donation and fertility preservation” because recent laboratory modifications have resulted in improved oocyte survival, fertilization, and pregnancy rates from frozen-thawed oo-cytes in IVF. The ASRM noted that from the limited research performed to date, there does not appear to be an increase in chromosomal abnormalities, birth defects, or developmental deficits in the children born from cryopreserved oocytes. The ASRM recommends that, pending further research, oocyte cryopreservation should be introduced into clinical practice on an in-vestigational basis and under the guidance of an Institutional Review Board (IRB). As with any new technology, safety and ef-ficacy must be evaluated and demonstrated through continued research.

there is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. Goals for achieving an op-timal cesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes, taking into account available medical and health resources and maternal preferences. This opinion is based on the idea that if left unchallenged.

WHATTYPES OF CELLS

AND TISSUESARE CRIO

PRESERVED.

Spermatazoa

Clevage stage embryos

Blastocysts

Oocytes

Testis tissue

Ovarian tissue

Other

26%

22%

5%8%

10%

13%

16%

IVF Live Birth Rate per Embryo TransferIncludes All Fresh Embryo and Blastocyst Transfer

Non - Donor Eggs, 2012

Age <35 35-37 38-40 41-42 N 105/108 45/100 28/58 6/30

58%

48%

41%38%

29%28%

20%17%

NationalRMACT

N of EmbryosFemale Age

Success rate per embrio transfer

IVF with eggs ( 35-40%)

IVF with donor eggs (53%)

Surrogscy with donor eggs ( 72%)

Surrogacy with own eggs(55%)

200%

Female Age

Percent with Freezing

58%

43%

31%

5%

<35 35-37 38-40 41-42 Cryopreservation of embryos is the process of preserving an embryo at sub-zero temperatures, generally at an embryogenesis stage corresponding to pre-implantation, that is, from fertilisation to the blastocyst stage.


Some screening tests performed on the woman are intended to detect traits or characteristics of the fetus. Others detect conditions in the woman that may have an adverse effect on the fetus, or that threaten the pregnancy. For example, abnormally low levels of the serum marker PAPP-A have been shown to correspond to an increased risk of pre-eclampsia, in which the mother’s high blood pressure can threaten the pregnancy, though many physicians find regular blood-pressure monitoring to be more reliable.

There are three purposes of prenatal diagnosis: (1) to enable timely medical or surgical treatment of a condition before or after birth, (2) to

give the parents the chance to abort a fetus with the diagnosed condition, and (3) to give parents the chance to “prepare” psychologically, socially, financially, and medically for a

baby with a health problem or disability, or for the likelihood of a stillbirth.Having this information in advance of the birth means that healthcare staff as well as parents can better prepare themselves for the delivery of a child with a health prob-lem. For example, Down Syndrome is associated with cardiac defects that may need intervention immediately upon birth.Many expectant parents would like to know the sex of their baby before birth. Methods include amniocentesis with karyotyping, and prenatal ultrasound. In some countries, health care providers are expected to withhold this information from parents, while in other countries they are expected to give this informa-tion.

Because of the miscarriage and fetal damage risks associated with amniocentesis and CVS procedures, many women prefer to first undergo screening so they can find out if the fetus’ risk of birth defects is high enough to justify the risks of in-vasive testing. Since screening tests yield a risk score which represents the chance

that the baby has the birth defect, the most common threshold for high-risk is 1:270. A risk score of 1:300 would therefore be considered low-risk by many physi-

cians. However, the trade-off between risk of birth defect and risk of complications from invasive testing is relative and subjective; some parents may decide that even a

1:1000 risk of birth defects warrants an invasive test while others wouldn’t opt for an invasive test even if they had a 1:10 risk score.

ACOG guidelines currently recommend that all pregnant women, regardless of age, be offered invasive testing to obtain a definitive diagnosis of certain birth defects. Therefore, most physicians offer diagnostic testing to all their patients, with or without prior screening and let the patient decide.The following are some reasons why a patient might consider her risk of birth defects already to be high enough to warrant skipping screening and going straight for invasive testing.

Women who have previously had premature babies or babies with a birth defect, especially heart or genetic problemsWomen who have high blood pressure, lupus, diabetes, asthma, or epilepsyWomen who have family histories or ethnic backgrounds prone to genetic disorders, or whose partners have theseWomen who are pregnant with multiples (twins or more)Women who have previously had miscarriages

PRENATAL DIAGNOSIS

The aim is to detect birth defects such as neural tube defects, Down syndrome, chro-mosome abnormalities, genetic diseases and other conditions, such as spina bifida, cleft palate, Tay Sachs disease, sickle cell anemia, thalassemia, cystic fibrosis, Muscular dys-trophy, and fragile X syndrome. Screening can also be used for prenatal sex discern-ment. Common testing procedures include amniocentesis, ultrasonography includ-ing nuchal translucency ultrasound, serum marker testing, or genetic screening. In some cases, the tests are administered to de-termine if the fetus will be aborted, though physicians and patients also find it useful to diagnose high-risk pregnancies early so that delivery can be scheduled in a tertiary care hospital where the baby can receive appro-priate care.Fetal screening has also been done to deter-mine characteristics generally not consid-ered birth defects, and avail for e.g. sex selection. The rise of designer babies and parental selection for specific traits raises a host of bioethical and legal issues that will dominate reproductive rights debates in the 21st century.

Diagnostic prenatal testing can be by inva-sive or non-invasive methods. An invasive method involves probes or needles being inserted into the uterus, e.g. amniocentesis, which can be done from about 14 weeks ges-

tation, and usually up to about 20 weeks, and chorionic villus sampling, which can be done earlier (between 9.5 and 12.5 weeks gestation) but which may be slightly more risky to the fetus. One study comparing transabdominal chorionic villus sampling with second trimester amniocentesis found no significant difference in the total pregnancy loss between the two procedures. However, transcervical chorionic vil-lus sampling carries a significantly high-er risk, compared with a second trimester amniocentesis, of total pregnancy loss (rela-tive risk 1.40; 95% confidence interval 1.09 to 1.81) and spontaneous miscarriage (9.4% risk; relative risk 1.50; 95% confidence in-terval 1.07 to 2.11).Non-invasive techniques include examina-tions of the woman’s womb through ultra-sonography and maternal serum screens (i.e. Alpha-fetoprotein). Blood tests for se-lect trisomies (Down syndrome in the Unit-ed States, Down and Edwards syndromes in China) based on detecting fetal DNA present in maternal blood have become available. If an elevated risk of chromosom-al or genetic abnormality is indicated by a non-invasive screening test, a more invasive technique may be employed to gather more information.In the case of neural tube de-fects, a detailed ultrasound can non-inva-sively provide a definitive diagnosis.

sCreening


Some screening tests performed on the woman are intended to detect traits or characteristics of the fetus. Others detect conditions in the woman that may have an adverse effect on the fetus, or that threaten the pregnancy. For example, abnormally low levels of the serum marker PAPP-A have been shown to correspond to an in-creased risk of pre-eclampsia, in which the mother's high blood pressure can threaten the pregnancy, though many physicians find regular blood-pressure monitoring to be more reliable.

There are three purposes of prenatal diag-nosis: (1) to enable timely medical or surgical treatment of a condition before or after birth, (2) to give the parents the chance to abort a fetus with the diagnosed condition, and (3) to give parents the chance to "pre-pare" psychologically, socially, financially, and medically for a baby with a health prob-lem or disability, or for the likelihood of a stillbirth.Having this information in advance of the birth means that healthcare staff as well as

parents can better prepare themselves for the delivery of a child with a health prob-lem. For example, Down Syndrome is as-sociated with cardiac defects that may need intervention immediately upon birth.Many expectant parents would like to know the sex of their baby before birth. Methods include amniocentesis with karyotyping, and prenatal ultrasound. In some countries, health care providers are expected to with-hold this information from parents, while in other countries they are expected to give this information.

Because of the miscarriage and fetal dam-age risks associated with amniocentesis and CVS procedures, many women prefer to first undergo screening so they can find out if the fetus' risk of birth defects is high enough to justify the risks of invasive test-ing. Since screening tests yield a risk score which represents the chance that the baby has the birth defect, the most common threshold for high-risk is 1:270. A risk score of 1:300 would therefore be considered low-risk by many physicians. However, the trade-off between risk of birth defect and risk of complications from invasive test-ing is relative and subjective; some parents

may decide that even a 1:1000 risk of birth defects warrants an invasive test while oth-ers wouldn't opt for an invasive test even if they had a 1:10 risk score.ACOG guidelines currently recommend that all pregnant women, regardless of age, be offered invasive testing to obtain a de-finitive diagnosis of certain birth defects. Therefore, most physicians offer diagnostic testing to all their patients, with or without prior screening and let the patient decide.The following are some reasons why a pa-tient might consider her risk of birth de-fects already to be high enough to warrant skipping screening and going straight for invasive testing.Women over the age of 35Women who have previously had prema-ture babies or babies with a birth defect, especially heart or genetic problemsWomen who have high blood pressure, lu-pus, diabetes, asthma, or epilepsyWomen who have family histories or ethnic backgrounds prone to genetic disorders, or whose partners have theseWomen who are pregnant with multiples (twins or more)Women who have previously had miscar-riages

In patience undergiong NC-FET If you add luteral phase support

Other

Both IM and VaginalProgesterone in di�erent cycles

5%

5%

3%7%

No support

43%IM injection

Vaginal

38%

Both in the same cycle

In patient ondergoing NC-FET If you add luteral suport

When do you stop it

At the timeof a positive pregnancy

9%

At the time fetalheart bit is detected

17%

19%At gestationalweek

At 10 gestationalweeks

25%


At the time of apositive pregnancy test

At the time fetalheart bit is detected

At 8 gestational weeks



> 12 gestational weeks

30%

In patients undergoing HRTWhen do u stop hormone repalcement

2% 5% 6%

16%

37%

34%


PAIN CONTROL

non pharmaCeutiCaL

Some women prefer to avoid analgesic med-ication during childbirth. They can still try to alleviate labor pain using psychological preparation, education, massage, acupunc-ture, TENS unit use, hypnosis, or water therapy in a tub or shower. Some women like to have someone to support them dur-ing labor and birth, such as the father of the baby, a family member, a close friend, a partner, or a doula. The human body also has a chemical response to pain, by releasing endorphins. Endorphins are present before, during, and immediately after childbirth. Some homebirth advocates believe that this hormone can induce feelings of pleasure and euphoria during childbirth, reducing the risk of maternal depression some weeks later.Water birth is an option chosen by some women for pain relief during labor and childbirth, and some studies have shown water birth in an uncomplicated pregnancy to reduce the need for analgesia, without evidence of increased risk to mother or

newborn. Hot water tubs are available in many hospitals and birthing centres.Meditation and mind medicine techniques are also used for pain control during labour and delivery. These techniques are used in conjunction with pro-gressive muscle relaxation and many other forms of relaxation for the mind and body to aid in pain control for women during childbirth. One such technique is the use of hyp-nosis in childbirth. There are a number of organizations that teach women and their partners to use a variety of techniques to assist with labor comfort, without the use of pharmaceuticals.A new mode of analgesia is sterile water in-jection placed just underneath the skin in the most painful spots during labor. A control trial in Iran of 0.5mL injections was con-ducted with normal saline which revealed a statistical superiority with water over saline.

Learning how to relax is so important in la-bour, otherwise you end up in the vicious cycle of fear tension pain. When you tense up and get tight (which is a natural reaction to any sort of pain) it actually makes that pain worse.

With Calmbirth, you learn To access your natural inner resources to alleviate the fear, anxiety and tension experienced during pregnancy, labour and childbirthPractical skills of relaxation, breathing and visualisation which are used during preg-

nancy, labour, childbirth and beyondHow the mother’s body is beautifully de-signed to birth her baby naturally and calm-ly and with the right preparation, to work with the process rather than resist itThe importance of a mother’s beliefs and attitudes about birth and how these can be one of the major differences between a pos-itive or negative birth experienceThe importance of bonding with your baby and how this effects your baby’s future lifeTo be empowered to take control of your own birthing experience

“I found one of the best forms of pain relief during labour was definitely our doula. Whilst I may have had different techniques to help me through labour pains, my dou-la was the one who helped me to find the best method of drug free relief for the stage of birth I was at. The support she offered throughout also helped me to stay focused which in itself is pain relief, as stress only leads to pain and she was able to help me keep calm.”

According to studies, women who use Doulas have 60% less requests for epi-

durals and 50% caesarean sections, amongst many other things. Having

a Doula present at your birth is a great way to avoid using pain relief, as she has expe-rience in support methods, positions and tools to help women get more comfortable and feel more supported in labour, so the woman doesn’t feel the need to request pain relief.

It isn’t just homebirth women or those strongly against pain relief who benefit – not only have all my clients been in hospi-tals, but many have said they weren’t sure how they would go in labour without pain relief as they have a low pain threshold. It’s surprising what you can deal with in labour with some great support.

The first stage of labour is the contractions prior to pushing – pushing is second stage. Most midwives and birth attendants will recommend getting into the bath once you are in ac-tive labour, as being in a bath creates buoyancy and you want to work with gravity in early

labour to make sure the labour isn’t going to stall.

Showers are also great, as you can remain upright and direct the show-

er head at your lower back if you have back pain. Even if you think you aren’t a shower person, in labour, many women choose to use the shower and some spend a great deal of their labours under the shower.

There are also many benefits for babies born in water. Andrew Davidson is an Obstetrician at John Flynn Hospital in Queensland who says that around 40% of women at the hospital use water immersion for labour. Birth satisfaction amongst those who waterbirth is very high.

THURSDAY 31 JANUARY 2013 13 14

Different measures for pain control have varying degrees of success and side effects to the woman and her baby. In some countries of Europe, doctors commonly prescribe inhaled nitrous oxide gas for pain control, especially as 50% nitrous oxide, 50% oxygen, known as Entonox; in the UK, midwives may use this gas without a doc-tor’s prescription. Pethidine (with or without promethazine) may be used early in labour, as well as other opioids such as fentanyl, but if given too close to birth there is a risk of respiratory depression in the infant.Popular medical pain control in hospitals include the regional anes-thetics epidural blocks, and spinal anaesthesia. Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost.Generally, pain and cortisol increased throughout labor in women without EDA. Pain and stress hormones rise throughout labor for women without epidurals, while pain, fear, and stress hormones decrease upon administration of epidural analgesia, but may rise again later. Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not ap-pear to have an immediate effect on neonatal status as determined by Apgar scores.

Both general and regional anesthesia (spinal, epidural or combined spinal and epidural anesthesia) are acceptable for use during Caesar-ean section. Regional anesthesia is preferred as it allows the mother to be awake and interact immediately with her baby. Other advan-tages of regional anesthesia include the absence of typical risks of general anesthesia: pulmonary aspiration (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and Oesophageal intubation.Regional anesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anesthesia being the most commonly

used regional techniques in scheduled Caesarean section. Regional anesthesia during Caesarean section is different to the analgesia (pain relief) used in labor and vaginal delivery. The pain that is ex-perienced because of surgery is greater than that of labor and there-fore requires a more intense nerve block. The dermatomal level of anesthesia required for Caesarean delivery is also higher than that required for labor analgesia.General anesthesia may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia. Gener-al anesthesia is also preferred in very urgent cases, such as severe fe-tal distress, when there is no time to perform a regional anesthesia.

To allow the catheter to be inserted, you lie curled on your side or sit on the edge of the bed while an anesthesiologist or nurse anes-thetist cleans your back, injects the area with numbing medicine, and carefully guides a needle into your lower back. (This may sound painful, but for most women, it’s not.)The anesthesiologist or nurse anesthetist then passes a catheter through the needle, withdraws the needle, and tapes the catheter in place so medication can be administered through it as needed. You can lie down at this point without disturbing the catheter.First you’re given a small “test dose” of medicine to be sure the epidural was placed correctly, followed by a full dose if there are no problems. Your baby’s heart rate is monitored continuously, and your blood pressure is taken every five minutes or so for a while af-ter the epidural is in to make sure it isn’t having any negative effects.The medication delivered by the epidural is usually a combination of a local anesthetic and a narcotic. Local anesthetics block sen-sations of pain, touch, movement, and temperature, and narcotics blunt pain without affecting your ability to move your legs. Used together, they provide good pain relief with less loss of sensation in your legs and at a lower total dose than you’d need with just one or the other.

pharmaCeutiCaL

You don’t need to be a professional to pro-vide massage in labour – loving, nurturing strokes and massage on a woman’s body in labour is all you need to provide.

Some studies have been done on pain relief and massage. One of the studies involved massage conducted by the woman’s partner. They found that the woman’s anxiety and pain was reduced and her mood improved. Another concluded that massage was a cost-effective option that could be imple-mented by midwives. Women perceived a reduction in their pain and anxiety levels, and found with partner involvement, they

had a more positive birth experience. Yet another concluded that women who were massaged during labour were less anxious, experienced less pain, had shorter labours and experienced less postnatal depression, opposed to the control group of women who did not receive massage.

Massage can be performed by your partner or a doula, but often midwives are too busy to perform massage, so plan for your part-ner or a support person to do the massage.Massage stimulates the production of en-dorphins which are natural pain killers and mood enhancers. In labour, massage can

be given on the shoulders, head, back, feet, legs and hands. If you buy oils for massage, make sure you check that the essential oils are safe in labour. Some essential oils need to be avoided. It’s best to buy a base carrier oil, like avocado, grapeseed or almond oil and add safe oils to it if you wish. Some oils safe in labour include lavender (relaxing), geranium (relaxing), orange (uplifiting, re-freshing), clary sage (strengthen contrac-tions), but please do check the correct doses with someone who is trained in aromather-apy – even if you go to a store like Jurlique they can help you out.

Cervix

Uterus

Placenta

Pelvis

Umbrical cord


POSTPARTUM DEPRESSION

Postpartum depression (PPD), also called postnatal depression, is a type of clinical de-pression which can affect women, and less frequently men, typically after childbirth. Studies report prevalence rates among women from 5% to 25%, but methodologi-cal differences among the studies make the actual prevalence rate unclear. Among men, in particular new fathers, the incidence of postpartum depression has been estimated to be between 1.% and 25.5%.Postpartum depression occurs in women after they have carried a child. Symptoms include sadness, fatigue, changes in sleeping and eating pat-terns, reduced libido, crying episodes, anxi-ety, and irritability. Although a number of risk factors have been identified, the caus-es of PPD are not well understood. Many women recover with a treatment consisting of a support group or counseling.The Edinburgh Postnatal Depression Scale, a standardized self-reported questionnaire, may be used to identify women who have postpartum depression.[ If the new mother scores more than 13, she is likely to develop PPD.

Postpartum depression usually begins in the first few months after childbirth. In Di-agnostic and Statistical Manual of Mental Disorders, Fourth Edition it is defined as depression with onset within 4 weeks after childbirth. Postpartum depression can also affect women who have suffered a miscar-

riage. It usually begins around two weeks after childbirth. It may last up to several months or even a year.

These factors are known to correlate with PPD. “Correla-tion” in this case means that, for example, high levels of pre-natal depression are associated with high levels of postnatal de-pression, and low levels of prenatal depression are associated with low levels of postnatal depression. But this does not mean the prenatal depres-sion causes postnatal depression—they might both be caused by some third fac-tor. In contrast, some factors, such as lack of social support, almost certainly cause postpartum depression. (The causal role of lack of social support in PPD is strong-ly suggested by several studies, including O’Hara 1985, Field et al. 1985; and Gotlib et al. 1991.) Anthropologists Kruckman and Stern tested the idea cross culturally, and their pioneering study determined six ways in which postpartum rituals, including the use of the postpartum ritual, la cuarentena, in Chicago Latina mothers, to protect or cushion the expression of mood disorders.In addition to Beck’s meta-analysis cited above, other academic studies have shown a correlation between a mother’s race, social class and/or sexual orientation and postpar-tum depression.

The etiology of PPD is not well understood. It is sometimes assumed that postpartum depression is caused by a lack of vitamins.Other studies tend to show that more likely causes are the significant changes in a wom-an’s hormones during pregnancy. Yet other studies have suggested there is no known correlation between hormones and postpar-tum mood disorders, and hormonal treat-ment has not helped postpartum depression victims. Further, fathers, who are not un-

dergoing profound hormonal changes, suffer PPD at relatively high rates.

Finally, all mothers experience these hormonal changes, yet only about 10–15% suffer PPD. This does not mean, however, that hormones do not play a role in PPD. For ex-ample, in women with a history of PPD, a hormone treatment simulating pregnancy and par-turition caused these women to suffer mood symptoms. The same treatment, however, did not cause mood symptoms in

women with no history of PPD. One in-terpretation of these results is that there is a subgroup of women who are vulnerable to hormone changes during pregnancy. Another interpretation is that simulating a pregnancy will trigger PPD in women who are vulnerable to PPD for any of the rea-sons indicated by Beck’s meta-analysis as summarized above.Profound lifestyle changes brought about by caring for the infant are also frequently claimed to cause PPD, but, again, there is little evidence for this hypothesis. Moth-ers who have had several previous chil-dren without suffering PPD can nonethe-less suffer it with their latest child. Plus, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.In 2009, researchers at the University of California, Irvine, reported that the levels of placental corticotropin-releasing hor-mone (CRH) during the 25th week of preg-nancy may help predict a woman’s chances of developing postpartum depression.

Research suggests that PPD is a functional component of human re-

productive decision-making, research supports the notion that PPD declined

mothers investment in their offspring. Human infants require an extraordinary

degree of care. Lack of support and insuf-ficient investment from fathers and/or oth-er family members will increase the costs borne by mothers, whereas infant health problems will reduce the evolutionary ben-efits to be gained. If ancestral mothers did not receive enough support from fathers or other family members, they may not have been able to afford raising the new infant without harming any existing children, or damaging their own health (nursing de-pletes mothers’ nutritional stores, placing the health of poorly nourished women in jeopardy).For mothers suffering inadequate social support or other costly and stressful cir-cumstances, negative emotions directed towards a new infant could serve an impor-tant evolved function by causing the mother to reduce her investment in an unaffordable

infant, thereby reducing her costs. Numer-ous studies support the correlation between postpartum depression and lack of social support or other childcare stressors. Kruck-man, using observations from anthropo-logical field work, suggests that supportive rituals and knowledge, if projected to the mother in a meaningful and sincere fash-ion, can affect the hypothalamus, pituitary and adrenal function and the production of endocrine signal molecules, and reduce the expression of anxiety or panic in postpar-tum women.Mothers with postpartum depression can unconsciously exhibit fewer positive emo-tions and more negative emotions toward their children, are less responsive and less sensitive to infant cues, less emotionally available, have a less successful maternal role attainment, and have infants that are less securely attached; and in more extreme cases, some women may have thoughts of harming their children are suffering some kind of cost, like inadequate social support, and consequently are mothering less.

postnataL depression

THURSDAY 31 JANUARY 2013 17 18

Association between the presence of depression and socio-demographic data

Major depression

Yes No Total Value of p OR (CI ti 95%) Variable

N % N % N %

Age

Up to 20

21 to 30

31 or more

Civil status

Education

Do you work?

Family income (MW)

Number of the person who depend on the income

Single/widow/separated

Married

Consensual union

Primary incompletePrimary complete

Secondary complete

Higered complete

Yes

No

Up to 1More than 1 to 5

More than 5

up to 3

4 till 6

7 or more

Number of kids with the last

1

2

3 or more

2 3,6 5,4 96,4 56 100.0

100.0

100.0

100.0

100.0

100.0100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

18 8,0 208 92,0 226

7

8

3

14

7

16

3

13

15

12

11

6

11

15

3

10

9

7

9 7,6

12,1

4,5

8,4

7,1

7,8

8,6

3,8

6,6

7,5

8,5

7,1

5,1

5,7

8,5

10,0

4,4

8,4

11,7

109

51

168

152

3985

170

77

185

185

129

144

98

183

161

27

217

98

53

92,4

87,9

95,5

91,6

92,9

92,4

91,4

96,3

93,4

92,5

91,5

92,9

94,2

94,3

91,5

90,0

95,6

91,6

88,3

118

58

176

166

4292

186

80

198

200

141

155

104

194

176

30

225

107

60

p = 0,516

p = 0,119

p = 0,576

p = 0,716

p = 0,713

p = 0,477

p = 0,093

1,00

2,34(0,53 to 10,38

2,23(0,46 to 10,68)

1,49(0,57 to 3,95)

1,49(0,57 to 3,95)

1,49(0,57 to 3,95)

0.52 (0,21 to 1,27)

0.52 (0,21 to 1,27)

1,97(0,38 to 10,24)

1,97(0,38 to 10,24)

1,97(0,38 to 10,24)

2,11(0,53 to 8,46)

2,11(0,53 to 8,46)

2,42(0,68 to 8,54)

1,00

1,00

1,00

1,55(0,69 to 4,19)

1,55(0,69 to 4,19)

1,15(0,53 to 2,49)