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January 2012 Issue for Perinatal Post

In this issue...

• Perinatal Mood Disorders
• Lamaze Supports Evidence-Based Childbirth Practices and Your Patient Relationship
• What is Folic Acid and Why Do You Need It?
• Global Maternity Health
• NCPA - North Carolina Perinatal Association
• AWHONN - Association of Women's Health, Obstetric and Neonatal Nurses
• Upcoming Perinatal CE Programs

Perinatal Mood Disorders

Fifteen to twenty percent of all pregnancies have some form of Postpartum Depression or Mood disorder.⁽¹⁾ When you think of the prevalence of gestational diabetes (GDM) at 3.5%, it is confusing that we routinely screen for GDM but not for Perinatal Mood Disorders. There are several reasons for this, including a scarcity of resources for women and their families who suffer with Perinatal Mood Disorders. It is a hard question to ask, but even harder if you do not have any resources to help these moms and their families. Stigma also plays a big part in the treatment or even identification of family's going through Perinatal Mood Disorders. Motherhood is "supposed to be" this beautiful and dreamy time when everyone is happy about being pregnant and many well-meaning friends ask "you have everything, what do you have to be depressed about?" The facts are that Perinatal Mood Disorders don't really care what a great family you have or how much you have wanted to have a baby. It is very indiscriminate. As stated above about 15-20% of all pregnancies will have some form of perinatal mood changes and these numbers increase with several risk factors:

• Prior history of depression/anxiety/bipolar disorder,
• Family history of major depression or other mental health issues,
• Recent stressful life events either negative or positive like, moving, getting a new job, or death of family or friend,
• Difficult delivery or delivery not turning out the way you expected,
• Medical complications for you and/or your baby,
• Chronic sleep deprivation,
• Isolation and,
• Lack of support from family and friends.

Other confounding issues in detection are that Perinatal Mood Disorders don't often present like major depression. Most women will be concerned about their inability to sleep or the overwhelming anxiety they are experiencing. While Perinatal Mood Disorders must meet criteria for major depression to be diagnosed as a Perinatal Mood Disorder, there are many symptoms that do not fit that mold. Included are:

• Feeling sad, irritable, hopeless, or overwhelmed,
• Crying spells,
• Guilty thoughts,
• Feeling inadequate to take care of your baby,
• Hypervigilence or worrying about something happening to the baby or someone else in the family,
• Scary thoughts about you, your baby, or other family members,
• Preoccupation with thoughts of death,
• Thoughts of running away or harming yourself,
• Restlessness or lack of control,
• Trouble concentrating and,
• Withdrawing from family and friends.

Those associated with perinatal anxiety and panic include:

• Excessive worry,
• Shortness of breath,
• Racing heart,
• Sweaty or cold clammy hands,
• Feeling keyed up or on the edge,
• Dizziness or light headed,
• Chest tightness,
• Fear of going crazy or doing something uncontrolled and,
• Disoriented or that the world has become unreal.

Last but not least is the controversy of treatment, especially if mom is pregnant or breastfeeding. Once a family has been identified at risk or is diagnosed with Perinatal Depression or Anxiety providers then face the difficult decision about treatment.

Treatment includes both pharmaceutical and non-pharmaceutical modalities. Cognitive Behavior Therapy (CBT) has been shown to be very helpful in treating mild to moderate depression. Self-care skills are also very important including adequate sleep for the parents, good nutrition and exercise can all work toward a positive result. Medication is used to treat moderate to severe symptoms including anxiety and insomnia. Much research has been focused on the effect of medication in pregnancy and lactation but we are beginning to see more evidence that untreated mood disorders can also have an effect on the developing fetus.

UNC opened the first In-patient Perinatal Psychiatric Unit in the country on August 15, 2011. The UNC Perinatal Mood Disorder Clinic provides both outpatient and in-patient treatment. Our mission is to help remove the stigma of Perinatal Mood Disorders and empower both women and health care providers in adequate and safe treatment. We are available for consultations on treatment and diagnosis and welcome collaboration with our colleagues throughout North Carolina.

Please visit our website for additional information and contact numbers. www.womensmooddisorders.org Or please feel free to contact Chris Raines MSN APRN_BC at 919-966-3115; christena_raines@med.unc.edu

-- Chris Raines MSN Perinatal Psychiatric Nurse Practitioner UNC Perinatal Mood Disorder

(1) Gavin N, Gaynes B, Lohr K, Meltzer-Brody S et al. (2005) Perinatal Depression: a systematic review of prevalence and incidence. Obstet Gynecol. 106:1071-83.

Lamaze Supports Evidence-Based Childbirth Practices and Your Patient Relationship

Today, the challenge for every provider and every health system is to offer care based on quality evidence. Lamaze supports your work in improving quality outcomes for your patients and enhancing their satisfaction with you and their care setting. Lamaze can be a valuable partner in your efforts to help women achieve good clinical outcomes and satisfying birth experiences.

• Simplify Birth. Everyone knows that childbirth can be demanding on a woman's body and mind, but Lamaze can help simplify the process of childbirth for your patients. It promotes a natural approach that alleviates a woman's fears and helps her manage pain - all with the goal of a safe and healthy birth, based on current evidence.
  • The Lamaze approach to birth can help reduce the use of unnecessary interventions, reducing costs and associated medical complications, while improving outcomes for all.
  • Lamaze reinforces your relationships with your patients, helping them to better understand what to expect during pregnancy and childbirth, providing information to help answer their questions and, in the end, facilitating patients' satisfaction and understanding ofthe medical care they receive.
• Use a Proven Approach. Lamaze practices are based on the best medical evidence available and are designed to promote safe and healthy pregnancies and births.
  • Lamaze's firm grounding in quality evidence reinforces your efforts to support optimal care for women and babies. Compared with non-evidence-based interventions, Lamaze can more significantly reduce the risk of adverse outcomes and the unnecessary use of resources.
• Improve Childbirth Understanding. The best start for your patients includes safe and healthy pregnancies and births, with practices based on current evidence. Lamaze can help your patients achieve this - and feel confident about giving birth - by serving as a resource for information about what to expect and the options available during the childbirth process.
  • When you support Lamaze, it becomes easier to successfully work with your patients to achieve healthy and satisfying outcomes.
  • Lamaze increases your patients' "childbirth literacy" by helping them become better educated about pregnancy and childbirth. Lamaze presents them with clinically sound, easy-to-understand information.
  • Lamaze can help you communicate more effectively with your patients. It serves as a critical information resource and reinforces your patients' responsibility to be a good partner with you in achieving healthy outcomes.
• Work as a Team. Women, families, providers and Lamaze educators each have an important role in the process of pregnancy, childbirth and early parenting. Together, all of you make up a community that works to help women and babies achieve safe and healthy outcomes.
  • Lamaze reinforces your efforts to support optimal care for women and babies. Compared with non-evidence-based interventions, Lamaze can more significantly reduce the risk of adverse outcomes and the unnecessary use of resources.

-- For more information about how Lamaze healthy birth practices can support you in your practice or how you can participate in an upcoming Lamaze Childbirth Educator seminar, please call Tara Owens Shuler at 919-684-2648 or tara.owens@duke.edu or visit http://dukeahec.mc.duke.edu

What is Folic Acid and Why Do You Need It?

Think you are getting all of the vitamins you need from your diet alone? Think again. Most people don't know that it is hard to get certain vitamins from food alone. They think they don't need to take multivitamins because they eat healthy foods. Multivitamins help fill in those nutrition gaps in the diet, especially when it comes to getting enough folic acid.

Folic acid is an essential B vitamin; therefore, everyone needs it in order to stay in good health. Folic acid helps build DNA and your body uses it for cell growth and reproduction, fundamental building block processing and genetic material production. Folic acid is water soluble; therefore it passes through your body very quickly. Taking folic acid every day ensures that you always have it in your system.

Other than being needed to create and regenerate cells in your body, it also has protective effects. Studies show that folic acid reduces the risk of certain cancers; cardiovascular diseases including coronary heart disease and stroke; and cognitive diseases or mental conditions such as Alzheimer's disease, age-related dementia or cognitive decline and depression.

For women in their childbearing years, it is particularly important to consume 400 mcg of folic acid daily. If all women of childbearing age took 400 mcg of folic acid every day, then the incidence of neural tube defects (NTDs) in the United States would decrease by 70 percent. NTDs are birth defects of the brain and spine. The most common are spina bifida and anencephaly. In North Carolina there is one child born with an NTD for every 1,160 live births, according to the North Carolina State Center for Health Statistics Birth Defects Monitoring Program. Since more than half of pregnancies are unplanned, it's important to take folic acid every day, even if you're not planning to get pregnant.

The March of Dimes North Carolina Preconception Health Campaign works to educate consumers and health care providers about the benefits and uses of folic acid, in addition to promoting other preconception health behaviors like healthy weight and tobacco cessation. Here in the Triad area, Stacie Turpin Saunders at the March of Dimes coordinates those efforts.

"My role is to make sure the message is being spread consistently and thoroughly," Saunders explains. "I offer educational trainings to women, I attend conferences and health fairs, and I educate health care providers about the importance of recommending folic acid to their female patients."

Saunders runs the local Community Ambassador program, a peer-to-peer health education program in which people are trained to carry on the folic acid message within their community.

"Since I can't educate everyone myself, the Campaign has come up with a way to reach as many people as possible," said Saunders. "Trained Community Ambassadors reach an additional 7-10 community groups each. Those groups include local civic groups, churches, teen groups, student groups, work sites, moms groups, parenting classes, preschool classes, house parties and beauty salons. The program is open to everyone, not just women."

Folic acid is the synthetic form of the naturally occurring folate. Folate is found in foods such as leafy green vegetables, beans, liver and some fruits. The synthetic version, folic acid, is found in multivitamins and fortified foods like breakfast cereal, pasta and bread. Scientists don't know exactly why, but folic acid is easier for your body to absorb than folate. Plus folate loses its potency easily and is hard to get in large amounts.

In 1998 the U.S. Food and Drug Administration started fortifying grain and cereal products with folic acid in order to reduce neural tube defects. While this was a great step in the fight to prevent birth defects, it is not enough to protect all women and their potential child

The Centers for Disease Control and Prevention, the U.S. Public Health Service, and the March of Dimes recommend that all women of childbearing age take 400 mcg of folic acid every day. The best and most reliable way to get that amount is to take a multivitamin, B vitamin complex pill or folic acid pill.

The March of Dimes North Carolina Preconception Health Campaign recommends that women take a multivitamin every day in order to get consistent amounts of other vitamins and minerals as well, like A, C, B6, E, Iron and Calcium. In addition, the Campaign suggests eating a healthy diet and getting regular physical activity.

People who are interested in joining the effort should contact Stacie Turpin Saunders at 336-231-3770 or by e-mail at STurpin-Saunders@marchofdimes.com. For more information about the March of Dimes North Carolina Preconception Health Campaign or folic acid, visit everywomannc.com or marchofdimes.com/northcarolina.

-- Megan Fazekas, Communications Coordinator, NC Preconception Health Campaign
March of Dimes, 6504 Falls of the Neuse Road, Suite 100, Raleigh, NC 27615. Tel: (919) 781-2481

Global Maternity Health

What is happening beyond the borders of North America? Implementation of the Millennium Development Goals began in 2005 by the United Nations and other organizations, with a focus on women and children. Current maternal mortality rates in the United States are approximately 17/100,000 live births, placing us in the rank of 45 of 195 nations. This high ranking is thought to be partially related to issues of access to care in the US.

Statistics from 2008 reflect an improvement in maternity mortality figures: a rate of one global maternal death per minute related to perinatal causes decreased to one death every 90 seconds. Even with the decrease, this reflects 342,900 deaths per year. Many approaches are needed to combat this staggering statistic.

One strategy involves access to antiretroviral medications for HIV-positive pregnant women in Africa. Others involve increasing the number of skilled birth attendants available to women giving birth and having women give birth in health care facilities instead of remote rural areas.

Hemorrhage accounts for approximately one-third of the deaths. Misoprostol (Cytotec) is now being disseminated to women in remote areas of Africa and Asia in an effort to combat this problem. This oral drug is saving the lives of thousands of women worldwide.

Global maternity health affects us all.

-- Edwards, JE. Why Global Health Matters. Nursing for Women's Health, 15 (5), 2011, pg 419-421.

North Carolina Perinatal Association

The North Carolina Perinatal Association, a coalition of healthy mothers and healthy babies, was formed in 1985 as a non-profit organization. The purpose of this organization is to improve perinatal health for childbearing families throughout the state. The North Carolina Perinatal Association (NCPA) provides leadership, education, and advocacy for healthy mothers and healthy infants. Through the use of state, regional, and local resources, and a multidisciplinary approach, the North Carolina Perinatal Association continues to promote the health and well being of families. NCPA membership is open to interested perinatal care provider. Please visit www.ncperinatalassociation.org to learn more about this professional organization in North Carolina.

AWHONN - Association of Women's Health, Obstetric and Neonatal Nurses

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) is a nonprofit membership organization that promotes the health of women and newborns. Our mission is to improve and promote the health of women and newborns and to strengthen the nursing profession through the delivery of superior advocacy, research, education and other professional and clinical resources to nurses and other health care professional.

North Carolina AWHONN exists to support the mission of the national organization while serving the North Carolina members through chapter support and providing a yearly educational program. The leadership of NC AWHONN is led by a Section Chair and Secretary/Treasurer elected biannually by the membership. The section advisory council includes all chapter leaders along with other appointed section leaders. NC AWHONN encourages members to be active participants at the chapter level and seeks involvement on the section level from interested members. Please visit www.awhonn-nc.org to learn about this professional organization.