December, 2002

 

• POSTPARTUM DEPRESSION
• CORD BLOOD BANKING
• LETTER FROM HOME

 

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POSTPARTUM DEPRESSION

Evanston Northwestern Healthcare, the current owner of Highland Park Hospital, has initiated a program of early intervention to help physicians increase their awareness diagnosing and treating postpartum depression. A bereaved couple who lost their daughter to a tragic suicide nine months after the birth of her first child, helped to fund this program. Our staff attended the meeting at Evanston Hospital where this new program was introduced. Psychiatrists, psychologists, social workers, and obstetricians spoke at this meeting and attempted to explain this all too common condition. They all agreed that the cause of this disabling syndrome is still unknown.

This meeting caused me to reflect upon my twenty-five years of experience in which I have rarely seen this serious condition, despite having delivered over 3,500 babies. I have often seen “baby blues” which is a self-limited condition that clears spontaneously. I have come to believe that it is the unique nature of our obstetrical practice which actually prevents this dangerous condition from occurring. As with any other disease, it is more effective to prevent it than to search for a cure after it develops.

I believe that the following routine services from our practice represent a formula that can help to prevent postpartum depression:

1. We caution all patients to plan to take two full weeks off following childbirth. Other people should be responsible for the cooking, shopping, cleaning, laundry, and care of the older children so the new mother can rest with the new baby. Breastfeeding is a twenty-four hour a day job; therefore daytime naps are needed to help the body heal from childbirth and to establish an abundant milk supply. Sleep deprivation is a known cause of depression as well as immune system suppression. This two week rest period should not be considered a luxury. Rather it is a necessity that helps to insure a healthy postpartum recovery.
2. The nutritional advice that we give during a pregnancy is designed to provide adequate protein, vitamins, minerals, antioxidants, and phytonutrients to create a healthy pregnancy, delivery, and newborn. In addition this same nutritional advice applies after delivery to help insure a healthy recovery. We recommend eating lean protein sources with each meal, multiple servings of vegetables and fruits, and monounsaturated fats rather than saturated or polyunsaturated fats. We also recommend avoiding highly refined foods, soda, aspartame, candy, luncheon meats, and trans fats. We advise taking natural food-based vitamins rather than synthetic vitamins. This way of eating aims to provide essential nutrients as well as to stabilize blood sugar. The brain is heavily dependent upon sugar from the blood for its metabolic functions. Providing a steady, stable blood sugar level will optimize brain function and minimize mood disorders such as depression.
3. Supplementation with the long-chain omega-3 fatty acids EPA and DHA in fish oil is known to enhance brain function and prevent depression. EPA and DHA act on the brain to improve blood flow and oxygen transport, and to increase levels of serotonin. DHA is a major constituent of the neuron cell membrane. Also its increased presence in breast milk has the added benefit of optimizing the baby’s brain and retina development. We recommend that all our pregnant and lactating mothers take 1,080 mg. of EPA and 720 mg. of DHA daily in the form of molecular distilled fish oil.
4. Breastfeeding releases endorphins, which are mood-elevating hormones. Breastfeeding is Nature’s method of preventing depression during a stormy period of hormonal changes, physical challenges, and sleep deprivation. We strongly encourage breastfeeding and virtually 100% of our patients breastfeed their babies. We back up our encouragement with numerous accumulated years of breastfeeding knowledge and expertise among our fine staff. We have a plethora of practical solutions for the common problems that new mothers face when initiating breastfeeding. Furthermore, we see these mothers and babies frequently in the office during this crucial neonatal period.
5. There is a hormonal upheaval following birth. The placenta which secretes 300 mg. of progesterone daily during the third trimester of pregnancy is suddenly gone. One of progesterone’s many functions is to elevate and stabilize the mother’s moods. At birth when this progesterone supply is suddenly cut off, certain women who are hormonally sensitive can develop mood swings. In these cases we supplement the mother with a physiologic dose of bio-identical transdermal progesterone cream, 15 mg. every 12 hours. This is usually enough to stabilize her mood until her body adjusts to the lower levels of progesterone. Some doctors prescribe micronized oral progesterone pills like “PrometriumTM”. However when progesterone is taken orally, the liver processes it before it enters the bloodstream. Then the liver releases metabolic by-products from the breakdown of oral progesterone into the blood. The by-products can actually make women feel worse. This is why we use the transdermal cream; it bypasses the liver and enters the blood through the skin unchanged, as pure progesterone.
6. Because we are family medicine specialists, we see the mother frequently during the prenatal period; then we continue to see the mother and baby together during the postpartum period. If a mother seems to be becoming depressed, we intervene early before the situation becomes a crisis. Our practice contrasts with programs in which women divide their maternity care between an obstetrician-gynecologist and a pediatrician, thus lacking a single practitioner who follows both mother and baby throughout the pre and post natal periods. Neither of these specialists is familiar with treating the mother and baby as a single unit.
7. A satisfying and fulfilling labor and delivery experience empowers a woman and increases her self-esteem and self-confidence. Most of our patients look back at their birthing experiences with a fondness and enthusiasm that keeps them elated throughout the postpartum period. One of our goals in providing natural childbirth services is to extend the miracle and marvel of childbirth far beyond the actual event of birth (see “Letter from Home” later in this newsletter.)

   A woman who feels that she was rushed through the birth process, or has had her labor unnecessarily tampered with, may harbor lasting resentment and anger. This can cloud over her postpartum recovery and her relationships with the baby and her family. Although these effects are not scientifically measurable, I have had numerous women tell me about previous negative birth experiences and the difficulties they created in their recoveries, even years later! I am convinced that the emotional support that a woman receives in pursuing her ideal image of giving birth will aid her later in developing roles as a mother, wife, and matriarch of her family. I am not surprised to find that with the escalating rates of pitocin inductions, epidural blocks, and Cesarean sections, there is a consequential epidemic rise of postpartum depression. Also contributory are early termination or failure in breastfeeding, poor nutrition, sleep deprivation, and early return to work. A common sense analysis allows one to quickly understand the root causes of postpartum depression. There is no single antidepressant or combination of pills that can solve this serious problem; it is shortsighted to look in that direction for a “cure”. The answer lies in preventing the syndrome from occurring, by respecting Nature’s processes throughout pregnancy, birth, and lactation, and maximally supporting each woman throughout each of the stages.

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CORD BLOOD BANKING

The blood contained in the baby’s umbilical cord at birth contains “stem cells.” Stem cells are immature blood cells, which haven’t yet differentiated into their final adult cell types. In the appropriate environment under certain conditions, these stem cells can mature into any adult blood or bone marrow cell component. For example with leukemia, cancerous cells replace the patient’s bone marrow. The bone marrow normally produces the body’s blood cells; leukemia patients become severely anemic because their bone marrow is unable to make new blood cells. One treatment for leukemia is to destroy the patient’s abnormal bone marrow with chemotherapy and/or radiation, then transplant fetal stem cells into his bone marrow. The fetal cells then repopulate the patient’s marrow with healthy new cells, thus curing his leukemia.

Recently entrepreneurs have offered families a program to store their baby’s cord blood in liquid nitrogen, to be used in case their child develops leukemia years later. The chances of a child someday requiring a stem cell transplant is estimated to be between 1:1,000 to 1:200,000, which is highly unlikely.

Our practice has always considered cord blood to be extremely important. This is why we have always done “late cord clamping” to allow the blood that is present in the placenta and in the umbilical cord during the first ten to fifteen minutes following the birth, to transfuse spontaneously into the baby. Nature in her wisdom has provided a dual oxygen supply for babies during the transitional period following birth. The placenta continues delivering oxygenated blood to the baby until his lungs are fully expanded and functioning. Swedish researchers have shown that the increased blood volume resulting from the post-delivery placental transfusion helps the newborn’s lungs to expand by increasing the pulmonary blood flow. Furthermore this iron rich blood which often measures 50 ml. (1-1/2 ounces) provides iron stores for the baby during the initial six months following birth, because breast milk is relatively low in iron.

The bad habit of early cord clamping began during the nineteenth century when obstetricians started delivering women in the “lithotomy” position (on her back in stirrups). The baby was born off the edge of the delivery table far from the mother. Since there was no convenient place to put the baby, the cord was quickly clamped and cut and the baby handed to the nurse to be swaddled in blankets. The obstetrician then proceeded to sew up the episiotomy (another nineteenth century convenience intervention.)

In direct contrast we deliver the baby on the bed, then place the child on his mother’s abdomen for warmth while waiting patiently for the umbilical cord to finish pulsating on its own. Incidentally this first skin-to-skin contact allows the baby’s sterile skin to become populated by his mother’s friendly bacteria rather than the hospital’s potentially pathogenic bacteria.

So if anyone asks you whether you want to bank your baby’s cord blood, the answer is: “If his blood is that valuable, I want it to remain in his body where it belongs!”

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LETTER FROM HOME

Dear Dr. Elvove—

A belated thank you for all that you did to help with E.’s birth.

I was expecting a lot from this birth and I wasn’t sure if my expectations could be met. At the end of my pregnancy with her, I prayed every night for a healthy baby and a “triumphant birth.” I didn’t want to disappoint myself and I didn’t want to think for the rest of my life that I could have done it better. I wanted to feel like doing that punching thing that Tiger Woods does when he sinks a putt, like — “I knew that one was going in!” I knew I was asking a lot, but it meant so much to me to do this the way I wanted to do it. And, as it turned out, the birth was actually more wonderful than I had hoped it would be.

It may sound like everything that I just described was only about what was inside my head during labor and that you didn’t have anything to do with that. But, this birth was really a culmination of the last eight years. What was going on in my head during the birth was a result of your wisdom and advice over the years, your incredibly calm demeanor during the births of the other three children and your belief in me and in the whole birth process. Does that make sense? I hope so, because one of the reasons it has taken me so long to write this is because I’m not sure how to explain it. Just the fact that your practice exists allows me to get to the point where I would want a birth experience like this. Otherwise, I could easily see myself as a scared person in the hospital, overwhelmed by the pain and wanting an epidural, especially given how painful the births have been for me.

Instead, E.’s birth was perfect. And having my three boys there to see her arrive was so moving to me that my heart feels like it’s going to explode every time I think about it. Again, without your practice, that wouldn’t have been possible.

So, I just wanted you to know how grateful I am to you for everything. There are just a few people that I have known in my entire life that have been life-changing for me—they have actually changed the way that I see things and think about things—and you are one of them. You are not only a wonderful doctor, but a wonderful person as well and I’m so glad that I know you. Thank you, thank you!

K. B.

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