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DEFINITION OF SIM :It is defined as a learning package that can be used by a learner without the presence of the teacher. (Dinesh Kumar Sharma)

ELEMENTS OF SELF INSTRUCTIONAL MODULE An introduction and statement of purpose, which include content, objectives and direction for its use. A list of pre-requisite skills that the learner needs to have to use the module. A list of behavioural objectives, which are clear and measurable statements describing which skills the learner is expected to acquire on completion of topic. An identification of resources and learning activities which specify the equipments needed, such as video tapes, slides etc. The total length of the module should be kept short. Periodic self assessment is necessary which provide feedback to the learner throughout the module. It should contain a post- test to evaluate the learners level of mastery in achieving the objectives.

PROCESS FOR THE DEVELOPMENT OF SELF INSTRUCTIONAL MODULEThe process of development is presented under three major headings: 1 Preparatory phase 2 Implementation phase 3 Evaluation phase

ADVANTAGES: The learner can study at home without undue disruption of work and at his/ her own time and place. The learning material can be used by greater number of people, which is not possible in classroom. As it involves active learning, it gives chance to review and reflect on information. It does not require physical teaching facilities. It is cost effective because they designed to be used by large number of individuals with minimal cost. SIM are excellent choices for annual training updates in selected topics or skills that require periodic view to determine competency.

DISADVANTAGES: There is minimum teacher learner interaction. Learner become self centred and may not develop team spirit. Language communication problems may arise when the emphasis is on written materials only. Learner with visual impairment can use module. Self study may be boring if this method is overused.


: Ms. Kawaljit Kaur


:- Respected Madam Mrs. Baljinder Kaur Respected Madam Ms. Chetna Saini

PREPARED FOR : Staff Nurses, Teachers, Students of B.Sc.Nursing 3rd Year ,Post Basic(B.Sc.)N 2nd Year, GNM 2nd Year.


Objectives of Self Instructional Module i.e. Women & Mental Health are :1) To explain normal reactions of conception , pregnancy and puerperium. 2) To Discuss problems related to Conception , pregnancy and puerperium And Its Management. 3) To explain about counselling Premarital , Marital and Genetic. 4) To discuss about facts- Women & Mental Health.


NORMAL OVULATION In most women one egg is released during every menstrual cycle. This usually occurs around the middle of the cycle. The first part of the cycle, from the start of the period to ovulation, is called the follicular phase. During this phase the egg that will be released that month, is selected from a batch of approximately 20 immature eggs. Each egg is surrounded by a layer of hormone-producing cells and together they constitute what is called a follicle. The follicle that is selected grows under the influence of a hormone called follicle

stimulating hormone (FSH). This hormone is released by a small gland at the base of the brain called the pituitary gland. As the follicle grows, a lake of hormone-rich fluid forms around the egg. This can be seen by using an ultrasound scan. Ultrasound produces a picture by using harmless sound waves. On the scan, the follicle appears as a black circle in the grey background of the ovary. When the follicle reaches a certain size and the egg is mature, a second hormone, luteinizing hormone, is released from the pituitary gland. This triggers the mechanisms that ultimately, some 36 hours later, lead to ovulation - the release of the egg. The hormone-producing cells in the follicle produce the sex hormone oestradiol. This is released into the bloodstream and stimulates the lining of the uterus, known as the endometrium, to thicken. After ovulation a second hormone, progesterone, is released from the same hormone-producing cells in the ovary. Together, the oestradiol and progesterone prepare the lining of the uterus for the developing embryo.

FERTILISATION The egg is collected by the fimbriae, the "fingers" on the end of the fallopian tube and moves into the wider part of the tube known as the ampulla. If sexual intercourse has occurred sperm will swim up through the cervix, through the uterus and along the fallopian tubes to the ampulla. Although many sperm will

surround the egg only one will enter through its protective coat, the zona pellucida, and penetrate the egg. A reaction then takes place in the egg so that no more sperm can enter. The fertilised egg remains in the ampullary part of the fallopian tube for up to 48 to 72 hours before starting the journey to the uterus, arriving in the uterus in about 5 days.

IMPLANTATION OR MENSTRUATION The small embryo has now formed into a cluster of cells known as a blastocyst. This blastocyst comes to rest against the side of the uterus and starts to implant about day 6 to 7 after fertilisation. As implantation is taking place this small early embryo sends a signal to the ovary, which continues to secrete the sex hormones, progesterone and oestradiol. These hormones keep the endometrium favourable for the early pregnancy to continue. If the egg fails to fertilise, the ovary will stop producing the sex hormones and the endometrium will break down and is shed as a period. The whole process then starts up again as the start of a new cycle.

Healthy pregnancy Infertility and mental health Pregnancy and mental health More information on trying to conceive, pregnancy, and mental health Both the stress of trying to conceive a baby and pregnancy can affect a woman's mental health. You may feel sad, scared, or not in control of your life either when you are trying hard to conceive or when you are pregnant. You may worry about the costs associated with assisted reproduction and/or pregnancy. You may worry about the new responsibilities that come with being a parent. Don't keep these feelings to yourself. Get help if you feel depressed, anxious, or overwhelmed! Preventing or treating depression helps both you and your child, and may also lower your child's risk of developing depression or other health problems later. NORMAL REACTION TO CONCEPTION & PREGNANCY It is an emotional time for the woman, who becomes pregnant ,especially if she pregnant for the first time .Forthcoming parenthood causes psychological changes in both mother and father. Pregnancy is an experience full of growth, change, enrichment and challenge.The occurrence of physiological changes along with the hormonal changes make pregnancy a psychological event for the woman. Hormonal levels are constantly fluctuating during pregnancy,which can lead to feelings

of anxiety ,depression, sadness ,elation and even confusion. The woman can report mood swings and irritability during and after their pregnancy. The feelings which the mother undergoes include feelings of depression , emotional liability , issues of self esteem and body image issues. In first trimester: - the changes occurring in the body of female are significant during this period ,though she may not be able to see the changes. Mother can feel anxiety about losing her baby. if the pregnancy was planned and wished for ,there is joy and anticipation to the news ,but if the pregnancy was unexpected ,there can be mixed feelings about it. Sometimes woman feel woman feel depression (crying unexpectedly ,inability to sleep especially with early morning waking ,sadness)during this time Mother is more concerned about health of the fetus .This phase is Challenging for some ,so adequate support must be provided by health team as well as the family members. In Second trimester: - Once the stress and anxiety of the first trimester have passed along with the physical discomforts of the first trimester ,the emotional changes of the second trimester begin. The feelings during this time are generally less intense .The mother experience a great feeling ,around 20 weeks ,when she starts feeling the movement of the baby. The fear of miscarriage ,which was prevalent in the first trimester ,usually disappears. Psychologically, the mother feels increased dependence on her partner. There can be a feeling of self consciousness about the weight which is being put on. Many woman considers themselves as unattractive and these feelings can lead to low self esteem. In third trimester:- During this time ,woman starts anticipating childbirth. She gets prepared for childbirth ,both physically and emotionally. While fears of losing the baby have usually disappeared by this point ,a new anxiety takes place the fear of babys arrival. Woman is also worried about labour and birth .First time mother have a great deal of anxiety about whether they will know when labour will start .During this time ,she needs extra attention from her partner ,family and friends .She put on around 10-11 kg of weight ,so there is need of reassurance regarding her physical appearance. CHANGES IN CONCEPTION & PREGNANCY Pregnancy is the fertilization and development of one or more offspring, known as

an embryo or fetus, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the

case of twins or triplets. Childbirth usually occurs about 38 weeks after conception; in women who have a menstrual cycle length of four weeks, this is approximately 40 weeks from the start of the last normal menstrual period (LNMP). Human pregnancy is the most studied of all mammalian pregnancies. Conception can be achieved through sexual intercourse or assisted reproductive technology. An embryo is the developing offspring during the first 8 weeks following conception, and subsequently the term fetus is used until birth. 40% of pregnancies in the United States and United Kingdom are unplanned, and between a quarter and half of those unplanned pregnancies were unwanted pregnancies. Of those unintended pregnancies that occurred in the US, 60% of the women used birth control to some extent during the month pregnancy occurred. In many societies' medical or legal definitions, human pregnancy is somewhat arbitrarily divided into three trimester periods, as a means to simplify reference to the different stages of prenatal development. The first trimester carries the highest risk of miscarriage (natural death of embryo or fetus). During the second trimester, the development of the fetus can be more easily monitored and diagnosed. The beginning of the third trimester often approximates the point of viability, or the ability of the fetus to survive, with or without medical help, outside of the uterus. One scientific term for the state of pregnancy is gravidity (adjective "gravid"), Latin for "heavy" and a pregnant female is sometimes referred to as a gravida. Similarly, the term parity (abbreviated as "para") is used for the number of times a female has given birth, counting twins and other multiple births as one pregnancy, and usually including stillbirths. Medically, a woman who has never been pregnant is referred to as a nulligravida, a woman who is (or has been only) pregnant for the first time as a primigravida and a woman in subsequent pregnancies as a multigravida ormultiparous. Hence, during a second pregnancy a woman would be described as gravida 2, para 1 and upon live delivery as gravida 2, para 2. An in-progress pregnancy, as well as abortions,miscarriages, or stillbirths account for parity values being less than the gravida number. In the case of twins, triplets etc., gravida number and parity value are increased by one only. Women who have never carried a pregnancy achieving more than 20 weeks of gestation age are referred to as nulliparous .


Stages in prenatal development, with weeks and months numbered from last menstrual period Initiation

The initial stages of human embryogenesis.

Fertilization and implantation in humans.

Although pregnancy begins with implantation, the process leading to pregnancy occurs earlier as the result of the female gamete, or oocyte, merging with the male gamete, spermatozoon. In medicine, this process is referred to as fertilization; in lay terms, it is more commonly known as "conception." After the point of fertilization, the fused product of the female and male gamete is referred to as a zygote or fertilized egg. The fusion of male and female gametes usually occurs following the act of sexual intercourse, resulting in spontaneous pregnancy. However, the advent of assisted reproductive technology such as artificial insemination and in vitro fertilisation have made achieving pregnancy possible without engaging in sexual intercourse. This approach may be undertaken as a voluntary choice or due to infertility. The process of fertilization occurs in several steps, and the interruption of any of them can lead to failure. Through fertilization, the egg is activated to begin its developmental process, and the haploid nuclei of new diploid organism. At the beginning of the process, the sperm undergoes a series of changes, as freshly ejaculated sperm is unable or poorly able to fertilize. The sperm must undergo capacitation in the female's reproductive tract over several hours, which increases its motility and destabilizes its membrane, preparing it for the acrosome reaction, the enzymatic penetration of the egg's tough membrane, the zona pellucida, which surrounds the oocyte. The sperm and the egg cell, which has been released from one of the female's two ovaries, unite in one of the two fallopian tubes. The fertilized egg, known as a zygote, then moves toward the uterus, a journey that can take up to a week to complete. Cell division begins approximately 24 to 36 hours after the male and female cells unite. Cell division continues at a rapid rate and the cells then develop into what is known as a blastocyst. The blastocyst is made up of three layers: the ectoderm (which will become the skin and nervous system), the endoderm (which will become the digestive and respiratory systems), and the mesoderm (which will become the muscle and skeletal systems). Finally, the blastocyst arrives at the uterus and attaches to the uterine wall, a process known as implantation. The mass of cells, now known as an embryo, begins the embryonic stage, which continues until cell differentiation is almost complete at eight weeks. Structures important to the support of the embryo develop, including the placenta and umbilical cord. During this time, cells begin to differentiate I nto the various body systems. The basic outlines of the organ, body, and nervous the two gametes come together to form the genome of a

systems are established. By the end of the embryonic stage, the beginnings of features such as fingers, eyes, mouth, and ears become visible. Once cell differentiation is mostly complete, the embryo enters the final stage and becomes known as a fetus. The early body systems and structures that were established in the embryonic stage continue to develop. Sex organs begin to appear during the third month of gestation. The fetus continues to grow in both weight and length, although the majority of the physical growth occurs in the last weeks of pregnancy. Duration Healthcare professionals name three different dates as the start of pregnancy:

the first day of the woman's last normal menstrual period, and the resulting fetal age is called the gestational age

the date of conception (about two weeks before her next expected menstrual period), with the age called fertilization age

the date of implantation (about one week after conception).

Since these are spread over a significant period of time, the duration of pregnancy necessarily depends on the date selected as the starting point chosen. As measured on a reference group of women with a menstrual cycle of exactly 28-days prior to pregnancy, and who had spontaneous onset of labor, the mean pregnancy length has been estimated to be 283.4 days of gestational age as timed from the first day of the last menstrual period as recalled by the mother, and 280.6 days when the gestational age was retrospectively estimated by obstetric ultrasound measurement of the fetal biparietal diameter (BPD) in the second trimester. Other algorithms take into account a variety of other variables, such as whether this is the first or subsequent child (i.e., pregnant woman is a primipara or a multipara, respectively), the mother's race, parental age, length of menstrual cycle, and menstrual regularity), but these are rarely used by healthcare professionals. In order to have a standard reference point, the normal pregnancy duration is generally assumed to be 280 days (or 40 weeks) of gestational age. There is a standard deviation of 89 days surrounding due dates calculated with even the most accurate methods. This means that fewer than 5 percent of births occur on the day of being 40

weeks of gestational age; 50 percent of births are within a week of this duration, and about 80 percent are within 2 weeks. It is much more useful and accurate, therefore, to consider a range of due dates, rather than one specific day, with some online due date calculators providing this information. The most common system used among healthcare professionals is Naegele's rule, which was developed in the early 19th century. This calculates the expected due date from the first day of the last normal menstrual period (LMP or LNMP) regardless of factors known to make this inaccurate, such as a shorter or longer menstrual cycle length. Pregnancy most commonly lasts for 40 weeks according to this LNMP-based method, assuming that the woman has a predictable menstrual cycle length of close to 28 days and conceives on the 14th day of that cycle Accurate dating of pregnancy is important, because it is used in calculating the results of various prenatal tests, (for example, in the triple test). A decision may be made to induce labour if a fetus is perceived to be overdue. Furthermore, if LMP and ultrasound dating predict different respective due dates, with the latter being later, this might signify slowed fetal growth and therefore require closer review. The age of fetal viability has been receding because of continued medical progress. Whereas it used to be 28 weeks, it has been brought back to as early as 23, or even 22 weeks in some countries. Preterm, term and post term Preterm birth and Post term pregnancy Pregnancy is considered "at term" when gestation has lasted 37 complete weeks (occurring at the transition from the 37th to the 38th week of gestation), but is less than 42 weeks of gestational age (occurring at the transition from the 42nd week to the 43rd week of gestation, or between 259 and 294 days since LMP). "Full term" refers to the gestation having lasted 40 weeks from the first day of the mother's last menstrual period. This is the end of gestation on average. Alternatively expressed, this corresponds to a gestational age of 40 weeks and 0 days, or 280 days, or approximately 9 months, and occurs at the transition from the 40th to the 41st week of gestation. On average, it corresponds to an embryonic age of 38 weeks or 266 days. Events before completion of 37 weeks (259 days) are considered preterm; from week 42 (294 days) events are considered postterm. When a pregnancy exceeds 42 weeks (294 days), the risk

of complications for both the woman and the fetus increases significantly.[15][16] Therefore, in an otherwise uncomplicated pregnancy, obstetricians usually prefer to induce labour at some stage between 41 and 42 weeks. Birth before 39 weeks by C section, even if considered "at term", results in an increases risk of complications and premature death, when not medically needed. This is from factors including underdeveloped lungs, infection due to underdeveloped immune system, problems feeding due to underdeveloped brain, and jaundice from underdeveloped liver. Some hospitals in the United States have noted a significant increase in neonatal intensive care unit patients when women schedule deliveries for convenience and are taking steps to reduce induction for non-medical reasons. Complications from Caesarean section are more common than for live births. Recent medical The literature prefers

terminology preterm and postterm to premature and postmature. Preterm and postterm are

unambiguously defined as above, whereas premature andpostmature have historical meaning and relate more to the infant's size and state of development rather than to the stage of pregnancy. Childbirth Main article: Childbirth Childbirth is the process whereby an infant is born. A woman is considered to be in labour when she begins experiencing regular uterine contractions, accompanied by changes of her cervix primarily effacement and dilation. While childbirth is widely experienced as painful, some women do report painless labours, while others find that concentrating on the birth helps to quicken labour and lessen the sensations. Most births are successful vaginal births, but sometimes complications arise and a woman may undergo a cesarean section. During the time immediately after birth, both the mother and the baby are hormonally cued to bond, the mother through the release of oxytocin, a hormone also released during breastfeeding. Studies show that skin-to-skin contact between a mother and her newborn immediately after birth is beneficial for both the mother and baby. A review done by the World Health Organization found that skin-to-skin contact between mothers and babies after birth reduces crying, improves mother-infant interaction, and helps mothers to breastfeed successfully. They

recommend that neonatesbe allowed to bond with the mother during their first two hours after birth, the period that they tend to be more alert than in the following hours of early life. Postnatal period Main article: Postnatal The postnatal period begins immediately after the birth of a child and then extends for about six weeks. During this period, the mother's body begins the return to pre pregnancy conditions that includes changes in hormone levels and uterus size. Diagnosis The beginning of pregnancy may be detected either based on symptoms by the pregnant woman herself, or by using medical tests with or without the assistance of a medical professional. Approximately 1 in 475 women at 20 weeks, and 1 in 2500 women at delivery, refuse to acknowledge that they are pregnant, which is called denial of pregnancy. Some non-pregnant women have a very strong belief that they are pregnant along with some of the physical changes. This condition is known as pseudocyesis or false pregnancy. Physical signs Linea nigra in a woman at 22 weeks pregnant. Most pregnant women experience a number of symptoms, which can signify pregnancy. The symptoms can include nausea and vomiting, excessive tiredness and fatigue, cravings for certain foods that are not normally sought out, and frequent urination particularly during the night. A number of early medical signs are associated with pregnancy. These signs typically appear, if at all, within the first few weeks after conception. Although not all of these signs are universally present, nor are all of them diagnostic by themselves, taken together they make a presumptive diagnosis of pregnancy. These signs include the presence of human chorionic

gonadotropin (hCG) in the blood and urine, missed menstrual period, implantation bleeding that occurs at implantation of the embryo in the uterus during the third or fourth week after last menstrual period, increased basal body temperature sustained of of the cervix, vagina, the cervix), Hegar's for over 2 weeks

after ovulation, Chadwick's sign (softening of the

sign (darkening vaginal portion

and vulva), Goodell's sign (softening of

the uterus isthmus), and pigmentation of linea alba Linea nigra, (darkening of the skin in a

midline of the abdomen, caused by hyperpigmentation resulting from hormonal changes, usually appearing around the middle of pregnancy). Breast tenderness is common during the first trimester, and is more common in women who are pregnant at a young age. Despite all the signs, some women may not realize they are pregnant until they are far along in pregnancy. In some cases, a few have not been aware of their pregnancy until they begin labour. This can be caused by many factors, including irregular periods (quite common in teenagers), certain medications (not related to conceiving children), and obese women who disregard their weight gain. Others may be in denial of their situation. Tests Pregnancy detection can be accomplished using one or more various pregnancy tests,[30] which detect hormones generated by the newly formedplacenta. Blood and urine tests can detect pregnancy 12 days after implantation. Blood pregnancy tests are more sensitive than urine tests (giving fewer false negatives). Home pregnancy tests are urine tests, and normally detect a pregnancy 12 to 15 days after fertilization. A quantitative blood test can determine approximately the date the embryo was conceived. Testing 48 hours apart can provide useful information regarding how the pregnancy is doing. A single test of progesterone levels can also help determine how likely a fetus will survive in those with a threatened miscarriage (bleeding in early pregnancy). An early obstetric ultrasonography can determine the age of the pregnancy fairly accurately. In practice, medical professionals typically express the age of a pregnancy (i.e., an "age" for an embryo) in terms of "menstrual date" based on the first day of a woman's last menstrual period, as the woman reports it. Unless a woman's recent sexual activity has been limited, she has been charting her cycles, or the conception is the result of some types of fertility treatment (such as IUI or IVF), the exact date of fertilization is unknown. Without symptoms such as morning sickness, often the only visible sign of a pregnancy is an interruption of the woman's normal monthly menstruation cycle, (i.e., a "late period"). Hence, the "menstrual date" is simply a common educated estimate for the age of a fetus, which is an average of 2 weeks later than the first day of the woman's last menstrual period. The term "conception date" may sometimes be used when that date is more certain, though even medical professionals can be imprecise with their use of the two distinct terms. The due date can be calculated by using Naegele's rule. The

expected date of delivery may also be calculated from sonogram measurement of the fetus. This method is slightly more accurate than methods based on LMP. Additional obstetric diagnostic techniques can estimate the health and presence or absence of congenital diseases at an early stage. Ultrasound One way to observe prenatal development is via ultrasound images. Ultrasound imaging before 24 weeks can help determine the due date and detect multiple pregnancies however in those who are at low risk it is unclear if this makes a significant difference in outcomes. Routine ultrasound imaging after 24 weeks gestation does not improve outcomes in either the mother or the baby and might increase the risk of a cesarean section. It is thus is not recommended. Modern 3D ultrasound images provide greater detail for prenatal diagnosis than the older 2D ultrasound technology. While 3D is popular with parents desiring a prenatal photograph as a keepsake, both 2D and 3D are discouraged by the FDA for non-medical use, but there are no definitive studies linking ultrasound to any adverse medical effects. The following 3D ultrasound images were taken at different stages of pregnancy:

3D Ultrasound of fetal movements at 12 weeks

75-mm fetus (about 14 weeks gestational age)

Fetus at 17 weeks

Fetus at 20 weeks Physiology

Breast changes as seen during pregnancy. Note the increase in size and darkening of the areola. Pregnancy is typically broken into three periods, or trimesters, each of about three months. Obstetricians define each trimester as lasting for 14 weeks, resulting in a total duration of 42 weeks, although the average duration of pregnancy is actually about 40 weeks. While there are no hard and fast rules, these distinctions are useful in describing the changes that take place over time. First trimester Traditionally, medical professionals have measured pregnancy from a number of convenient points, including the day of last menstruation, ovulation, fertilization, implantation and chemical












developing embryo becomes implanted in the endometrial lining of a woman's uterus. Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience minimal bleeding. After implantation, the uterine endometrium is called the decidua. The placenta, which is formed partly from the decidua and partly from outer layers of the embryo, connects the developing embryo to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. The umbilical cord is the connecting cord from the embryo or fetus to the placenta. The developing embryo undergoes tremendous growth and changes during the process of fetal development. Morning sickness occurs in about seventy percent of all pregnant women, and typically improves after the first trimester. Although described as "morning sickness", women can experience this nausea during afternoon, evening, and throughout the entire day. Shortly after conception, the nipples and areolas begin to darken due to a temporary increase in hormones. This process continues throughout the pregnancy. The first 12 weeks of pregnancy are considered to make up the first trimester. The first two weeks from the first trimester are calculated as the first two weeks of pregnancy even though the pregnancy does not actually exist. These two weeks are the two weeks before conception and include the woman's last period. The third week is the week in which fertilization occurs and the 4th week is the period when implantation takes place. In the 4th week, the fecundated egg reaches the uterus and burrows into its wall which provides it with the nutrients it needs. At this point, the zygote becomes a blastocyst and the placenta starts to form. Moreover, most of the pregnancy tests may detect a pregnancy beginning with this week. The 5th week marks the start of the embryonic period. This is when the embryo's brain, spinal cord, heart and other organs begin to form. At this point the embryo is made up of three layers, of which the top one (called the ectoderm) will give rise to the embryo's outermost layer of skin, central and peripheral nervous systems, eyes, inner ear, and many connective tissues.[47] The heart and the beginning of the circulatory system as well as the bones, muscles and kidneys are made up from the mesoderm (the middle layer). The inner layer of the embryo will serve as the starting point for the development of the lungs, intestine and bladder. This layer is referred to as

the endoderm. An embryo at 5 weeks is normally between 116 and 18 inch (1.6 and 3.2 mm) in length. In the 6th week, the embryo will be developing basic facial features and its arms and legs start to grow. At this point, the embryo is usually no longer than 16 to 14 inch (4.2 to 6.4 mm). In the following week, the brain, face and arms and legs quickly develop. In the 8th week, the embryo starts moving and in the next 3 weeks, the embryo's toes, neck and genitals develop as well. According to the American Pregnancy Association, by the end of the first trimester, the fetus will be about 3 inches (76 mm) long and will weigh approximately 1 ounce (28 g). Once pregnancy moves into the second trimester, all the risks of miscarriage and birth defects occurring drop drastically. Progesterone has noticeable effects on respiratory physiology, increasing minute ventilation by 40% in the first trimester. By the end of the second trimester, the expanding uterus has created a visible "baby bump". Although the breasts have been developing internally since the beginning of the pregnancy, most of the visible changes appear after this point. Weeks 13 to 28 of the pregnancy are called the second trimester. Most women feel more energized in this period, and begin to put on weight as the symptoms of morning sickness subside and eventually fade away. The uterus, the muscular organ that holds the developing fetus, can expand up to 20 times its normal size during pregnancy. Although the fetus begins to move and takes a recognizable human shape during the first trimester, it is not until the second trimester that movement of the fetus, often referred to as "quickening", can be felt. This typically happens in the fourth month, more specifically in the 20th to 21st week, or by the 19th week if the woman has been pregnant before. However, it is not uncommon for some women not to feel the fetus move until much later. The placenta fully functions at this time and the fetus makes insulin and urinates. The reproductive organs distinguish the fetus as male or female. During the second trimester, most women begin to wear maternity clothes. Final weight gain takes place, which is the most weight gain throughout the pregnancy. The fetus will be growing the most rapidly during this stage, gaining up to 28 g per day. The woman's belly will transform in shape as the belly drops due to the fetus turning in a downward position

ready for birth. During the second trimester, the woman's belly would have been very upright, whereas in the third trimester it will drop down quite low, and the woman will be able to lift her belly up and down. The fetus begins to move regularly, and is felt by the woman. Fetal movement can become quite strong and be disruptive to the woman. The woman's navel will sometimes become convex, "popping" out, due to her expanding abdomen. This period of her pregnancy can be uncomfortable, causing symptoms like weak bladder control and backache. Movement of the fetus becomes stronger and more frequent and via improved brain, eye, and muscle function the fetus is prepared for ex utero viability. The woman can feel the fetus "rolling" and it may cause pain or discomfort when it is near the woman's ribs and spine.

1858 engraving of a pregnant woman showing the fetus in the womb There is head engagement in the third trimester, that is, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perenium and cervix are further flattened and the head may be felt vaginally. Head engagement is known colloquially as the baby drop, and in natural medicine as thelightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic floor and the rectum, and the mother may experience the perpetual sensation that the fetus will "fall out" at any moment. It is also during the third trimester that maternal activity and sleep positions may affect fetal development due to restricted blood flow. For instance, the enlarged uterus may impede blood flow by compressing the lower

pressured vena cava, with the left lateral laying positions appearing to providing better oxygenation to the infant. It is during this time that a baby born prematurely may survive. The use of modern medical intensive care technology has greatly increased the probability of premature babies surviving, and has pushed back the boundary of viability to much earlier dates than would be possible without assistance. In spite of these developments, premature birth remains a major threat to the fetus, and may result in ill health in later life, even if the baby survives. Prenatal development Prenatal development is divided into two primary biological stages. The first is the embryonic stage, which lasts for about two months. At this point, thefetal stage begins. At the beginning of the fetal stage, the risk of miscarriage decreases sharply, and all major structures including the head, brain, hands, feet, and other organs are present, and they continue to grow and develop. When the fetal stage commences, a fetus is typically about 30 mm (1.2 inches) in length, and the heart can be seen beating via ultrasound; the fetus can be seen making various involuntary motions at this stage. Electrical brain activity is first detected between the 5th and 6th week of gestation, though this is still considered primitive neural activity rather than the beginning of conscious thought, something that develops much later in fetation. Synapses begin forming at 17 weeks, and at about week 28 begin to multiply at a rapid pace which continues until 3 to 4 months after birth.[56]

Embryo at 4 weeks after fertilization.

Fetus at 8 weeks after fertilization

Fetus at 18 weeks after fertilization

Fetus at 38 weeks after fertilization

Relative size in 1st month (simplified illustration)

Relative size in 3rd month (simplified illustration)

Relative size in 5th month (simplified illustration)

Relative size in 9th month (simplified illustration) Physiological changes

Melasma pigment changes to the face due to pregnancy

During pregnancy, the woman undergoes many physiological changes, which are entirely normal, including cardiovascular, hematologic, metabolic,renal and respiratory changes that

become very important in the event of complications. The body must change its physiological and homeostatic mechanisms in pregnancy to ensure the fetus is provided for. Increases in blood sugar, breathing and cardiac output are all required. Levels of progesterone and oestrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle. Many women and medical professionals mistakenly think that breastfeeding causes their breasts to sag (medically referred to as ptosis), and as a result some are reluctant to nurse their infants. In February 2009, Cheryl Cole told British Vogue that she hesitated to breastfeed because of the effect it might have on her breasts. "I want to breastfeed," she said, "but I've seen what it can do, so I may have to reconsider." Research shows that breastfeeding is less of a factor than previously thought. The main risk factors for ptosis are cigarette smoking, a woman's body mass index (BMI), hernumber of pregnancies, her breast cup size before pregnancy, and age.

INFERTILITY AND MENTAL HEALTH Infertility means not being able to get pregnant after one year of trying (or after trying for 6 months if a woman is 35 or older). Women who can get pregnant but are unable to stay pregnant may also be infertile. Infertility affects 10 to 15 percent of couples. Women who want a child but have not yet conceived often experience the following:


Depression Anxiety Marital problems Sexual dysfunction Social isolation Low self-esteem Researchers are not sure if mental health can affect fertility, although it is clear that infertility can affect mental health. It's possible, though, that high levels of depression, anxiety, and stress can affect the hormones that regulate ovulation. This could make it difficult for a woman to become pregnant. Treatment Couples with infertility have many treatments available to help them conceive. Most of these treatments cost a lot of money and may not be covered by health insurance. While many couples who seek infertility treatment are already stressed, the process and cost of assisted reproduction itself can also cause anxiety, depression, and stress. If you are trying fertility treatments and they are not working, you may be at risk for

further depression and self-esteem problems. Try to keep a positive attitude, and be sure to talk to your doctor about getting help if you feel you need it. A number of research studies show that women who are distressed have lower pregnancy rates among women trying infertility treatments. Talk therapy, either one-on-one or in a group, can lower stress and mood symptoms. Women who had talk therapy during their infertility treatments were more likely to get pregnant than those who did not. Researchers are still learning whether drugs like antidepressants can help infertile women. Many women don't want to take medications during infertility treatments because they are afraid it may affect the outcome of a pregnancy.

PREGNANCY AND MENTAL HEALTH Pregnancy is generally thought to be a time of happiness and emotional well-being for a woman. However, for many women, pregnancy and motherhood increase their vulnerability to psychiatric conditions such as depression, anxiety disorders, eating disorders, and psychoses. These conditions are often under diagnosed because they are attributed to pregnancy-related changes in maternal temperament or physiology. In addition, such conditions are often undertreated because of concerns about potential harmful effects of medication. A common myth states that hormones released during pregnancy protect women from psychiatric disorders and foster a period of emotional well-being. Recent studies, however, have shown that up to 20% of women suffer from mood or anxiety disorders during the gestation and postpartum periods. Whether the symptoms develop at the onset of pregnancy or are a continuation of a previous history, women face a difficult decision about how to manage their illness during pregnancy. It is common for women to discontinue or avoid pharmacologic treatment in order to decrease the risks of prenatal exposure to medications. This is not always the safest option, however, as psychiatric illness in the mother can in some cases cause significant morbidity for the mother and child. It is important for the

patient to be well informed about the risks involved on both sides and take into account her specific diagnosis and the recommendations of her health care provider. COMMON PSYCHIATRIC DISORDERS Given the numerous physiological and hormonal changes the body undergoes and the stressors involved in pregnancy, anxiety and depression are the most common emotional disturbances during the perinatal period. Reported rates of depression in pregnant women have ranged from 5% to almost 30%. In very mild cases, symptoms are usually manageable with counseling, support groups, environmental manipulation, and diversions such as walking, warm baths, and keeping up social contacts. When the depression and anxiety does not respond to these approaches, professional psychotherapy is recommended. Brief hospital stays, intensive outpatient programs, or, for more severe cases, medication may effectively treat the illness. Major depression, a mood disorder that affects a persons ability to experience normal mood states, affects up to 10% of pregnant women. Symptoms include a depressed mood most of the day, nearly every day, for two weeks or longer and/or the loss of interest or pleasure in activities that the person usually enjoys. Other symptoms can include: Fatigue or lack of energy Restlessness or feeling slowed down Feelings of guilt or worthlessness Difficulty concentrating Trouble sleeping or sleeping too much Recurrent thoughts of death or suicide

Untreated major depression has serious potential risks for mother and fetus. Symptoms may develop and worsen into the postpartum period. Continued depression may lead to

poor nutrition, smoking, drinking, suicidal behavior, prolonged or premature labor, and low birth weights. Anxiety disorders can also be stimulated or compounded by pregnancy. Panic disorder, obsessive compulsive disorder, and generalized anxiety disorder appear to be as common as depression. Perinatal anxiety symptoms can include: panic attacks hyperventilation repeated thoughts or images of frightening things happening to the baby excessive worry restless sleep Depression, panic disorder, bipolar illness, and other psychiatric conditions can occur during pregnancy and should be considered when assessing the health of a pregnant patient.

Depression in pregnancy During pregnancy, symptoms of depression such as changes in sleep, appetite, and energy are often difficult to distinguish from the normal experiences of pregnancy. Although up to 70% of women report some negative mood symptoms during pregnancy, the prevalence of women who meet the diagnostic criteria for depression has been shown to be between 13.6% at 32 weeks gestation and 17% at 35 to 36 weeks gestation . The course of depression varies throughout pregnancy: most studies report a symptom peak during the first and third trimesters and improvement during the second trimester In a recent study, more women became depressed between 18 and 32 weeks gestation than between 32 weeks gestation and 8 weeks postpartum Depression is the most common psychiatric disorder associated with pregnancy. Pregnant women may also suffer from anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and eating disorders. While it is rare for women to experience first-onset psychoses during pregnancy, relapse rates are high for

women previously diagnosed with some form of psychosis. (A full description of pharmacological and nonpharmacological therapies for these disorders will appear in Part 2 of this theme issue in April 2005.) Several risk factors and psychosocial correlates have been identified as contributing to depression during pregnancy. The most clearly identified risk factors include a previous history of depression, discontinuation of medication(s) by a woman who has a history of depression, a previous history of postpartum depression, and a family history of depression. Several key psychosocial correlates may also contribute to depression during pregnancy: a negative attitude toward the pregnancy, a lack of social support, maternal stress associated with negative life events, and a partner or family member who is unhappy about the pregnancy. Depression that is left untreated in pregnancy, either because symptoms are not recognized or because of concerns regarding the effects of medications, can lead to a host of negative consequences, including lack of compliance with prenatal care recommendations, poor nutrition and self-care, self-medication, alcohol and drug use, suicidal thoughts and thoughts of harming the fetus, and the development of postpartum depression after the baby is born. An additional and important implication of untreated maternal depression is the psychological effect that the depression may have on the fetus. One study that examined 1123 mother-infant pairs reported that infants of mothers depressed in pregnancy showed less frequent positive facial expressions and vocalizations, and that these infants were also harder to console. Thus, the relationship between maternal depression and early childhood problems may be part of a sequence that starts with depressive symptoms during pregnancy. Depression is a common problem during and after pregnancy. When you are pregnant or after you have a baby, you may be depressed and not know it. Some normal changes during and after pregnancy can cause symptoms similar to those of depression. How long symptoms last, and how often they occur, is different for each patient. Symptoms of depression include:

Feeling restless or moody Feeling sad, hopeless, and overwhelmed Crying a lot Having no energy or motivation

Eating too little or too much Sleeping too little or too much Having trouble focusing or making decisions Having memory problems Feeling worthless and guilty Losing interest or pleasure in activities you used to enjoy Withdrawing from friends and family Having headaches, aches and pains, or stomach problems that don't go away Having suicidal thoughts

Certain factors may increase your risk of depression during and after pregnancy:

A personal history of depression or another mental illness A family history of depression or another mental illness A lack of support from family and friends Anxiety or negative feelings about the pregnancy Problems with a previous pregnancy or birth Marriage or money problems

Stressful life events Young age Substance abuse Women who are depressed during pregnancy have a greater risk of depression after giving birth. It's important to know that if you take medicine for depression, stopping your medicine when you become pregnant can cause your depression to come back. Do not stop any prescribed medicines without first talking to your doctor. Not using medicine that you need may be harmful to you or your baby. Treatment of depression in pregnancy relies on the same therapies used for depression at any time in life, with the added need to ensure the safety of the fetus. Psychotherapies that have been recognized as effective treatment for depression include cognitive behavioral therapy and interpersonal psychotherapy. Education and support are also important, particularly as pregnancy is a unique experience for women, some of whom may not know what to expect. Pharmacological therapies are also recognized as effective treatment for depression. However, full disclosure of both the risk and benefits of various antidepressant medications should be made to the patient and, if possible, her partner prior to starting any pharmacological treatment.

Anxiety disorders in pregnancy Data are available on some of the disorders that affect pregnant women (panic disorder and obsessivecompulsive disorder) but very little information exists regarding others (generalized anxiety disorder and social phobia).

Panic disorder The course of panic disorder during pregnancy is variable and remains unclear. While case reports of pregnant women with pre-existing panic disorder have suggested a decrease in symptoms during pregnancy, large-scale studies have reported that there is no decrease in symptoms for women with preexisting panic disorder. In addition, a subgroup of women may experience first-onset panic disorder during pregnancy. Women presenting with panic attacks for the first time should be screened for thyroid disorder. The possible effects of anxiety and panic on the course of the pregnancy and the health of the fetus are not well understood. One study showed a correlation between increased anxiety and increased resistance in uterine artery blood flow. The correlation between plasma levels of cortisol in the mother and in the fetus may have implications for the developing fetal brain. Treatments for panic disorder in pregnancy may include pharmacological therapies, particularly benzodiazepines for nighttime sedation and symptomatic relief, and antidepressants, as well as non pharmacological therapies such as cognitive behavioral therapy, supportive psychotherapy, relaxation techniques, sleep hygiene, and dietary counseling.

Obsessive-compulsive disorder Obsessive-compulsive disorder (OCD) is characterized by thoughts that cannot be controlled (obsessions) and repetitive behaviors or rituals that cannot be controlled (compulsions) in response to these thoughts. Several reports suggest that women may be at an increased risk for the onset of OCD during pregnancy and the postpartum period. In one study of women with diagnosed OCD, 39% of the participants reported that their OCD began during a pregnancy. Treatments for OCD in pregnancy are the same as those in non pregnant adults and include cognitive behavioral therapy and pharmacotherapy. Women with severe OCD can become quite incapacitated and will require treatment.

Generalized anxiety disorder There are no data on the prevalence or course of generalized anxiety disorder (GAD) through pregnancy. Most women, naturally enough, worry about the health of the fetus and how they will cope with labor and bodily changes. Excessive worrying, however, may be a symptom of GAD or depression.

Social phobia There are no data on either first-onset social phobia or pre-existing social phobia in pregnancy. A very small number of women experience tocophobia, an unreasonable dread of childbirth. These women are more prone to postpartum depression if denied the delivery method of their choice (i.e., cesarean section).

Eating disorders in pregnancy The prevalence of eating disorders in pregnant women is approximately 4.9%.While studies have suggested that the severity of symptoms may actually decrease during pregnancy, there are many negative consequences for both the mother and her infant. One recent study reported that pregnant women with active eating disorders appear to be at greater risk for delivery by cesarean section and for postpartum depression. In addition, eating disorders during pregnancy have been linked with higher rates of miscarriage and lower infant birth weights.

Psychosis in pregnancy The occurence of new episodes of psychosis during pregnancy is extremely rare. However, for women with a history of psychosis, particularly psychosis in previous pregnancies, the relapse rates are high, with the most common manifestations being bipolar illness, followed by psychotic depression and schizophrenia.

Bipolar mood disorder The information regarding the course of bipolar disorder in pregnancy is limited. It appears that some women with bipolar disorder may experience a relief from symptoms during pregnancy, but that the risk for relapse in the postpartum period is high. One recent study reported that pregnancy had no impact on the course of bipolar disorder in women who discontinued lithium prior to conception, with the relapse rates for either depression or mania in the pregnant women being the same as in nonpregnant matched women. In another study, pregnancy appeared to have a protective effect against an increase in symptoms in women with lithium-responsive bipolar I disorder who had discontinued their lithium during pregnancy; however, there was a 14% rate of relapse in the last 5 weeks of pregnancy. In both studies, the risk of relapse in the postpartum period was very high, ranging from 25% to 70%. In women with a history of bipolar mood disorder, the decision whether to use mood stabilizers must be made following an assessment of risks and benefits. Factors to consider include number and severity of previous episodes, level of insight, family

supports, and the wishes of the woman. Careful monitoring of psychological symptoms throughout the pregnancy is of paramount importance.

Schizophrenia The limited data on schizophrenia in pregnancy suggest that this disease has a variable course, with some women experiencing an improvement in symptoms, while others experience a worsening of their illness. Regardless of the course of the illness, women with a history of psychosis require close monitoring by health care professionals during pregnancy. Psychosis during pregnancy can have devastating consequences for both the mother and her fetus, including failure to obtain proper prenatal care, negative pregnancy outcomes such as low birth weight and prematurity, and neonaticide or suicide. Treatment of acute psychosis in pregnancy is mandatory and includes mobilization of supports, pharmacotherapy, and hospitalization. Electroconvulsive therapy may be used for psychotic depression.

Early identification and treatment of psychiatric disorders in pregnancy can prevent morbidity in pregnancy and postpartum with the concomitant risks to mother and baby. Both psychotherapy and pharmacotherapy should be considered. In British Columbia, the Reproductive Mental Health program offers consultation and education services to practitioners and allied health professionals throughout the province.

Managing Pregnancy and Bipolar Disorder Many women with chronic mental illnesses, including bipolar disorder, become pregnant or plan to have children at some point in their lives. Managing bipolar disorder throughout a pregnancy is a delicate balance of the risks and benefits of the illness versus treatment, and should be done in close collaboration with knowledgeable professionals, both psychiatric and obstetric. Many women are concerned about the impact of a pregnancy on their illness and about the potential effects of medications they take on their child. Because bipolar disorder typically emerges during young adulthood and persists throughout the lifespan, the illness usually overlaps with a womans prime childbearing years. Pregnancy and delivery often increase the symptoms of bipolar disorder: pregnant women or new mothers with bipolar disorder have a sevenfold higher risk of hospital admission and a twofold higher risk for a recurrent episode, compared with those who have not recently delivered a child or

are not pregnant. A recent study published in the American Journal of Psychiatry also found substantial risks associated with discontinuing bipolar medications around the time of pregnancy: women who discontinued medication between six months prior to conception and 12 weeks after conception were more than twice as likely to suffer a recurrence of at least one episode of the illness (85.5 percent compared to 37.0 percent).These same women experienced bipolar symptoms throughout 40 percent of the pregnancy, compared with only 8.8 percent of the time for women who continued medications throughout the pregnancy. Women who discontinued their medications abruptly were especially vulnerable to relapse. Careful planning is very important and can help women with bipolar disorder minimize both their symptoms and risks to their children. This planning should happen well before conception, given the importance of the first four weeks after conception, and should continue throughout the pregnancy, postpartum, and breastfeeding periods. Also, since many pregnancies are unplanned, all women of childbearing age should talk to their psychiatrists about managing bipolar disorder throughout a pregnancy regardless of their future reproductive plans. Our knowledge about the risks of untreated bipolar disorder, the risks and benefits of specific medications, and the predictors of relapse during and after pregnancy is still evolving. A 2004 review article concluded the following about medications used to treat bipolar disorder during pregnancy: Lithium and first-generation antipsychotics (e.g., Haldol, Thorazine) are preferred mood stabilizers because they consistently show minimal risks to the fetus.2 Some anticonvulsants (e.g., Depakote and Tegretol) have been proven harmful to fetuses, possibly contributing to birth defects. Studies show that exposure to only one mood stabilizing medication is less harmful to the developing fetus than exposure to multiple medications. Some details concerning specific medications are listed below. Lithium For many people, lithium is a mainstay of their treatment for bipolar disorder. The decision to continue taking lithium during pregnancy can be life saving to the mother. Other women might switch to lithium because it has fewer risks to the developing fetus than their current medication. While taking lithium, it is important that women stay hydrated to prevent lithium toxicity in themselves and the fetus. Careful monitoring of lithium levels, especially during delivery and

immediately after birth, can help prevent a relapse in the mother and will also show if there are high lithium levels in the infant. Lithium is the only drug proven to reduce the rate of relapse of illness from nearly 50 percent to less than 10 percent when women continue or begin lithium treatment after giving birth. Women who choose to breast-feed should know that lithium is secreted in breast milk. Breast-fed newborns whose mothers take lithium should have their blood monitored for lithium. Depakote Since Depakote is a substance proven to have harmful effects on fetuses, many experts recommend that women switch to another mood stabilizer before conception. However, half of all women do not plan their pregnancies, and those taking Depakote who later become pregnant must weigh the risks and benefits of continuing this treatment. If a woman decides to continue taking Depakote, a single daily dose can be more harmful than separate doses. Experts recommend that doses of less than 1000 mg/day be taken in divided doses. It is recommended that women continuing Depakote also take vitamin K to help prevent conditions that affect the infant's head and face. No adverse effects have been reported among infants whose mothers were treated with Depakote. The American Academy of Neurology and the America Academy of Pediatrics agree that Depakote is compatible with breast-feeding. Tegretol Most experts feel that Tegretol should only be used during pregnancy if there are no other options. However, an unplanned pregnancy may not be discovered until after the risk period for the harmful effects of Tegretol has already passed. For women who choose to continue therapy with Tegretol, vitamin K should be taken to promote mid-facial growth and the formation of proper blood clotting factors in fetuses. It is important to note that women who start taking Tegretol after conception incur more risk of serious side effects (such as rare blood disorder and liver failure) than women receiving treatment with Tegretol at the time of conception. Concentrations of Tegretol in breast milk were low when measured in women who took this medication during pregnancy. The American Academy of

Neurology and the American Academy of Pediatrics agree that Tegretol is compatible with breastfeeding. First-Generation Antipsychotic Medications First-generation antipsychotic medications continue to play a major role in the acute treatment of mania. Since they have a longer history of use than many mood stabilizers, their effect on pregnant women is better documented. Some health care professionals suggest that a woman's medication be switched from lithium or an anticonvulsant to a first-generation antipsychotic medication for either the entire pregnancy or the first trimester. The switch appears to be especially beneficial for women who have benefited from mood stabilization with these medications in the past. First-generation antipsychotic medications may also be useful to women who elect to stop medication therapy during pregnancy but experience a recurrence of symptoms while pregnant. Though studies are small, no adverse effects have been noted in the majority of cases where women take firstgeneration antipsychotic medications and breast-feed. Second-Generation Antipsychotic Medications Few studies have been reported on the use of second-generation medications during pregnancy. Several second-generation antipsychotic medications have not yet been approved for maintenance therapy for bipolar disorder, including Seroquel (quetiapine) and Risperdal (risperidone). Early studies indicate that Zyprexa (olanzapine), which has been approved by the Food and Drug Administration (FDA) for the treatment of acute mania, is not associated with birth defects. However, Zyprexa has been associated with weight gain, gestational diabetes, and high blood pressure. Weight gain, blood sugar levels, and blood pressure should be monitored carefully in all pregnant women taking Zyprexa. Tranquilizer and Sedative Medications Difficulty sleeping and anxiety are powerful triggers for the recurrence of episodes in bipolar disorder. Tranquilizers and sedatives, which help to regulate sleep, may reduce the risk of episodes during or after pregnancy. Medications that stay in the body the least amount of time are preferred. Sedatives and hypnotics are excreted in breast milk, but there have been few reports of complications due to their use.

Electroconvulsive Therapy (ECT) When used in women who are pregnant, ECT may pose fewer risks than untreated mood episodes or treatment with medications known to be harmful to fetuses. Complications of ECT during pregnancy are uncommon. Monitoring heart rate and oxygen levels of the fetus during ECT can detect most problems, and medications are available to correct difficulties. Though some birth defects, developmental delays, or mental retardation have been described in the children of women who underwent ECT while pregnant, there is not a number or pattern to these reports that suggests a relationship to ECT. It is very important for pregnant women who undergo ECT to stay nourished and hydrated to help prevent premature contractions. Intubation or antacids may also be used to decrease the risk of gastric regurgitation or lung inflammation during anesthesia for ECT. Psychosocial Interventions Though little research has been done on the direct or indirect effects of non-pharmacological treatments, it is widely believed that psychotherapy can help improve functioning in social and occupational settings, minimize loss of sleep (which often precipitates mania), and help prevent relapses. Regular exercise, stress management, and other structured daily activities, which help minimize sleep deprivation and reduce rapid shifts in moods, are very important during pregnancy and during the post-partum period. Knowing the early warning signs of mood symptoms, which can differ from one woman to another, is also helpful and women can enlist loved ones and others as part of a support group to provide feedback. In conclusion, there is clearly a need for more research on bipolar disorder treatment during and after pregnancy. Women with bipolar disorder who are pregnant or plan to have children should work closely with knowledgeable health care providers to identify the best options for them. Information and careful planning are the keys to successfully managing bipolar disorder both during and after pregnancy.

PUERPERIUM Puerperium is defined as the time from the delivery of the placenta through the first few weeks after the delivery. This period is usually considered to be 6 weeks in duration. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the non pregnant state. An overview of the relevant anatomy and physiology in the postpartum period follows. Uterus The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 g. In the 6 weeks following delivery, the uterus recedes to a weight of 50-100 g. Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. Thereafter, most of the reduction in size and weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to return to the true pelvis. Over the next several weeks, the uterus slowly returns to its nonpregnant state, although the overall uterine size remains larger than prior to gestation. The endometrial lining rapidly regenerates, so that by the seventh day endometrial glands are already evident. By the 16th day, the endometrium is restored throughout the uterus, except at the placental site. The placental site undergoes a series of changes in the postpartum period. Immediately after delivery, the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium ("physiologic ligatures") result in hemostasis. The size of the placental bed decreases by half, and the changes in the placental bed result in the quantity and quality of the lochia that is experienced. Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable. The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, the discharge continues to

decrease in amount and color and eventually changes to yellow (lochia alba). The period of time the lochia can last varies, although it averages approximately 5 weeks. The amount of flow and color of the lochia can vary considerably. Fifteen percent of women have continue to have lochia 6 weeks or more postpartum. Often, women experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site. This is the classic time for delayed postpartum hemorrhages to occur. Cervix The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to the nulliparous state. By the end of the first week, the external os closes such that a finger cannot be easily introduced. Vagina The vagina also regresses but it does not completely return to its prepregnant size. Resolution of the increased vascularity and edema occurs by 3 weeks, and the rugae of the vagina begin to reappear in women who are not breastfeeding. At this time, the vaginal epithelium appears atrophic on smear. This is restored by weeks 6-10; however, it is further delayed in breastfeeding mothers because of persistently decreased estrogen levels. Perineum The perineum has been stretched and traumatized, and sometimes torn or cut, during the process of labor and delivery. The swollen and engorged vulva rapidly resolves within 1-2 weeks. Most of the muscle tone is regained by 6 weeks, with more improvement over the following few months. The muscle tone may or may not return to normal, depending on the extent of injury to muscle, nerve, and connecting tissues. Abdominal wall The abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state depends greatly on maternal exercise. Ovaries The resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. The woman who breastfeeds her infant has a longer period of amenorrhea and an ovulation than the mother who chooses to bottle-feed. The mother who does not breastfeed may ovulate as

early as 27 days after delivery. Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks. In the breastfeeding woman, the resumption of menses is highly variable and depends on a number of factors, including how much and how often the baby is fed and whether the baby's food is supplemented with formula. The delay in the return to normal ovarian function in the lactating mother is caused by the suppression of ovulation due to the elevation in prolactin. Half to three fourths of women who breastfeed return to periods within 36 weeks of delivery. Breasts The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. If delivery ensues, lactation can be established as early as 16 weeks' gestation. Lactogenesis is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone, with the continued presence of prolactin. If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-3 weeks. The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. High in protein content, this liquid is protective for the newborn. The colostrum, which the baby receives in the first few days postpartum, is already present in the breasts, and suckling by the newborn triggers its release. The process, which begins as an endocrine process, switches to an autocrine process; the removal of milk from the breast stimulates more milk production. Over the first 7 days, the milk matures and contains all necessary nutrients in the neonatal period. The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby. Routine Postpartum Care The immediate postpartum period most often occurs in the hospital setting, where the majority of women remain for approximately 2 days after a vaginal delivery and 3-5 days after a cesarean delivery. During this time, women are recovering from their delivery and are beginning to care for the newborn. This period is used to make sure the mother is stable and to educate her in the care of her baby (especially the first-time mother). While still in the hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and ability to void.

Routine practices include a check of the baby's blood type and administration of the RhoGAM vaccine to the Rh-negative mother if her baby has an Rh-positive blood type. At minimum, the mother's hematocrit level is checked on the first postpartum day. Women are encouraged to ambulate and to eat a regular diet. Vaginal delivery After a vaginal delivery, most women experience swelling of the perineum and consequent pain. This is intensified if the woman has had an episiotomy or a laceration. Routine care of this area includes ice applied to the perineum to reduce the swelling and to help with pain relief. Conventional treatment is to use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, little evidence supports this method over other methods of postpartum perineum treatment. Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum. Hemorrhoids are another postpartum issue likely to affect women who have vaginal deliveries. Symptomatic relief is the best treatment during this immediate postpartum period because hemorrhoids often resolve as the perineum recovers. This can be achieved by the use of corticosteroid creams, witch hazel compresses, and local anesthetics. Tampon use can be resumed when the patient is comfortable inserting the tampon and can wear it without discomfort. This takes longer for the woman who has had an episiotomy or a laceration than for one who has not. The vagina and perineum should first be fully healed, which takes about 3 weeks. Tampons must be changed frequently to prevent infection. Cesarean delivery The woman who has had a cesarean delivery usually does not experience pain and discomfort from her perineum but rather from her abdominal incision. This, too, can be treated with ice to the incision and with the use of systemic pain medication. Women who have had a cesarean delivery are often slower to begin ambulating, eating, and voiding; however, encourage them to quickly resume these and other normal activities.

Sexual intercourse Sexual intercourse may resume when bright red bleeding ceases, the vagina and vulva are healed, and the woman is physically comfortable and emotionally ready. Physical readiness usually takes about 3 weeks. Birth control is important to protect against pregnancy because the first ovulation is very unpredictable. Patient education Substantial education takes place during the hospital stay, especially for the first-time mother. The mother (and often the father) is taught routine care of the baby, including feeding, diapering, and bathing, as well as what can be expected from the baby in terms of sleep, urination, bowel movements, and eating. Provide education, support, and guidance to the breastfeeding mother. Breastfeeding is neither easy nor automatic. It requires much effort on the part of the mother and her support team. Breastfeeding should be initiated as soon after delivery as possible; in a normal, uncomplicated vaginal delivery breastfeeding is possible almost immediately after birth. Encourage the mother to feed the baby every 2-3 hours (at least while she is awake during the day) to stimulate milk production. Long feedings are unnecessary, but they should be frequent. Milk production should be well established by 36-96 hours. In women who choose not to breastfeed, the care of the breasts is quite different. Care should be taken not to stimulate the breasts in any way in order to prevent milk production. Ice packs applied to the breasts and the use of a tight brassiere or a binder can also help to prevent breast engorgement. Acetaminophen or NSAIDs can alleviate the symptoms of breast engorgement (eg, tenderness, swelling, fever) if it occurs. Bromocriptine was formerly administered to suppress milk production; however, its use has diminished because it requires 2 weeks of administration, does not always work, and can produce adverse reactions. For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Postpartum Perineal Care, Birth Control FAQs, Birth Control Overview, Birth Control Spermicides, and Breastfeeding. Discharge instructions The mother must be given discharge instructions. The most important information is who and where to call if she has problems or questions. She also needs details about resuming her normal activity. Instructions vary, depending on whether the mother has had a vaginal or a cesarean delivery.

The woman who has had a vaginal delivery may resume all physical activity, including using stairs, riding or driving in a car, and performing muscle-toning exercises, as long as she experiences no pain or discomfort. The key to resuming normal activity is not to overdo it on one day to the point that the mother is completely exhausted the next day. Pregnancy, labor, delivery, and care of the newborn are strenuous and stressful, and the mother needs sufficient rest to recover. The woman who has had a cesarean delivery must be more careful about resuming some of her activities. She must avoid overuse of her abdomen until her incision is well healed in order to prevent an early dehiscence or a hernia later on. Women typically return for their postpartum visit at approximately 6 weeks after delivery. No sound reason for this exists; the time has probably become the standard so that women who are returning to work can be medically cleared to return. Anything that must be done at a 6-weeks' postpartum visit can be done earlier or later than 6 weeks. An earlier visit can often aid a new mother in resolving problems she may be having or in providing a time to answer her questions. The mother must be counseled about birth control options before she leaves the hospital. She may not be ready to decide about a method, but she needs to know the options. Her decision will be based on a number of factors, including her motivation in using a particular method, how many children she has, and whether she is breastfeeding. A systemic review of ovulation and menses in nonlactating women found that although most women begin ovulation at least 6 weeks postpartum, with mean day of first ovulation occurring 45-94 days postpartum, a limited number ovulate soonerTwo studies reporting earliest day of first ovulation reported it occurring on days 25 and 27 postpartum, emphasizing the need for early postpartum contraception discussion and method initiation to decrease the risk of pregnancy soon after delivery. Many options are available, as follows:

Natural methods can be used in highly motivated couples, to include the use of monitoring the basal body temperature and the quality and quantity of the cervical mucus to determine what phase of the menstrual cycle the woman is in and if it is safe to have intercourse.

Barrier methods of contraception, such as condoms, are widely available, as are vaginal spermicides. Condoms are available over-the-counter, while diaphragms and cervical caps must be fitted.

Hormonal methods of contraception are numerous. Combined estrogen-progestin agents are taken daily by mouth or monthly by injection. Progestin-only agents are available for daily intake or by long-acting injections that are effective for 12 weeks.

Intrauterine devices can be placed a few weeks after delivery. Permanent methods of birth control (ie, tubal ligation, vasectomy) are best for the couple who has more than one child and who are sure that they do not want more. Postpartum Disorders Hemorrhage Postpartum hemorrhage is defined as excessive blood loss during or after the third stage of labor. The average blood loss is 500 ml at vaginal delivery and 1000 mL at cesarean delivery. Since diagnosis is based on subjective observation, it is difficult to define clinically. Objectively, postpartum hemorrhage is defined as a 10% change in hematocrit level between admission and the postpartum period or the need for transfusion after delivery secondary to blood loss. Early postpartum hemorrhage is described as that occurring within the first 24 hours after delivery. Late postpartum hemorrhage most frequently occurs 1-2 weeks after delivery but may occur up to 6 weeks postpartum. Infections Endometritis Endometritis is an ascending polymicrobial infection. The causative agents are usually normal vaginal flora or enteric bacteria. Urinary Tract Infections A urinary tract infection (UTI) is defined as a bacterial inflammation of the bladder or urethra. Greater than 105 colony-forming units from a clean-catch urine specimen or greater than 10,000 colony-forming units on a catheterized specimen is considered diagnostic of a UTI. Treatment Treatment is started empirically in uncomplicated infection because the usual organisms have predictable susceptibility profiles. When sensitivities are available, use them to guide antimicrobial selection.

Treatment is with a 3- or 7-day antibiotic regimen. Commonly used antibiotics include trimethoprim/ sulfamethoxazole, ciprofloxacin, and norfloxacin. Amoxicillin is often still used, but it has lower cure rates secondary to increasing resistance of E coli. The quinolones are very effective but are considerably more expensive than amoxicillin and trimethoprim/sulfamethoxazole and should not be used in breastfeeding mothers. Mastitis Mastitis is defined as inflammation of the mammary gland. Treatment Milk stasis sets the stage for the development of mastitis, which can be treated with moist heat, massage, fluids, rest, proper positioning of the infant during nursing, nursing or manual expression of milk, and analgesics. When mastitis develops, penicillinase-resistant penicillins and cephalosporins, such as dicloxacillin or cephalexin, are the drugs of choice. Erythromycin, clindamycin, and vancomycin may be used for infections that are resistant to penicillin. Resolution usually occurs 48 hours after the onset of antimicrobial therapy. Wound Infection Wound infections in the postpartum period include infections of the perineum developing at the site of an episiotomy or laceration, as well as infection of the abdominal incision after a cesarean birth. Wound infections are diagnosed on the basis of erythema, induration, warmth, tenderness, and purulent drainage from the incision site, with or without fever. This definition can be applied both to the perineum and to abdominal incisions. Treatment Perineal infections: Treatment of perineal infections includes symptomatic relief with NSAIDs, local anesthetic spray, and sitz baths. Identified abscesses must be drained, and broad-spectrum antibiotics may be initiated. Abdominal wound infections: These infections are treated with drainage and inspection of the fascia to ensure that it is intact. Antibiotics may be used if the patient is afebrile.

Most patients respond quickly to the antibiotic once the wound is drained. Antibiotics are generally continued until the patient has been afebrile for 24-48 hours. Patients do not require long-term antibiotics unless cellulitis has developed. Studies have shown that closed suction drainage or suturing of the subcutaneous fat decreases the incidence of wound infection when the subcutaneous tissue is greater than 2 cm in depth. Septic Pelvic Thrombophlebitis Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy. Treatment The standard therapy after diagnosis of septic pelvic thrombophlebitis includes anticoagulation with intravenous heparin to an aPTT that is twice normal and continued antibiotic therapy. A therapeutic aPTT is usually reached within 24 hours, and heparin is continued for 7-10 days. In general, long-term anticoagulation is not required. Antibiotic therapy is most commonly with gentamicin and clindamycin. Other choices include a second- or third-generation cephalosporin, imipenem, cilastin, or ampicillin and sulbactam. All of these antibiotics have a cure rate of greater than 90%. Initially, it was thought that patients defervesce within 24-28 hours. More recent studies show that it takes 5-6 days for the fevers to resolve. In a 1999 prospective randomized study, women who were treated with heparin in addition to antibiotics responded no faster than patients treated with antibiotics alone. These findings do not support the empiric practice of heparin therapy for septic pelvic thrombophlebitis and raise the question of whether a new standard protocol should be developed Endocrine Disorders Prevalence and Types Postpartum thyroid dysfunction can occur any time in the first postpartum year. Clinical or laboratory dysfunction occurs in 5-10% of postpartum women and may be caused by primary disorders of the thyroid, such as postpartum thyroiditis (PPT) and Graves disease, or by secondary disorders of the hypothalamic-pituitary axis, such as Sheehan syndrome and lymphocytic hypophysitis.[43] Postpartum Thyroiditis PPT is a transient destructive lymphocytic thyroiditis occurring within the first year after delivery.

Treatment No treatment is available to prevent PPT. 1) Thyrotoxicosis phase: No treatment is required for the thyrotoxicosis phase unless the patient's symptoms are severe. In this case, a beta-blocker is useful. For example, propranolol can be started at 20 mg every 8 hours and can be doubled if the patient remains symptomatic. Propylthiouracil (PTU) has no role in the treatment of PPT because the disorder is caused by the release of hormone from the damaged thyroid and is not secondary to increased synthesis and secretion. 2)Hypothyroid phase: Since the hypothyroid phase of PPT is often transient, no treatment is required unless necessitated by the patient's symptoms. Treatment is with thyroxine (T4) replacement. T4 is most often given for 12-18 months, then gradually withdrawn. The starting dose is 0.05-0.075 mg, which may be increased by 0.025 mg every 4-8 weeks until a therapeutic level is achieved. Postpartum Graves Disease Postpartum Graves disease is not as common as PPT, but it accounts for 15% of postpartum thyrotoxicosis. Similar to classic Graves disease, postpartum Graves disease is an autoimmune disorder characterized by diffuse hyperplasia of the thyroid gland caused by the production of antibodies to the thyroid TSH receptor, resulting in increased thyroid hormone production and release. No clinical features distinguish postpartum Graves disease from Graves disease in other settings; therefore, diagnosis and management of this disorder is beyond the scope of this article . Lymphocytic Hypophysitis Lymphocytic hypophysitis is a rare autoimmune disorder causing pituitary enlargement and hypopituitarism, leading to a decrease in TSH and to hypothyroidism. Symptoms include headache, visual field deficits, difficulty lactating, and amenorrhea. Diagnosis requires histopathologic examination. Most patients do not require transsphenoidal hypophysectomy, so diagnosis is based on history, physical, diagnostic imaging, and the temporal relationship to pregnancy. Identification of the disorder becomes clearer as the pituitary reverts to its normal size and recovers some of its normal function. During the acute phase of this disease, hormone replacement is often necessary. Sheehan Syndrome

Sheehan syndrome is the result of ischemia, congestion, and infarction of the pituitary gland, resulting in panhypopituitarism caused by severe blood loss at the time of delivery. Patients have trouble lactating and develop amenorrhea, as well as symptoms of cortisol and thyroid hormone deficiency. Treatment is with hormone replacement in order to maintain normal metabolism and response to stress.

Psychiatric Disorders Three psychiatric disorders may arise in the postpartum period: postpartum blues, postpartum depression (PPD), and postpartum psychosis.

Postpartum blues is a transient disorder the lasts hours to weeks and is characterized by bouts of crying and sadness.

PPD is a more prolonged affective disorder that lasts for weeks to months. PPD is not well defined in terms of diagnostic criteria, but the signs and symptoms do not differ from depression in other settings.

Postpartum psychosis occurs in the first postpartum year and refers to a group of severe and varied disorders that elicit psychotic symptoms. Etiology The specific etiology of these disorders is unknown. The current view is based on a multifactorial model. Psychologically, these disorders are thought to result from the stress of the peripartum period and the responsibilities of child rearing. Other authorities ascribe the symptoms to the sudden decrease in the endorphins of labor and the sudden fall in estrogen and progesterone levels that occur after delivery. Low free serum tryptophan levels have been observed, which is consistent with findings in major depression in other settings. Postpartum thyroid dysfunction has also been correlated with postpartum psychiatric disorders. Risk factors include undesired pregnancy, feeling unloved by mate, age younger than 20 years, unmarried status, medical indigence, low self-esteem, dissatisfaction with extent of education, economic problems with housing or income, poor relationship with husband or boyfriend, being part of a family with 6 or more

siblings, limited parental support (either as a child or as an adult), and past or present evidence of emotional problems. Women with a history of PPD and postpartum psychosis have a 50% chance of recurrence. Women with a previous history of depression unrelated to childbirth have a 30% chance of developing PPD. Incidence

Approximately 50-70% of women who have given birth develop symptoms of postpartum blues. PPD occurs in 10-15% of new mothers.[47] The incidence of postpartum or puerperal psychosis is 0.14-0.26%. Morbidity and mortality Psychiatric disorders can have deleterious effects on the social, cognitive, and emotional development of the newborn These ailments can also lead to marital difficulties. History

Postpartum blues is a mild, transient, self-limited disorder that usually develops when the patient returns home. It commonly arises during the first 2 weeks after delivery and is characterized by bouts of sadness, crying, anxiety, irritation, restlessness, mood lability, headache, confusion, forgetfulness, and insomnia.

PPD: Patients suffering from PPD report insomnia, lethargy, loss of libido, diminished appetite, pessimism, incapacity for familial love, feelings of inadequacy, ambivalence or negative feelings toward the infant, and an inability to cope. Consult a psychiatrist when PPD is associated with comorbid drug abuse, lack of interest in the infant, excessive concern for the infant's health, suicidal or homicidal ideations, hallucinations, psychotic behavior, overall impairment of function, or failure to respond to therapeutic trial.

Postpartum psychosis: The signs and symptoms of postpartum psychosis typically do not differ from those of acute psychosis in other settings. Patients with postpartum psychosis usually present with schizophrenia or manic depression, which signals the emergence of preexisting mental illness induced by the physical and emotional stresses of pregnancy and delivery. Treatment

Postpartum blues, which has little effect on a patient's ability to function, often resolves by postpartum day 10; therefore, no pharmacotherapy is indicated. Providing support and education has been shown to have a positive effect.

PPD generally lasts for 3-6 months, with 25% of patients still affected at 1 year. PPD greatly affects the patient's ability to complete activities associated with daily living.

Supportive care and reassurance from healthcare professionals and the patient's family is the first-line therapy for patients with PPD. Research on pharmacological treatment for PPD is limited because postpartum women are often excluded from large clinical trials. Empirically, the standard treatment modalities for major depression have been applied to PPD.

First-line agents include selective serotonin reuptake inhibitors (SSRIs) or secondary amines. Studies on these drugs show that they can be used by nursing mothers without adverse effects on the infant. Consider electroconvulsive therapy for patients with PPD because it is one of the most effective treatments available for major depression. Treatment is recommended for 9-12 months beyond remission of symptoms, with tapering over the last 1-2 months.

Postpartum psychosis: Treatment of postpartum psychosis should be supervised by a psychiatrist and should involve hospitalization. Specific therapy is controversial and should be targeted to the patient's specific symptoms. Patients with postpartum psychosis are thought to have a better prognosis than those with nonpuerperal psychosis. Postpartum psychosis generally lasts only 2-3 months.

Secondary to the overlap between the normal sequelae of childbirth and the symptoms of PPD, the former is often underdiagnosed. Screening for PPD increases the identification of women suffering from this disorder. The Edinburgh Postnatal Depression Scale has proven to be an effective tool for this type of screening. It requires little extra time and is acceptable to both patients and physicians.

Emotional Reactions and Post Partum Depression

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What is depression? What causes depression?

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Symptoms of Post Partum Depression Treatment for Post Partum Depression More information

What is depression? Depression can be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. But true clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended time. Depression can be mild, moderate, or severe. The degree of depression, which your doctor can determine, influences how you are treated. How common is depression during and after pregnancy? Depression that occurs during pregnancy or within a year after delivery is called perinatal depression. The exact number of women with depression during this time is unknown. But researchers believe that depression is one of the most common complications during and after pregnancy. Often, the depression is not recognized or treated, because some normal pregnancy changes cause similar symptoms and are happening at the same time. Tiredness, problems sleeping, stronger emotional reactions, and changes in body weight may occur during pregnancy and after pregnancy. But these symptoms may also be signs of depression. What causes depression? There may be a number of reasons why a woman gets depressed. Hormone changes or a stressful life event, such as a death in the family, can cause chemical changes in the brain that lead to depression. Depression is also an illness that runs in some families. Other times, it's not clear what causes depression. During pregnancy, these factors may increase a woman's chance of depression:

History of depression or substance abuse Family history of mental illness Little support from family and friends Anxiety about the fetus Problems with previous pregnancy or birth Marital or financial problems Young age of mother

Depression after pregnancy is called postpartum depression or peripartum depression. After pregnancy, hormonal changes in a woman's body may trigger symptoms of depression. During pregnancy, the amount of two female hormones, estrogen and progesterone, in a woman's body increases greatly. In the first 24 hours after childbirth, the amount of these hormones rapidly drops back down to their normal non-pregnant levels. Researchers think the fast change in hormone levels may lead to depression, just as smaller changes in hormones can affect a woman's moods before she gets her menstrual period. Occasionally, levels of thyroid hormones may also drop after giving birth. The thyroid is a small gland in the neck that helps to regulate your metabolism (how your body uses and stores energy from food). Low thyroid levels can cause symptoms of depression including depressed mood, decreased interest in things, irritability, fatigue, difficulty concentrating, sleep problems, and weight gain. A simple blood test can tell if this condition is causing a woman's depression. If so, thyroid medicine can be prescribed by a doctor. Signs and Symptoms of Depression Other factors that may contribute to postpartum depression include:

Feeling tired after delivery, broken sleep patterns, and not enough rest often keeps a new mother from regaining her full strength for weeks.

Feeling overwhelmed with a new, or another, baby to take care of and doubting your ability to be a good mother.

Feeling stress from changes in work and home routines. Sometimes, women think they have to be "super mom" or perfect, which is not realistic and can add stress. Having feelings of loss loss of identity of who you are, or were, before having the baby, loss of control, loss of your pre-pregnancy figure, and feeling less attractive.

Having less free time and less control over time. Having to stay home indoors for longer periods of time and having less time to spend with the your partner and loved ones. What are symptoms of depression? Any of these symptoms during and after pregnancy that last longer than two weeks are signs of depression:

Feeling restless or irritable Feeling sad, hopeless, and overwhelmed Crying a lot

Having no energy or motivation Eating too little or too much Sleeping too little or too much Trouble focusing, remembering, or making decisions Feeling worthless and guilty Loss of interest or pleasure in activities Withdrawal from friends and family Having headaches, chest pains, heart palpitations (the heart beating fast and feeling like it is skipping beats), or hyperventilation (fast and shallow breathing) After pregnancy, signs of depression may also include being afraid of hurting the baby or oneself and not having any interest in the baby.

What is the difference between baby blues, postpartum depression, and postpartum psychosis? The baby blues can happen in the days right after childbirth and normally go away within a few days to a week. A new mother can have sudden mood swings, sadness, crying spells, loss of appetite, sleeping problems, and feel irritable, restless, anxious, and lonely. Symptoms are not severe and treatment isn't needed. But there are things you can do to feel better. Nap when the baby does. Ask for help from your spouse, family members, and friends. Join a support group of new moms or talk with other moms. Postpartum depression can happen anytime within the first year after childbirth. A woman may have a number of symptoms such as sadness, lack of energy, trouble concentrating, anxiety, and feelings of guilt and worthlessness. The difference between postpartum depression and the baby blues is that postpartum depression often affects a woman's well being and keeps her from functioning well for a longer period of time.

Postpartum depression needs to be treated by a doctor. Counseling, support groups, and medicines are things that can help. Postpartum psychosis is rare. It occurs in 1 or 2 out of every 1000 births and usually begins in the first 6 weeks postpartum. A woman who has bipolar disorder or another psychiatric problem called schizoaffective disorder has a higher risk for developing postpartum psychosis. Symptoms may include delusions, hallucinations, sleep disturbances, and obsessive thoughts about the baby. A woman may have rapid mood swings, from depression to irritability to euphoria. What steps can I take if I have symptoms of depression during pregnancy or after childbirth? Some women don't tell anyone about their symptoms because they feel embarrassed, ashamed, or guilty about feeling depressed when they are supposed to be happy. They worry that they will be viewed as unfit parents. Perinatal depression can happen to any woman. It does not mean you are a bad or not together mom. You and your baby don't have to suffer. There is help. There are different types of individual and group talk therapies that can help a woman with perinatal depression feel better and do better as a mom and as a person. Limited research suggests that many women with perinatal depression improve when treated with anti-depressant medicine. Your doctor can help you learn more about these options and decide which approach is best for you and your baby. The next section contains more detailed information about available treatments. Speak to your doctor or midwife if you are having symptoms of depression while you are pregnant or after you deliver your baby. Your doctor or midwife can give you a questionnaire to test for depression and can also refer you to a mental health professional that specializes in treating depression. Here are some other helpful tips: 1. Try to get as much rest as you can. Try to nap when the baby naps. 2. Stop putting pressure on yourself to do everything. Do as much as you can and leave the rest! 3. Ask for help with household chores and nighttime feedings. Ask your husband or partner to bring the baby to you so you can breastfeed. If you can, have a friend, family member, or professional support person help you in the home for part of the day. 4. Talk to your husband, partner, family, and friends about how you are feeling.

5. Do not spend a lot of time alone. Get dressed and leave the house. Run an errand or take a short walk. 6. Spend time alone with your husband or partner. 7. Talk with other mothers, so you can learn from their experiences. 8. Join a support group for women with depression. Call a local hotline or look in your telephone book for information and services. 9. Don't make any major life changes during pregnancy. Major changes can cause unneeded stress. Sometimes big changes cannot be avoided. When that happens, try to arrange support and help in your new situation ahead of time. How is depression treated? There are two common types of treatment for depression. Talk therapy. This involves talking to a therapist, psychologist, or social worker to learn to change how depression makes you think, feel, and act. Medicine. Your doctor can give you an antidepressant medicine to help you. These medicines can help relieve the symptoms of depression. Women who are pregnant or breastfeeding should talk with their doctors about the advantages and risks of taking antidepressant medicines. Some women are concerned that taking these medicines may harm the baby. A mother's depression can affect her baby's development, so getting treatment is important for both mother and baby. The risks of taking medicine have to be weighed against the risks of depression. It is a decision that women need to discuss carefully with their doctors. Women who decide to take antidepressant medicines should talk to their doctors about which antidepressant medicines are safer to take while pregnant or breastfeeding. What effects can untreated depression have? Depression not only hurts the mother, but also affects her family. Some researchers have found that depression during pregnancy can raise the risk of delivering an underweight baby or a premature infant. Some women with depression have difficulty caring for themselves during pregnancy. They may have trouble eating and won't gain enough weight during the pregnancy; have trouble sleeping; may miss prenatal visits; may not follow medical instructions; have a poor diet; or may use harmful substances, like tobacco, alcohol, or illegal drugs.

Postpartum depression can affect a mother's ability to parent. She may lack energy, have trouble concentrating, be irritable, and not be able to meet her child's needs for love and affection. As a result, she may feel guilty and lose confidence in herself as a mother, which can worsen the depression. Researchers believe that postpartum depression can affect the infant by causing delays in language development, problems with emotional bonding to others, behavioral problems, lower activity levels, sleep problems, and distress. It helps if the father or another caregiver can assist in meeting the needs of the baby and other children in the family while mom is depressed. All children deserve the chance to have a healthy mom. All moms deserve the chance to enjoy their life and their children. Don't suffer alone. If you are experiencing symptoms of depression during pregnancy or after having a baby, please tell a loved one and call you doctor or midwife right away. COUNSELING Pre marital counseling Premarital counseling is a type of therapy that helps couples prepare for marriage. Premarital counseling can help ensure that you and your partner have a strong, healthy relationship giving you a better chance for a stable and satisfying marriage. Premarital counseling can also help you identify weaknesses that could become bigger problems during marriage. Premarital counseling is often provided by licensed therapists known as marriage and family therapists. These therapists have graduate or postgraduate degrees and many choose to become credentialed by the American Association for Marriage and Family Therapy (AAMFT). Premarital counseling might be offered through religious institutions as well. In fact, some spiritual leaders require premarital counseling before conducting a marriage ceremony. Premarital counseling helps couples improve their relationships before marriage. Through premarital counseling, couples are encouraged to discuss a wide range of important and intimate topics related to marriage, such as:

Finances Communication

Beliefs and values Roles in marriage Affection and sex Children and parenting Family relationships Decision making Dealing with anger Time spent together Premarital counseling helps partners improve their ability to communicate, set realistic expectations for marriage and develop conflict-resolution skills. In addition, premarital counseling can help couples establish a positive attitude about seeking help with their marriages down the road. Keep in mind that you bring your own values, opinions and personal history into a relationship, and they might not always match your partner's. In addition, many people go into marriage believing it will fulfill their social, financial, sexual and emotional needs and that's not always the case. By discussing differences and expectations before marriage, you and your partner can better understand and support each other during marriage. Early intervention is important because the risk of divorce is highest early in marriage The only preparation needed for premarital counseling is to find a therapist. Loved ones and friends might give recommendations based on their experiences. Your health insurer, employee assistance program, clergy, or state or local mental health agencies also might offer recommendations. Before scheduling sessions with a specific therapist, consider whether the therapist would be a good fit for you and your partner. You might ask questions like these:

Education and experience. What is your educational and training background? Are you licensed by the state? Are you credentialed by the AAMFT? What is your experience with premarital counseling?

Logistics. Where is your office? What are your office hours? Treatment plan. How long is each session? How often are sessions scheduled? How many sessions should I expect to have? What is your policy on canceled sessions?

Fees and insurance. How much do you charge for each session? Do you accept my insurance? Will I need to pay the full fee upfront?

Premarital counseling typically includes five to seven meetings with a counselor. Often in premarital counseling, each partner is asked to separately answer a written questionnaire, known as a premarital assessment questionnaire. These questionnaires encourage partners to assess their perspectives of one another and their relationship. They can also help identify a couple's strengths, weaknesses and potential problem areas. The aim is to foster awareness and discussion and encourage couples to address concerns proactively. Your counselor can help you interpret your results together, encourage you and your partner to discuss areas of common unhappiness or disagreement, and set goals to help you overcome challenges. Your counselor might also have you and your partner use a tool called a Couples Resource Map a picture and scale of your perceived support from individual resources, relationship resources, and cultural and community resources. You and your partner will create separate maps at first. Following a discussion with your counselor about differences between the two maps, you'll create one map as a couple. The purpose is to help you and your partner remember to use these resources to help manage your problems. In addition, your counselor might ask you and your partner questions to find out your unique visions for your marriage and clarify what you can do to make small, positive changes in your relationship.

Remember, preparing for marriage involves more than choosing a wedding dress and throwing a party. Take the time to build a solid foundation for your relationship.

Marital counseling Marriage counseling, also called couples therapy, is a type of psychotherapy. Marriage counseling helps couples of all types recognize and resolve conflicts and improve their relationships. Through marriage counseling, you can make thoughtful decisions about rebuilding your relationship or going your separate ways. Marriage counseling is often provided by licensed therapists known as marriage and family therapists. These therapists have graduate or postgraduate degrees and many choose to become credentialed by the American Association for Marriage and Family Therapy (AAMFT). Marriage counseling is often short term. Marriage counseling typically includes both partners, but sometimes one partner chooses to work with a therapist alone. The specific treatment plan depends on the situation. Marriage counseling can help couples in all types of intimate relationships heterosexual or homosexual, married or not. Some couples seek marriage counseling to strengthen their bonds and gain a better understanding of each other. Marriage counseling can also help couples who plan to get married. This premarriage counseling can help couples achieve a deeper understanding of each other and iron out differences before marriage. In other cases, couples seek marriage counseling to improve a troubled relationship. You can use marriage counseling to address many specific issues, including:

Communication problems Sexual difficulties

Conflicts about child rearing or blended families Substance abuse Financial problems Anger Infidelity Divorce Marriage counseling might also be helpful in cases of domestic abuse. If violence has escalated to the point that you're afraid, however, counseling alone isn't adequate. Contact the police or a local shelter or crisis center for emergency support. The only preparation needed for marriage counseling is to find a therapist. You can ask your primary care doctor for a referral to a therapist. Loved ones and friends might give recommendations based on their experiences. Your health insurer, employee assistance program, clergy, or state or local mental health agencies also might offer recommendations. Before scheduling sessions with a specific therapist, consider whether the therapist would be a good fit for you and your partner. You might ask questions like these:

Education and experience. What is your educational and training background? Are you licensed by the state? Are you credentialed by the AAMFT? What is your experience with my type of issue?

Logistics. Where is your office? What are your office hours? Are you available in case of emergency?

Treatment plan. How long is each session? How often are sessions scheduled? How many sessions should I expect to have? What is your policy on canceled sessions?

Fees and insurance. How much do you charge for each session? Are your services covered by my health insurance plan? Will I need to pay the full fee upfront?

Marriage counseling typically brings couples or partners together for joint therapy sessions. Working with a therapist, you'll learn skills to solidify your relationship. These skills might include communicating openly, solving problems together and discussing differences rationally. You'll analyze both the good and bad parts of your relationship as you pinpoint and better understand the sources of your conflicts. Talking about your problems with a marriage counselor might not be easy. Sessions might pass in silence as you and your partner seethe over perceived wrongs or you might bring your fights with you, perhaps even yelling or arguing during sessions. Both are OK. Your therapist can act as mediator or referee and help you cope with the resulting emotions and turmoil. If you or your partner is coping with mental illness, substance abuse or other issues, your therapist might work with other health care providers to provide a complete spectrum of treatment. If your partner refuses to attend marriage counseling sessions, you can go by yourself. It's more challenging to mend a relationship when only one partner is willing to go to therapy, but you can still benefit by learning more about your reactions and behavior in the relationship. Marriage counseling is often short term. You might need only a few sessions to help you weather a crisis or you might need marriage counseling for several months, particularly if your relationship has greatly deteriorated. The specific treatment plan will depend on the situation. In some cases, marriage counseling helps couples discover that their differences truly are irreconcilable and that it's best to end the relationship. Making the decision to go to marriage counseling can be tough. If you have a troubled relationship, however, seeking help is more effective than ignoring your problems or hoping they get better on their own Genetic counseling is the process by which patients or relatives, at risk of an inherited disorder, are advised of the consequences and nature of the disorder, the probability of developing or transmitting it, and the options open to them in management and family planning. This complex process can be separated into diagnostic (the actual estimation of risk) and supportive aspects.

Genetic counselors The National Society of Genetic Counselors (NSGC) officially defines genetic counseling as the understanding and adaptation to the medical, psychological and familial implications of genetic contributions to disease. This process integrates:

Interpretation of family and medical histories to assess the chance of disease occurrence or recurrence.

Education about inheritance, testing, management, prevention, resources Counseling to promote informed choices and adaptation to the risk or condition.

A genetic counselor is an expert with a Master of Science degree in genetic counseling. In the United States they are certified by the American Board of Genetic Counseling. In Canada, genetic counselors are certified by the Canadian Association of Genetic Counsellors. Most enter the field from a variety of disciplines, including biology, genetics, nursing, psychology, public health and social work Genetic counselors should be expert educators, skilled in translating the complex language of genomic medicine into terms that are easy to understand. Genetic counselors work as members of a health care team and act as a patient advocate as well as a genetic resource to physicians. Genetic counselors provide information and support to families who have members with birth defects or genetic disorders, and to families who may be at risk for a variety of inherited conditions. They identify families at risk, investigate the problems present in the family, interpret information about the disorder, analyze inheritance patterns and risks of recurrence, and review available genetic testing options with the family. Genetic counselors are present at high risk or specialty prenatal clinics that offer prenatal diagnosis, pediatric care centers, and adult genetic centers. Genetic counseling can occur before conception (i.e. when one or two of the parents are carriers of a certain trait) through to adulthood (for adult onset genetic conditions, such as Huntington's disease or

hereditary cancersyndromes). Patients Any person may seek out genetic counseling for a condition they may have inherited from their biological parents.

A woman, if pregnant, may be referred for genetic counseling if a risk is discovered through prenatal testing (screening or diagnosis). Some clients are notified of having a higher individual risk forchromosomal abnormalities or birth defects. Testing enables women and couples to make a decision as to whether or not to continue with their pregnancy, and helps provide information that can be used to prepare for the birth of a child with medical issues. A person may also undergo genetic counseling after the birth of a child with a genetic condition. In these instances, the genetic counselor explains the condition to the patient along with recurrence risks in future children. In all cases of a positive family history for a condition, the genetic counselor can evaluate risks, recurrence and explain the condition itself. Counseling session structure The goals of genetic counseling are to increase understanding of genetic diseases, discuss disease management options, and explain the risks and benefits of testing. Counseling sessions focus on giving vital, unbiased information and non-directive assistance in the patient's decision making process. Seymour Kessler, in 1979, first categorized sessions in five phases: an intake phase, an initial contact phase, the encounter phase, the summary phase, and a follow-up phase.[4] The intake and follow-up phases occur outside of the actual counseling session. The initial contact phase is when the counselor and families meet and build rapport. The encounter phase includes dialogue between the counselor and the client about the nature of screening and diagnostic tests. The summary phase provides all the options and decisions available for the next step. If counselees wish to go ahead with testing, an appointment is organized and the genetic counselor acts as the person to communicate the results. Reasons and results Families or individuals may choose to attend counseling or undergo prenatal testing for a number of reasons.

Family history of a genetic condition or chromosome abnormality Molecular test for single gene disorder Increased maternal age (35 years and older) Increased paternal age (40 years and older) Abnormal maternal serum screening results or ultrasound findings

Increased nuchal translucency measurements on ultrasound Strong family history of cancer Predictive testing for adult-onset conditions

Detectable conditions Many disorders cannot occur unless both the mother and father pass on their genes, such as Cystic Fibrosis. Some diseases can be inherited from one parent, such as Huntington disease, and DiGeorge syndrome. Other genetic disorders are the cause of an error or mutation occurring during the cell division process (e.g.trisomy). Testing can reveal conditions that are easily treatable as long as they are detected (Phenylketonuria or PKU). Results from genetic testing may also reveal:

Down syndrome Sickle-cell anemia Tay-Sachs disease Spina bifida Muscular dystrophy Mental retardation

Genetic counselors as support Genetic Alliance states that counselors provide supportive counseling to families, serve as patient advocates and refer individuals and families to community or state support services. They serve as educators and resource people for other health care professionals and for the general public. Many engage in research activities related to the field of medical genetics and genetic counseling. The field of genetic counseling is rapidly expanding and many counselors are taking on "non-traditional roles" which includes working for genetic companies and laboratories When communicating increased risk, counselors anticipate the likely distress and prepare patients for the results. Counselors help clients cope with and adapt to the emotional, psychological, medical, social, and economic consequences of the test results. Each individual considers their family needs, social setting, cultural background, and religious beliefs when interpreting their risk. Clients must evaluate their reasoning to continue with testing

at all. Counselors are present to put all the possibilities in perspective and encourage clients to take time to think about their decision. When a risk is found, counselors frequently reassure parents that they were not responsible for the result. An informed choice without pressure or coercion is made when all relevant information has been given and understood. Prenatal genetic counseling If an initial noninvasive screening test reveals a risk to the baby, clients are encouraged to attend genetic counseling to learn about their options. Further prenatal investigation is beneficial and provides helpful details regarding the status of the fetus, contributing to the decision-making process. Decisions made by clients are affected by factors including timing, accuracy of information provided by tests, and risk and benefits of the tests. Counselors present a summary of all the options available. Clients may accept the risk and have no future testing, proceed to diagnostic testing, or take further screening tests to refine the risk. Invasive diagnostic tests possess a small risk of miscarriage (1-2%) but provide more definitive results. Increased risk result is commonly presented in positively and negatively ways. While families seek direction and suggestions from the counselors, they are reassured that no right or wrong answer exists. When discussing possible choices, counselor discourse predominates and is characterized by examples of what some people might do. Discussion enables people to place the information and circumstances into the context of their own lives. Clients are given a decision-making framework they can use to situate themselves. Counselors focus on the importance of individual choice based on the experiences, morals, and viewpoints of the couple/individual/family. Testing is offered to provide a definitive answer regarding the presence of a certain genetic condition or chromosomal abnormality. There is often no therapy or treatment available for these conditions, and as such parents may have to make decisions regarding the management of the pregnancy

Recognition of the need for genetics knowledge is not new to social work. Infact, MaryRichmond(1917) advocated that a social worker get the facts of heredity in the face of marriage between closerelatives,miscarriage,tuberculosis,alcoholism,mentaldisorder,nervousness,epilepsy,cancer, deformities or abnormalities ,or an exceptional ability. Almost 50 years later, James Watson and Francis

Crick (1953) first described the mechanisms of genetic inheritance. But it was not until 1970 that our knowledge of genetics began to explode. In 1990,the Human Genome Project(HGP) was funded by the U.S. Department of Energy and the National Institutes of Health as an international effort tomapall the human genes by 2003.By June 2000,thefirstworking draft of the human genome was completed, and in 2003 this project ended. The knowledge that resulted from the HGP has altered social work practice in many areas, primarily in working with persons of reproductive age. Genetic research continues around the world, with future findings that will continue to impact social work practice.

Genetic Mechanisms Chromosomes and genes are the essential components of the hereditary process. Genetic instructions are coded in chromosomes found in contain each cell; each chromosome carries genes ,or segments of the codes producing particular traits

deoxyribonucleic acid(DNA),that

anddispositions.Eachmaturegermcellovumorspermcontains23chromosomes,half of the set of 46 present in each parents cells. As you can see in Exhibit 2.1,when the sperm penetrates the ovum(fertilization),the parents chromosomes combine to make a total of 46 chromosomes arrayed in 23pairs. The Human Genome Project (19902003) genetic researchers estimated that there are 20,000 to 25,000 genes in human DNA, with an average of 3,000 to 5,000 genes per chromosome, slightly more than the number mice have (Human Genome Project,2009a).The goal now is to determine the complete sequencing of the three billion subunits of the human genome, an effort of global proportions involving both public and privately funded projects in more than18 countries, including some developing countries (HumanGenome Project,2009a).The genes constitute a map that guides the protein and enzyme reactions fore very subsequent cell in the developing person and across the life course. Thus, every physical trait and many behavioral traits are influenced by the combined genes from the ovum and sperm. Genetic Counseling in Conception, Pregnancy, and Childbirth Every person has a unique genotype, or array of genes, unless the person is an identical twin. Yet, the

environment may influence how each gene pilots the growth of cells. The result is a phenotype (observable trait)that differs somewhat from the genotype. Thus, even a person who is an identical twin has some unique characteristics. On initial observation, you may not be able to distinguish between identical twins, but if you look closely enough ,you will probably find some variation, such as differences in the size of an ear, hair thickness, or temperament. A chromosome and its pair have the same types of genes at the same location. The exception is the last pair of chromosomes, the sex chromosomes, which, among other things, determines sex. The ovum can contribute only an X chromosome to the 23rd pair, but the sperm can contribute either an X or Y and therefore determines the sex of the developing person. A person with XX sex chromosomes is female; a person with XY sex chromosomes is male(refer to Exhibit 2.1). Genes on one sex chromosome that do not have a counterpart on the other sex chromosome create sex-linked traits. A gene for red/green color

blindness, for example, is carried only on the X chromosome. When an X chromosome that carries this gene is paired with a Y chromosome, which could not carry the gene ,red/green color blindness is manifested. So, almost all red/green color blindness is found in males. This gene for color blindness does not manifest if paired with an X chromosome unless the gene is inherited from both parents, which is rare. However, if a woman inherits the gene from either parent, she can unknowingly pass it on to her sons. Whether genes express certain traits depends on their being either dominant or recessive. Traits governed be recessive genes(e.g., hemophilia, baldness, thin lips)will only be expressed if the responsible gene is present on each chromosome of the relevant pair. In contrast, traits governed by dominant genes(e.g., normal blood clotting, curly hair, thick lips)will be expressed if one or both paired chromosomes have the gene. When the genes on a chromosome pair give competing, yet controlling, messages, they are called interactive genes, meaning that both messages may be followed to varying degrees. Hair, eye, and skin color often depend on such interactivity. For example, a light-skinned person with red hair and hazel eyes may mate with a person having dark skin, brown hair, and blue eyes and produce a child with a dark complexion, red hair, and blue eyes.

Although Mary Richmond noted in1917that many physical traits, medical problems, and mental health problems have a genetic basis, only recently has technology allowed us to identify the specific genes governing many of these traits. Now that the initial mapping of the human genome is complete, as further

research is done, the goal is to develop genetic interventions to prevent or cure various diseases or disorders as well as affect conception, pregnancy, and childbirth in other ways. More than 1,000 genetic tests are available ,ranging in costs from $200 to $3,000; they are seldom covered by insurance, and there is no federal regulation (Human Genome Project, 2009b).At present, research is under way to genetically alter sperm, leading to male contraception(Herdiman,Nakash,&Beedham,2006).Our quickly increasing ability to read a persons genetic code and understand the impact it could have on the persons life oftentimes demands the expertise of a genetic counsel or to provide information and advice to guide decisions for persons concerned about hereditary abnormalities. Social workers, with their bio psychosocial perspective, are well positioned to assess then and in some circumstances provide such services(Bishop,1993;Schild&Black,1984;Takahashi&Turnbull,1994).The interdisciplinary field of genetic counseling acknowledges social work as one of its essential disciplines, thereby making at least a rudimentary understanding of genetics and related bioethical issues essential for social work practice(Garver,1995;HumanGenome Project,2009b;Rauch,1988;Reed,1996).For example, researchers recently reported that a genetic variation has been identified that may explain why there is a higher rate of premature delivery for African American women compared with European American women. This is information that a social worker could use to encourage pregnant African American clients to seek medical consultation related to possible genetically based premature birth risks(Wang et al.,2006). Social workers need to understand the rising bio ethical concerns that genetic research fosters and to use such knowledge to help clients faced with genetically related reproductive decisions. The U.S. government has the largest 54 DIMENSIONS OF HUMAN BEHAVIOR: THE CHANGING LIFE COURSE bioethics program in the world to address questions such as the following: Who should have access to genetic information? Do adoptive parents have the right to know the genetic background of an adoptee? Will genetic maps be used to make decisions about a pregnancy? Which genes should be selected for reproduction? Will persons who are poor be economically disadvantaged in the use of genetic information?

A major concern of genetic counseling is whether all genetic information should be shared with a client. Some information may only cause distress, because the technology for altering genes is in its infancy and applicable to only a few situations. But recent advances allow for earlier diagnosis, which reduces or prevents the effects of some rare diseases as well as gives some clients more decision options. Today, for example, a late-life pregnancy such as Hazel Gerekes could be evaluated genetically using amniocentesis in the third trimester, or earlier in the first trimester using chorionic villus testing, which allowed Cecelia Kin to know that her unborn child had Down syndrome. Such evaluation could lead to decisions ranging from abortion to preparation for parenting a child with a disability. However, these options typically are economic,political,legal,ethical,moral,andreligiousconsiderations(Andrews,1994;Chadwick,Levitt,&Shickl e,1997).Ethical issues related to genetic engineering have an impact not only at the individual and family levels but also at the societal level. For example, when we are able to manipulate genes at will, we must be on guard against geneticelitism. It is one thing to use genetic engineering to eliminate such inherited diseases as sickle-cell anemia but quite another to use it to select the sex, body type, or coloring of a child. We are living in a time of tremendous ethical complexity, involving the interplay of new reproductive technologies; changing family structures, values, and mores; political and religious debate; and economic considerations. This ethical complexity extends to issues of social justice; as increasing numbers of persons gain the ability to control conception, plan pregnancy, and control pregnancy outcomes, social workers need to protect the interests of those who lack the knowledge and other resources to do so.

Womens mental health: the facts

As per Census 2001, The total female population (all ages) is 49.6 Crores which constitute 48.26 % of the countrys total population. Of the 49.6 Crores females, 36.09 Crores live in rural areas. Among the female population, 35.07 % are girl children (<= 14years), 57.10 % are women aged 15-60 years and 7.83 % are elderly women (>= 60 years). As per the various censuses, The sex ratio has shown, A decrease of 13 points (from 946 in 1951 to 933 in 2001) for all India. A decrease of 19 points (from 965 in 1951 to 946 in 2001) for Rural India. An increase of 40 points (from 860 in 1951to 900 in 2001) for Urban India. Depressive disorders account for close to 41.9% of the disability from neuropsychiatry disorders among women compared to 29.3% among men. Leading mental health problems of the elderly are depression, organic brain syndromes and dementias. A majority are women. An estimated 80% of 50 million people affected by violent conflicts, civil wars, disasters, and displacement are women and children. In women age gr 15-44, unipolar depression was the leading cause of disease burden in both developed and developing countries Schizophrenia,BPD and OCD ranked top ten leading cause of burden for women aged 15-44 yrs However, the multiple roles that they fulfill in society render them at greater risk of experiencing mental problems than others in the community. Women bear the burden of responsibility associated with being wives, mothers and careers of others. Increasingly, women are becoming an essential part of the labor force and in one-quarter to one-third of households they are the prime source of income (WHO, 1995). In addition to the many pressures placed on women, they must contend with significant gender discrimination and the associated factors of poverty, hunger, malnutrition and overwork. An extreme but common expression of gender inequality is sexual and domestic violence perpetrated against women.

These forms of socio-cultural violence contribute to the high prevalence of mental problems experienced by women. MENTAL DISORDERS AND WOMEN

Prevalence rates of depression and anxiety disorders as well as psychological distress are higher for women than for men. These findings are consistent across a range of studies undertaken in different countries and settings (Desjarlais et al, 1995).

Women are much more likely to receive a diagnosis of obsessive compulsive disorder, somatization disorder and panic disorder (Russo, 1990). Only a small part of the 'iceberg of morbidity 'is visible in health statistics or clinical practice ( White etal, 1961). It's gender hue varies, most likely being deeply feminine at the bottom and gradually fading until it is intensely masculine at the very top. The bulk of the iceberg is of a feminine shade.

BIBLIOGRAPHY Townsend C. Mary. Psychiatric Mental Health Nursing concepts of care in Evidenced based practice. 7 ed: Philadelphia:F A Davis;232-240. Laraia Michele T, Gail W.Stuart. Principles and practice of psychiatric nursing .7 th ed. Evolve.319 Lippincotts .Manual of psychiatric nursing care plans. Lippincotts BasavanthappaBT .Psychiatric mental health nursing . jaypee. New Delhi .: 2007 http://www.integritycounseling.biz http://en.wikipedia.org/wiki/Personal_boundaries