Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 16 When Post Partum Becomes Complicated

Our culture embraces a joyous picture of new motherhood: A stylish, slender mother tending to her beautiful, chubby baby with minimal signs of stress or fatigue. But this depiction doesn’t represent reality. After the birth, many mothers just try to get through the days and nights with a newborn as best as they can. They may need months to become confident, comfortable, and happy with baby care and their new roles as mothers.

For some women and their families, postpartum recovery is more challenging than usual because of a traumatic birth experience, a physical condition that makes recuperation difficult, an emotional complication such as postpartum depression, or a strained relationship. This chapter addresses some of these unexpected and uncommon complications and troubling situations that can challenge the postpartum period. It also offers empathetic advice and solutions so you can learn how to manage these complications and focus on enjoying life with your baby.

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In this chapter, you’ll learn about:

• The effects of a traumatic birth experience and how to resolve them

• Physical, emotional, and mental health challenges that can complicate post-partum recovery

• Social and relationship challenges that can complicate life after the birth such as relationship problems, single parenthood, and returning to work

Traumatic Birth Experience

If birth was much worse than you’d expected, you may feel traumatized, sad, angry, and confused. In the weeks and months afterward, as your baby needs less immediate care and you have time to think about your experience, these feelings may intensify.

Ignoring feelings of extreme sadness, fear, loss, or anger won’t make them go away. An event such as a new pregnancy or the birth of a friend’s baby can unexpectedly bring up unresolved feelings you may have about your labor, birth, and postpartum experience.

To deal with these feelings, talk with your caregiver (or someone knowledgeable about birth) about your experience to help you understand how events unfolded. You may want to work with a therapist or counselor who can help you acknowledge the unusual difficulty of your experience and find healthy ways to express your feelings and be an advocate for yourself, your baby, and your family. For example, if you choose to have another baby, you can work with your caregiver on a plan for having a better birth experience.

Physical Challenges after the Birth

Physical challenges can prolong postpartum recovery and make it more painful than usual. After giving birth, you may find it difficult to sit, walk, or carry your baby. You may be in constant pain and require frequent medical appointments or even hospitalization. If you’re in this condition, you’ll need extra help and support from family members, friends, or professionals such as lactation consultants or postpartum doulas. These people can help take care of you, your baby, your family, and your household.

The following sections discuss common physical challenges after birth and comfort measures to help manage them.

LARGE EPISIOTOMY OR SEVERE PERINEAL TEARING

To reduce the pain from a large episiotomy or severe perineal tearing (laceration), use the comfort measures discussed on page 336 and take any prescribed pain medication. Because constipation is a common side effect of narcotics such as Vicodin, see page 120 for tips to treat constipation. To reduce swelling, lie down as often as possible. If the pain worsens, contact your caregiver to detect problems that need further treatment.

URINARY INCONTINENCE

For a short time after giving birth, you may have urinary incontinence, a condition that causes you to leak urine when you have a full bladder, exercise, cough, or sneeze. Leaking usually stops on its own within weeks of the birth.1To treat urinary incontinence, practice your Kegel exercises (see page 95) frequently each day. Use maxi pads or incontinence pads to protect clothing.

Sometimes, leaking happens even without a full bladder or exercise, and it can persist for more than a month or two. This condition is more serious—and often embarrassing and depressing. Talk with your caregiver about treatment options. If necessary, consider asking your caregiver to recommend a physical therapist to evaluate the effectiveness of your Kegels and suggest other exercises and therapies.2 In rare cases, caregivers recommend surgery if the condition persists for more than a year.

Advice from the Authors

Asking for Help

When asking family members and friends for help during your postpartum recovery, you may find that people are more eager to help if given specific tasks such as cooking meals, shopping, housecleaning, or holding your baby. This way, your loved ones don’t have to worry their help is misdirected, unwanted, or duplicated by someone else. Plus, by letting people know what you’d like them to do, you ensure you get the kind of help you need when you need it.

FECAL INCONTINENCE

After giving birth, you may have fecal incontinence, an embarrassing and upsetting condition that causes you to uncontrollably pass gas or leak stool.3 The condition may persist for the first few weeks after the birth. (If it persists for more than a month, contact your caregiver.)

To treat fecal incontinence, practice your Kegel exercises. Research shows that Kegels can help a woman regain bowel control.4 Use incontinence pads to protect clothing. Consult with your caregiver about medications or changes to your diet that can help stop fecal incontinence. On rare occasions, caregivers recommend surgery to correct the problem.

PERSISTENT HEMORRHOIDS

Pregnancy often causes hemorrhoids (dilated veins in the anus and rectum that can cause pain or itchiness). Most hemorrhoids disappear in the first month following the birth; however, some persist for months.

To help prevent and treat hemorrhoids, follow the recommendations in on page 335. If these measures don’t provide adequate relief, consult with your caregiver about any outpatient procedures that may help. In rare circumstances, a caregiver may recommend surgery to correct the problem.

SEVERE ANEMIA

Anemia is a condition in which the number of red blood cells is lower than normal. Many women are mildly anemic during pregnancy and after the birth, but 2 to 4 percent of women become severely anemic from postpartum hemorrhage. Anemia is also a risk factor for developing postpartum depression (see page 357).5

Symptoms of anemia include weakness, lightheadedness, shortness of breath, and overwhelming fatigue. A caregiver can diagnose anemia by analyzing a blood sample.

To treat anemia, caregivers advise women to take an iron supplement and eat iron-rich foods. (Visit our web site, http://www.PCNGuide.com, for more information on iron-rich foods.). Caregivers rarely order a blood transfusion to treat anemia unless the blood loss is life threatening.

If you have severe anemia, you’ll need extra help with baby care and housework. When getting up from sitting or lying down, move slowly. Have someone accompany you to the bathtub or shower to prevent falling if you become lightheaded.

In Their Own Words

I had retained placental fragments that caused significant bleeding two weeks after the birth. I had a D&C under general anesthesia to remove the fragments. I continued to bleed. I returned for a second D&C. With each procedure, I was separated from my nursing baby, and it took several days for me to feel well again. I decided to wait until I felt better before talking with my caregiver about my experience. It may be a while before I consider another pregnancy.

—Kristen

LATE POSTPARTUM HEMORRHAGE

Late postpartum hemorrhage is a large loss of blood occurring between twenty-four hours to six weeks after the birth. Infection or retained fragments of the placenta usually cause the bleeding, which occurs in 1 percent of women. If a woman loses a significantly large amount of blood, she may develop anemia (see page 353).

To treat late postpartum hemorrhage, a caregiver removes the fragments of placenta using medications or a D&C (see page 128), or treats a uterine infection with antibiotics.

BACK AND HIP PAIN

After giving birth, many women experience pain in the lower back or pelvic region. Sometimes, the pain results after a woman twists or overstretches her lower back or pelvic and hip joints while she’s numb from epidural or spinal anesthesia. This pain may last for the first few days or weeks after the birth, and many caregivers recommend ibuprofen for relief. If you develop this pain and it interferes with your ability to walk or roll over, ask your caregiver to refer you to a physical therapist.

If you injured or broke your tailbone (coccyx) before the birth, your baby’s passage through your pelvis may flex or even re-break your tailbone, causing pain and bruising. Even if you didn’t injure or break your tailbone before birth, it may break or become injured during birth if your baby is large. The tailbone will reset itself, but it may take weeks to months. Taking ibuprofen, applying heat or cold packs, and sitting on a firm surface can help relieve pain.

Sometimes in pregnancy or during birth, the pubic joint in the front of the pelvis (pubic symphysis) widens or separates, causing some women to experience mild to debilitating pain in the pubic region after giving birth. Because pubic pain isn’t well documented, caregivers may underestimate the severity of the condition or even dismiss it as normal pain that will disappear with time.

To treat pubic pain, avoid lifting objects and making movements that cause pain, such as stair climbing, vacuuming, and spreading your legs or knees wide apart. Use a walker or a sturdy baby stroller if walking is especially painful. Working with a physical therapist can speed recovery.

NUMBNESS AND PAIN IN YOUR HANDS

After birth, you may experience numbness, tingling, weakness, or pain in your hands and wrists. These symptoms may stem from the swelling around the nerves in your wrists (for example, carpal tunnel syndrome), caused by extra fluid your body retained in pregnancy. After the birth, the swelling diminishes as the fluid level naturally decreases over time; however, until it does, repetitive activities—such as holding, lifting, and carrying your baby—can exacerbate these symptoms.

To treat numbness and pain, try to keep your wrists in a neutral position (not bent or curled) when handling or feeding your baby. Consider buying wrist splints if keeping your wrists in a neutral position is difficult. If symptoms don’t improve, ask your caregiver to refer you to a physical therapist or hand specialist for ultrasonic therapy, custom splinting, exercises, or corticosteroid treatments.

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In Their Own Words

Because of complications, I didn’t have the home birth I’d planned. Then I had a life-threatening postpartum hemorrhage that left me unable to make enough milk for my baby. My midwife helped me understand the events of my labor and supported me during the early weeks. A physician specializing in breastfeeding medicine supported my breastfeeding efforts and helped me find donated milk. I also attended a support group that was facilitated by a knowledgeable, empathetic lactation consultant, and I discovered there were other mothers who had breastfeeding difficulties.

—Alisha

PERSISTENT BREASTFEEDING PROBLEMS

In the first weeks after the birth, most breastfeeding women experience sore nipples and breast fullness. But some women have intense breastfeeding challenges that continue for weeks or months. If you find breastfeeding to be an ongoing painful, time-consuming challenge and you dread the next feeding, you may feel angry, sad, or even depressed because your breastfeeding experience isn’t what you expected.

If breastfeeding problems make you think about quitting breastfeeding, contact a lactation consultant or other breastfeeding expert for support, information, suggestions, and tips. These professionals can tell you whether and how soon the problem can be fixed, and they can help you adjust your approach to nursing if necessary. If the problem requires medical attention, they can refer you to a physician who specializes in breastfeeding medicine, dermatology, or infectious disease. Some communities offer support groups for women with breastfeeding challenges.

Despite having excellent support and a commitment to breastfeeding, some women have problems that don’t improve, causing exhaustion and despair. These women realize that stopping breastfeeding is the only solution—one that may cause great sadness or great relief. If you’re in this position, a lactation consultant or your caregiver can help you sort out your feelings with the decision, acknowledge the hard work you put into breastfeeding, and show you how to feed your baby with formula. If you have strong negative feelings about your breastfeeding experience, consider talking to a counselor to help you come to terms with your decision.

For more information on breastfeeding challenges, see pages 419–424 and pages 428–434.

THYROID PROBLEMS

Three to eight months after giving birth, 5 to 7 percent of women develop postpartum thyroiditis, a two-phase condition in which the thyroid gland first becomes inflamed and overactive (hyperthyroidism) and then returns to normal function or becomes underactive (hypothyroidism).

Symptoms of hyperthyroidism typically last a short time and include feeling overheated, muscle weakness, shakiness, anxiety, rapid heart rate, inability to concentrate, and weight loss. The thyroid may recover completely from hyperthyroidism, but if the inflammation damaged the gland, it may then become underactive.

Symptoms of hypothyroidism include tiredness, constipation, memory loss, intolerance of cold, muscle cramps, weakness, weight gain, and inadequate breast milk production. Hypothyroidism may disappear and the thyroid function may return to normal. If the gland remains underactive, caregivers typically prescribe thyroid hormone replacement medication.

If you experience these symptoms, don’t ignore them or blame them on sleep deprivation. Instead, call your caregiver. Because thyroiditis is a risk factor for developing postpartum depression (see page 357), it’s important to diagnose and treat the condition or rule it out as the cause of your symptoms.

GALLBLADDER PROBLEMS

The gallbladder is a small organ that receives bile from the liver and concentrates it before sending it to the digestive tract to aid with fat digestion. Pregnancy hormones slightly increase the risk of developing gallstones, caused by a slowdown in the passage of bile from the gallbladder. When the stones leave the gallbladder, they may clog the bile duct and cause sharp and extreme pain.

Symptoms of gallstones include nausea, vomiting, abdominal bloating, burping, gas, indigestion, and steady, increasing pain in the upper abdomen, under the right shoulder, or between the shoulder blades. The pain often occurs after eating fatty foods or at night and lasts thirty minutes to several hours. If you experience sweating, chills, fever, yellow skin, or clay-colored bowel movements, see your caregiver immediately. The treatment for gallbladder problems is laparoscopic surgery.

POSTPARTUM HIGH BLOOD PRESSURE (HYPERTENSION)

Hypertensive disorders (high blood pressure) affect 6 to 8 percent pregnancies in the United States.6 For most women with gestational hypertension (see page 140), blood pressure returns to normal after the birth. Some women, however, continue to have high blood pressure, and a few women develop the condition after the birth.

Little information exists on preventing or treating postpartum hypertension,7 but complementary medical approaches (such as acupuncture, meditation, and yoga) may help augment traditional medical therapies.

If you develop postpartum hypertension, your blood pressure will most likely return to normal, but it may remain a continuing health concern. To monitor your blood pressure and find an effective medication for treatment, you’ll need to see your caregiver frequently. While these appointments can complicate postpartum life, they’re necessary to ensure your health. If breastfeeding, ask your caregiver or a lactation consultant if a blood pressure medication is safe for nursing.

Emotional and Mental Health Challenges

Postpartum mood disorders (PPMD) include the emotional conditions that can develop in the first year after giving birth, such as anxiety and panic disorder, obsessive-compulsive disorder, postpartum depression, bipolar disorder, and post-traumatic stress disorder. About 20 percent of women will develop one of these conditions or a combination of them after giving birth.

PPMD are more serious than “baby blues” (see page 348) and can complicate the postpartum period significantly. They can be emotionally paralyzing and cause feelings of hopelessness and isolation. In addition, our culture finds PPMD shameful, which may lead affected new mothers to hide their symptoms and not seek the help they need and deserve.

The following sections describe PPMD and their risk factors. As you read about the conditions, know that the severity of the symptoms varies among women.

POSTPARTUM ANXIETY AND PANIC DISORDER

About 10 percent of women have postpartum anxiety and panic attacks; however, those women with a history of anxiety and panic disorder have an increased risk of developing the condition after giving birth. Symptoms include shortness of breath, sensations of choking, lightheadedness, faintness, rapid heart rate, chest pain, nausea, and diarrhea. If you develop this disorder, an overwhelming fear of being alone, dying (you or your baby), or leaving your home may immobilize you.

POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER (OCD)

About 3 to 5 percent of women develop postpartum OCD, a condition characterized by obsessive (uncontrollable) thoughts and compulsive rituals to protect the baby. All mothers typically have instincts to protect their babies, but these instincts are extreme in women with postpartum OCD. Examples of obsessive thoughts include a fear of being a “bad” mother, of hurting the baby, or of germs. Compulsive rituals can include constant hand washing (hundreds of times each day), frequent housecleaning, excessively checking on the baby, or constantly ensuring that doors are locked. Not surprisingly, these rituals interfere with normal daily living.

POSTPARTUM DEPRESSION

Postpartum depression occurs in 10 to 20 percent of new mothers. For a woman with a history of depression, the risk of developing the condition increases to 30 percent. For a woman with past postpartum depression, the risk increases to 70 percent.8

Postpartum depression generally occurs between two weeks to one year after the birth, although the onset typically begins between the sixth week and the sixth month. Symptoms vary in severity among women and include the following:

• Feelings of hopelessness, despair, and exhaustion

• Feelings of extreme inadequacy and low self-esteem

• Lack of energy

• Loss of interest in everything

• Inability to sleep, even when an opportunity arises

• Overeating or forgetting to eat

• Constant crying

• Surprising and frightening outbursts of anger at loved ones

• Recurring thoughts about hurting oneself (even committing suicide) or the baby

In Their Own Words

I had preeclampsia and a very premature birth. Soon after the birth, my daughter was admitted to the neonatal intensive care unit and I had two seizures. It was a frightening time. A year later, I became upset when I visited a friend in the same hospital. After leaving my friend, I sat in my car and cried for quite some time. I knew then that I needed to understand what had happened to me and to learn how to deal with the triggers (such as being in a hospital) that had caused me to feel deeply and inconsolably sad. I talked with my doctor, who helped me understand the events of my pregnancy and birth. I also found a therapist to help me deal with my feelings and reactions.

—Elsa

BIPOLAR DISORDER OR MANIC DEPRESSION

Bipolar disorder (BD) occurs in 2 percent of the population. A woman diagnosed with BD before pregnancy will likely relapse if not treated during pregnancy and the postpartum period.

BD usually begins with extreme mood elevation, energy, and grandiose thoughts within a few days to weeks after the birth. A long-term period of depression may follow. Suicide is a risk during both mania and depression. A woman with BD needs the care of a psychiatrist or therapist with expertise in treating the condition.

POSTPARTUM POST-TRAUMATIC STRESS DISORDER

After the birth, post-traumatic stress disorder (PTSD) may result from a difficult or frightening birth or from traumatic situations such as an unexpected illness, sudden problems for the baby, or insensitive or hurtful care. PTSD can also occur when birth triggers memories of a traumatic event such as a frightening hospital experience, physical or sexual abuse, or rape.

Common symptoms of PTSD include preoccupation with the trauma, flashbacks to the event or recurrent nightmares (both possibly accompanied by anxiety and panic attacks), anger or rage, and extreme protectiveness of oneself or the baby.

RISK FACTORS FOR PPMD

While no one can predict who will have PPMD, the following factors increase your risk of developing one of the conditions:

History of mental health challenges

• Panic disorder, OCD, depression, or BD (or history of these challenges in an immediate family member)

• Physical, emotional, or sexual abuse

• Eating disorders

• Substance abuse (or living with someone who’s abusing drugs or alcohol)

Challenges with menstruation, pregnancy, birth, or your baby

• History of severe premenstrual symptoms

• History of infertility or miscarriages

• Unplanned and unwanted pregnancy

• Traumatic pregnancy or birth

• High-needs baby or a baby with a chronic medical condition

• Feeding problems with your baby

Temperament

• Low self-esteem

• High expectations to be perfect and in control

Myths and Facts about PPMD

Myth:  

• All women feel sad, anxious, or angry after giving birth. The feelings will go away if I just “tough it out” or ignore or deny them.

Fact:  

• Acknowledging how you feel and getting help will speed your recovery.

Myth:  

• Having PPMD means I’m a weak person.

Fact:  

• Strong, intelligent women have PPMD. You didn’t cause the condition by anything you did.

Myth:  

• Having PPMD means I’m a “bad” mother.

Fact:  

• Many women with PPMD think only “bad” mothers ever get angry or have thoughts about hurting themselves or their babies. It may help you to know that these thoughts don’t make a mother “bad.” All mothers do the best they can, and women with PPMD who recognize that these thoughts are harmful don’t act on them.

Myth:  

• If I take medication for PPMD, I can’t breastfeed.

Fact:  

• Medications that are compatible with breastfeeding exist. Check with your caregiver or therapist.

Recent stressful life events

• Death in the family

• Moving to a new home

• Changing jobs or losing a job

• Getting married, separating, or divorcing

• Financial pressures

• Excessive sleep deprivation

Lack of support

• Unsupportive partner or no partner

• Unsupportive friends or family

• Poor or absent relationship with your mother

Health issues

• Thyroid disease

• Anemia9

Inflammation

Research shows that inflammation and a lack of omega-3 fatty acids in a woman’s diet are major risk factors for PPMD (as well as for depression in the general population).

Consuming too many omega-6 fatty acids (found in vegetable oils and many processed foods) can cause inflammation. Late pregnancy and postpartum stressors (such as sleep deprivation, major life stress, and pain) also raise inflammation levels.

Consuming omega-3 fatty acids (found in fish, flax meal, and other foods and supplements) can lower high levels of inflammation and prevent or treat postpartum depression and possibly other PPMD.10 For more information on omega-3 fatty acids, see page 114.

TREATING PPMD

If you have any of the risk factors for PPMD (see page 358), arrange for professional help before the birth so you can report any symptoms quickly and begin treatment. Early treatment can shorten the duration of PPMD.

Appropriate treatment for PPMD depends on the severity of the symptoms and may include therapy, medications, and lifestyle changes such as the following suggestions:

• Eat well.

• Avoid alcohol, caffeine, and over-the-counter sleep medications.

• Exercise regularly.

• Get information about PPMD and their treatments.

• Get enough sunlight or use a light box to decrease the risk of developing seasonal affective disorder (SAD).

• Take time for yourself each day—even if it’s just for five minutes.

• Get adequate rest and sleep.

• Get enough omega-3 fatty acids to reduce inflammation. (See page 359.)

Other treatment options include the following:

• Attend a PPMD support group, which helps women and their families understand the conditions, recognize the causes, and learn about resources for support. Your caregiver, childbirth educator, local hospital, or health department can refer you to a support group in your area. You can also contact Postpartum Support International by phone (800-944-4773) or by visiting their web site at http://postpartum.net.

• Get counseling or therapy. Choose a therapist or psychiatrist who specializes in PPMD.

• Take prescribed medication for anxiety, OCD, depression, and bipolar disorder.

• Get counseling along with taking medication (which can help with a more rapid recovery than taking medication without counseling).

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A Note to Fathers, Partners, and Relatives

PPMD can affect the whole family. Women with PPMD often worry about their ability to be physically and emotionally available to their babies. You may worry, too.

To help a mother with PPMD, encourage her to get treatment, provide support and care, gather information on interacting with a newborn, help with housework, and find ways to ensure she gets rest and sleep.

Getting enough sleep may be the most important step to recovery, but it can also be the most challenging. Help with nighttime feeding and parenting so the mother gets two or more three-to four-hour stretches of sleep each night. Consider getting support from other family members, a postpartum doula (see page 27), or mother/baby support groups.

POSTPARTUM PSYCHOSIS

Postpartum psychosis is a rare condition that’s more serious than PPMD. It occurs soon after birth in about .01 percent of women. Symptoms include severe agitation, mood swings, depression, and delusions. Women with postpartum psychosis need immediate care and psychiatric treatment. Hospitalization is often necessary at the onset of the condition, at which time women take medications to treat symptoms. Once home, women continue taking medications (monitored by a psychiatrist) and receive ongoing psychotherapy.

Social and Relationship Challenges

The postpartum period can become more challenging than usual if there are problems in your relationship with your partner or if the relationship is abusive. You may also feel stress if you feel your partner isn’t taking on a fair share of the parenting and housekeeping tasks.

If you’re a single parent, or if you need to return to work early or to a hostile or unsupportive workplace, you may have additional stress.

The following sections discuss these challenges and suggest ways to manage them.

YOUR RELATIONSHIP WITH YOUR PARTNER

Research finds that many spouses (especially women) become less satisfied with their marriages after the birth of their first babies.11 Caring for a newborn disrupts family life and can cause chaos and confusion until the family establishes new comfortable patterns.

New parenthood can leave little time to nurture a couple’s relationship. If a new mother believes her partner isn’t as supportive as she expected, or if the couple’s lifestyles and activities grow apart after becoming parents, the relationship can become strained.12 Relationship problems may also arise if relatives are intrusive or unsupportive, or if the baby is high-needs or has serious medical needs.

How can relationships survive the strain of new parenthood? Having a good relationship before the birth best predicts that a couple will have continued satisfaction with the relationship after the birth. Also, if both parents wanted to have the baby, they’re more likely to be happy with their relationship than if one of them had reservations about adding to the family.13

Two Views on Relationships after the Birth

I had an unexpected, frightening, and very premature birth. My son spent a month in the neonatal intensive care unit and another month in the special care nursery. Because my marriage was strong, my husband and I together faced the fears and challenges of having a baby born so early. It did take months for us to feel safe taking our son out in public, but now he’s almost a year old, and we see he’s a strong and hearty boy. I’m grateful my husband and I had each other to lean on during that first tough year.

—Morgan

The birth of our son was a frightening time. I worried that I might lose both my wife and my child. Over the next months, I came to be in awe of both my wife’s and son’s resilience. Yes, there were some tough days and weeks, but we just took one day at a time. Now we have a sturdy one-year-old, and we are talking about having another baby.

—James

If your relationship with your partner becomes strained after the birth, improving matters will usually require a joint effort. First, you and your partner need to agree that a problem exists. Second, you need to agree to get the counseling that’s critical to the relationship’s survival and to your baby’s healthy development. (If one of you refuses to get help, the other will still benefit from counseling.)

Professionals and resources that can help your relationship include marriage or couples counselors, religious counselors with professional expertise in helping families, or courses designed to provide practical, researched-based strategies for building strong relationships between couples, such as Becoming Parents Program, Inc. (http://www.becomingparents.com) and Bringing Baby Home (http://www.bbhonline.org).

ABUSE AND DOMESTIC VIOLENCE

Abuse and domestic violence (any combination of verbal, psychological, emotional, sexual, economic, or physical abuse) affect rural and urban women of all ages, physical abilities, and lifestyles and of all religious, ethnic, socioeconomic, and educational backgrounds. The only risk factor for abuse and domestic violence is being a woman,14 and the risk increases during pregnancy and especially after the birth.15

If you’re in an abusive relationship, you are not at fault. The goal of abuse is to leave you feeling confused, ashamed, powerless, hopeless, and out of control. National and local agencies can help you and your children. Memorize the phone number for the National Domestic Violence Hotline, 800-799-SAFE (7233), and call if you need to talk to someone or need resources, including help making an escape plan for you and your children.

SINGLE PARENTHOOD

About 30 percent of new mothers are single parents, some by choice and others by circumstance. For some single mothers, money is tight, and they need to find affordable child care and return to work soon after the birth. Others have jobs that pay well and provide excellent maternity leave benefits. For still others, the father may provide financial support or family members may provide a home and help with child care.

If you’re a single mother, you’ll need support as you recover from the birth and gain confidence as a parent. New parenthood can be socially isolating, especially if there aren’t adults to talk to in the days following the birth. Organizations and networks exist that provide single mothers with opportunities to talk with one another. Visit http://www.singlemothers.org or http://www.singlemothersbychoice.com to learn more information.

RETURNING TO WORK

By three months after giving birth, 60 percent of employed, first-time mothers in the United States return to work.16 During pregnancy, a three-month leave from work after the birth may seem reasonable; however, by the third postpartum month, new mothers are just getting to know their babies and establishing a relationship with them. Many women dread having to leave their babies in someone else’s care, especially when no other options are available.

In addition to finding suitable and affordable child care, mothers need to figure out how to get their babies to and from the care location. Breastfeeding mothers must also determine how much milk to pump and store. If either the mother or baby has health complications or feeding difficulties, or if the mother has PPMD (see page 357) or a stressful or unsupportive job, returning to work can be even more challenging. Once back at work, many mothers worry how sleep deprivation will affect their ability to function.

If your child-care options are unacceptable or your work situation is unbearable, try to negotiate with your employer for a delayed return to work, work shorter or flexible hours, or work part-time or from home. If these options aren’t possible, you and your family will need to ask yourselves some tough questions: Should you quit your job? Should you try to find another job? Can your family’s budget function without your income? How much energy do you want to devote to improving your workplace’s attitude toward new parents and families? See page 28 for information to help you answer these questions.

If you want to help improve maternity and family benefits in the United States, support political action groups such as MomsRising (http://www.momsrising.org), whose efforts seek to change public policy on maternity and family leave and other benefits for mothers and families.

Key Points to Remember

• For some women and families, physical, emotional, or social challenges can complicate the postpartum period and prolong recovery and adjustment to life with a newborn.

• Acknowledging the difficult circumstances of your postpartum period and seeking help are essential for recovery.

• If your pregnancy has been complicated or if you anticipate problems during birth or afterward, find supportive resources and explore options before the birth to reduce further postpartum complications and provide help if necessary.