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Post-Partum Depression: A Clinical, Not Legal, Issue

California case has experts calling for better provider education

A nurse who called law enforcement on a patient out of concern that she could harm her newborn infant could be a sign of a wider problem related to provider education about post-partum depression, experts said.

According to Kaiser Health News, a California woman sought care at a women’s clinic to discuss options for treating what she suspected was post-partum depression. The nurse handling her case called the police after the patient mentioned that she had violent thoughts relating to herself and her baby. The police escorted the woman and baby to the emergency department, where both were put under observation.

While the patient’s point of view has been widely reported, healthcare professionals said it’s very likely that the nurse lacked the resources about how to best approach this situation.

“It’s easy for us to vilify, and point to all the things that went wrong in that situation — and there were many — but it points to the fact that our frontline providers need more education in this area,” Lauren Osborne, MD, assistant director of the Johns Hopkins Women’s Mood Disorders Center in Baltimore, told MedPage Today.

“The reality is these kind of thoughts the patient was talking about were intrusive thoughts — they were violent and horrifying to her, but they are things that she’d never act on. This is incredibly common during the post-natal period,” Osborne added. She noted that post-partum depression may affect up to 15% to 20% of women, but post-partum psychosis, which is much more severe, affects a much smaller number.

“Ideally, a woman in this situation would see a psychiatric/mental health provider in the same setting,” Ursula Kelly, PhD, associate professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta said. “Women seeking help for symptoms of postnatal depression or other concerning symptoms is a positive action, not a criminal one.”

But others said that the nurse did exactly the right thing, at least from an ethical standpoint.

“All healthcare professionals, including physicians and nurses, have both a legal and ethical duty to report possible abuse or neglect of a child. They don’t have to be 100% certain, but any suspicion or reason to believe an infant is being harmed should be reported,” said Jonathan Fanaroff, MD, director of the center for pediatric ethics at University Hospitals Rainbow Babies & Children’s Hospital in Cleveland. He added that it is then up to the child welfare agency to investigate and determine whether harm is occurring.

Jay Wolfson, DrPH, distinguished service professor, public health, medicine and pharmacy, at the University of South Florida in Tampa agreed that the provider “did the right thing, given the facts and circumstances.”

“Extreme prudence is now expected, with potential criminal liability for gross negligence accruing to providers and their institutions, especially in matters affecting children,” he said.

Osborne pointed out that how to treat these patients often varies by state. Massachusetts, for example, has a hotline providers can call and speak with a perinatal psychiatrist. California does not have the same set-up. In her home state of Maryland, a task force recently submitted a recommendation to the governor for creating a similar hotline, she stated.

But education is the key to increasing provider awareness, Osborne argued. She said she is developing a national standardized curriculum in reproductive psychiatry, and discussed potentially mandating training in this field for providers, similar to the education providers must undergo about opioids.

Pauline Walfisch, LCSW, program director, outpatient perinatal psychiatry services at Zucker Hillside Hospital-Northwell Health in Glen Oaks, New York, agreed that more education is necessary.

“We in the medical community have a responsibility to provide more training and education to our providers, as well as to increase access to care when it is needed most. We want providers to be able to make an evidence-based risk assessment in real time, have resources available, and be able to quickly link these mothers to the support and treatment they need,” she said.

But Wolfson questioned the feasibility of programs with more education for providers, saying “creating separate, new programs with new money to enhance awareness is a nice thought, but it does not pay practitioners more do their jobs, and more completely manage and care for their pregnant and post-partum patients. That is where the money and education should go.”

Kelly emphasized that these symptoms and seeking help for them should be “a clinical issue, not a legal issue.”

“The more these symptoms and problems are recognized as the clinical problem … by healthcare providers and the public … the more likely it is that women will seek help, and get the help that they need, by the appropriate provider in the appropriate setting,” she said.

Osborne acknowledged that mandating this kind of training in reproductive psychiatry for providers may happen further down the road, but not right now.

“Maybe it should be a requirement for family practice physicians, ob/gyns and social workers, but we’re a long way from being able to implement it,” she said. “But we can use this story to raise awareness — not to vilify providers, but to advocate for more education.”

Can I Really Not Sleep With a Tampon in During My Period?

Let’s talk toxic shock syndrome.

You’ve probably heard a lot of alarming warnings about toxic shock syndrome (TSS), a rare but life-threatening complication of certain bacterial infections.

One of the most prevalent rumors is that sleeping with a tampon in during your period is practically a guarantee that you’ll wind up with TSS, so you should never do it unless you want to take that risk. But sleeping with a tampon in also happens to be way more convenient and significantly less messy than relying on a pad—so how concerned should you really be? Here, experts discuss the truth about tampons and toxic shock syndrome.

No doubt you’ve heard of TSS before, but you may be hazy on the details.

TSS is primarily caused by Staphylococcus aureus (staph) bacteria, but it can also be caused by a kind of Streptococcus (strep) bacteria, according to the Mayo Clinic. Clostridium sordellii can cause this infection as well, according to the Cleveland Clinic.

Your vagina has its own natural bacterial flora, and it can contain these bacteria without making you sick, G. Thomas Ruiz, M.D., an ob/gyn at MemorialCare Orange Coast Medical Center in Fountain Valley, Calif., tells SELF. But sometimes this bacteria can produce the toxins that lead to toxic shock syndrome, according to the Mayo Clinic.

Unfortunately, no one really knows the exact mechanism that links tampons to TSS, Mary Jane Minkin, M.D., a clinical professor of obstetrics and gynecology and reproductive sciences at Yale Medical School, tells SELF. One theory is that if you leave a tampon in for too long, these bacteria can flourish and become trapped, then enter your uterus through your cervix, according to the Cleveland Clinic.

This may be more likely if you use a really absorbent tampon when your period is too light to need one. Not only does this make it less likely that you’ll change it as often as you should, but the more absorbent a tampon is, the more it can dry out your vaginal mucosa, Lauren Streicher, M.D., an associate professor of clinical obstetrics and gynecology at Northwestern University Feinberg School of Medicine, tells SELF. This can increase the risk of tears in the vagina, which can allow bacteria to enter the body. The cuts don’t need to be big—even microscopic disruptions in your vaginal mucosa can be enough, Dr. Streicher says.

But TSS isn’t just associated with tampons. People can also develop TSS after getting a cut or burn on their skin, having recent surgery, using diaphragms or sponges, or having a viral infection like the flu or chickenpox, according to the Mayo Clinic.

While present-day tampons can cause TSS, the condition was most prevalent when women were using ultra-absorbent tampons that are no longer on the market.

Those tampons contained ingredients like polyester foam and carboxymethylcellulose, a thickening agent that enabled more expansion than other tampons did, according to the Centers for Disease Control and Prevention (CDC). This allowed women to keep ultra-absorbent tampons in for longer periods of time, but the longer wear allowed bacteria to colonize, Suzanne Fenske, M.D., assistant professor of obstetrics, gynecology, and reproductive sciences at Mount Sinai Health System, tells SELF.

Tampons with these ingredients were pulled from shelves after the spate of TSS cases, according to the CDC. Now, the Food and Drug Administration requires that manufacturers use a set system for measuring tampon absorbency so as not to get into dangerous territory. That doesn’t mean that the tampons on sale today can’t cause TSS, but that they’re much less likely to do so than higher-absorbency ones from decades ago.

The vast majority of people who leave a tampon in too long will be fine.

TSS isn’t as common as it once was, but there’s still a small risk of developing it. At its peak in 1980, incidence rates of TSS were 6 to 12 per 100,000 women between the ages of 12 and 49, according to the CDC. By 1986, that went down to 1 in 100,000 women between the ages of 15 and 44, and that’s still the approximate incidence today.

“The most common side effect [of using a tampon for too long] is a smelly vaginal odor,” Sherry A. Ross, M.D., an ob/gyn and women’s health expert at Providence Saint John’s Health Center in Santa Monica, Calif., and author of She-ology: The Definitive Guide to Women’s Intimate Health. Period., tells SELF.

It’s unclear why a few unlucky people develop TSS after leaving a tampon in for too long while so many others others don’t, Maura Quinlan, M.D., M.P.H., an assistant professor in the Department of Obstetrics and Gynecology at the Northwestern University Feinberg School of Medicine, tells SELF. “For some women, their immune system may not fight off the bacteria as well,” she says. But again, doctors really don’t know.

Still, it’s important to learn the signs of TSS so that, if it ever does happen to you or someone close to you, you can get help as soon as possible.

Common TSS symptoms include a sudden high fever, low blood pressure, vomiting or diarrhea, a rash that looks like a sunburn, confusion, muscle aches, seizures, and headaches, according to the Mayo Clinic.

If you suspect that you have TSS, get to the emergency room immediately—the condition can progress quickly, Dr. Quinlan says. There’s no one test for TSS, but doctors will likely take blood and urine samples to test for a staph or strep infection, according to the Mayo Clinic.

While doctors try to figure out the source of the infection, you’ll be treated with antibiotics, receive medication to stabilize your blood pressure if it’s low, get fluids to treat dehydration, and have other care based on how your illness is presenting. In very serious cases, surgery can be necessary to remove dead tissue that resulted from the infection.

Bottom line: TSS is scary, but you can sleep with a tampon in as long as you don’t push the eight-hour limit.

It’s also important to use the lowest-absorbency tampon possible to lower the odds that you’ll develop TSS, Dr. Minkin says. The less absorbent your tampon, the less likely you’ll leave it in for too long, and the less likely it’ll sap your vaginal mucosa of too much moisture. The guidelines are there for a reason—if you want to be as safe as possible, follow them.

Dr. Ruiz recommends putting in a new tampon right before you go to sleep and changing it as soon as you get up. Even better if you can manage it when you get up to pee in the middle of the night, he says, but it’s not a requirement—if you’d rather tumble back into bed and deal with it in the morning, feel free. And if you’d prefer to avoid the whole question of sleeping with a tampon in altogether, you may want to try something like a menstrual cup instead. These reusable products are typically made of medical-grade silicone, collect blood rather than absorbing it, and can be used safely for up to 12 hours—more than enough time to hit snooze and still be completely in the clear.

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