Chapter 69 Maternal mental health and psychological problems
After reading this chapter, you will:
This chapter offers a comprehensive overview of the psychological and mental health problems that pregnant and childbearing women may encounter. Pregnancy is a time associated with joy and happiness. The reality, however, is that for many women, pregnancy will, in fact, cause a recurrence of impaired mental health, increase otherwise controlled anxiety problems or be the precursor of a primary illness. Pregnancy is more often described as a life crisis and a time where there is a huge shift in the emotional and psychological balances in a woman’s life. In some ways the emotional ebb and flow mask the real issues that women are trying to deal with and society often considers these emotional changes as the pregnancy norm.
There is recognition that despite improvements in the understanding, detection and treatment of pregnancy-related mental health disorders, many women will not seek help and try to cope with their illness, hiding their unhappiness from their caregivers and family. Women still fear discrimination and long-term repercussions if they reveal a previous emotional disturbance or psychiatric illness (MIND 2001, Robinson 2002). This remains the case despite the fact that one in four people will experience mental health problems at some time during their lifetime. Up to 50% of all women are thought to have suffered some form of emotional disturbance during their lives and the risk is much higher amongst women who are socially excluded (MIND 2001).
In western society there is greater awareness of mental wellbeing and illness; however, it remains by and large a poorly understood aspect of healthcare.
Depression is a serious public health issue and it is estimated by the World Health Organization to be the greatest burden of disease and cause of premature death worldwide by 2020 (WHO 2000). In this authoritative report, WHO propose that women are twice as likely as men to be diagnosed with depression and that violence and self-inflicted injuries will also feature as a characteristic of women’s mental health.
Saltman (1991) identified that one of the reasons for the high rates of women’s psychological and mental morbidity is the focus on mortality. Whilst mortality overall is reduced, there has been little progress in the understanding and redressing of factors that contribute to mental illness. Another primary concern in understanding the mental wellbeing of women is suicide and its determinants (DH 1999). In global studies of women in their peak reproductive years, ages 15–44, it was shown that suicide was second only to tuberculosis as a cause of death. Murray & Lopez (1996) found that in 1990, 180,000 women in China alone committed suicide and 87,000 women in India died by self-immolation.
Further research has shown that there are strong inverse relationships with poverty, social position, ethnic background, marital support and access to healthcare (Bartley & Owen 1996). Being a participant in decisions about healthcare and life choices has a significant impact upon psychological and mental wellbeing, during and outside of pregnancy; a sense of control is critical to wellness.
Health and social behaviours may have an impact upon wellbeing, with tobacco usage and drug and alcohol misuse being common in women with anxiety and depressive disorders (DH 2003). Understanding the dependency that such behaviours provoke is critical for midwives to support positive pregnancy outcomes.
Whilst it would be easy to believe that in the western world higher stress levels might indicate a higher predilection for mental health disorders, there is substantial evidence that developing societies are also at risk. The most common cause in the underdeveloped and Third World populace is the impact of unstable governments and social structures giving rise to conflict and violence.
Whether by their intimate partners or men not known to them, violence is probably the most prevalent and certainly the most representative gender-based cause of depression in women. In studies of the effect upon women in war-torn communities, it was revealed that rape, torture and murder were by far the most common weapon in the entrapment and subjugation of women and their children (WHO 2000). The impact of these crimes leads to a range of mental health illnesses; depression, self-harm and trauma.
Violence and abuse of women consistently features in mental health and physical morbidity. Abusive behaviour, particularly in an intimate relationship, has a detrimental impact on the woman; fear, lack of freedom, humiliation and threat of harm all contribute to deny women’s Human Rights (WHO 1997) (Ch. 23).
Women are more likely than men to suffer abuse throughout their lifetime, particularly rape, sexual assault and child sexual abuse. Research has consistently shown that between 20% and 30% of women have been sexually abused as a child, compared with 10% of male children (DH 2003). This report indicates that 1 in 10 women have experienced some form of sexual victimization, including rape, and that ‘strangers’ are only responsible for 8% of rapes. Sexual abuse particularly experienced as a child has considerable significance for childbearing women, physically during the birth and psychologically throughout childbirth and parenting (Gutteridge 2001).
It would appear that societal influences, largely gender based, have negative influences on the psychological/mental wellbeing of women. Mental health cannot be explained through biomedical determinants alone and it is naive to see women’s mental health only through a framework of reproductive perspective. This explanation is understandable since, globally, women’s health is often influenced by fertility and childbearing. Understanding the impact of pregnancy and childbearing on women’s mental wellbeing with its application across all cultures is significant to developing approaches suitable for women and their families.
There is an increased risk of mental illness associated with childbirth, mostly in the postpartum period, but problems may also be present before or during pregnancy. Many of the factors associated with postnatal mental illness, such as lack of a confiding relationship, lack of support, marital tension, socioeconomic problems and a previous psychiatric history, are present during pregnancy (O’Hara & Zekoski 1988, O’Hara et al 1991, Romito 1989) and so depression may occur both in pregnancy and in the postpartum period (Evans et al 2001, Green & Murray 1994, Watson et al 1984). There appears to be a positive correlation between women who lack positive maternal role models and the development of anxiety-based depressive disorders during pregnancy and the postnatal period (Gutteridge, unpublished data, 1998).
Whilst there is deepening awareness of postnatal depression and psychotic illness following childbirth, there is relatively little published work on the incidence of, and morbidity associated with, antenatal depression. This is despite the fact that depressed mood in pregnancy has been associated with poor attendance at antenatal clinics, substance misuse, low birthweight and preterm labour (Hedegaard et al 1993, Pagel et al 1990). Whereas it was once thought that pregnancy was a protective factor against depression, Watson et al (1984) found that in 24% of cases of detected postnatal depression, symptoms were present during pregnancy.
There is now clear evidence that psychopathological symptoms in pregnancy have physiological consequences for the fetus (Teixeira et al 1999). A cohort study of depressed mood during pregnancy and after childbirth concluded that research and clinical efforts towards recognizing and treating antenatal depression must be improved (Evans et al 2001). The Confidential Enquiry into Maternal Deaths (Lewis 2004) recommends better detection and management of psychiatric disorders antenatally, to reduce the mortality rate. Services must be designed to meet the needs of all women, and a crucial part of the service should address the mental health needs of women.
Many women experience mixed reactions to their pregnancy, with transient feelings of anxiety and fear; they should be reassured that this is normal and be encouraged to discuss these feelings openly (Ch. 12). The incidence of detected mental illness in the first trimester of pregnancy is thought to be as high as 15%, with only 5% of these women having suffered from previous episodes of mental illness. In the second and third trimesters of pregnancy, the incidence of new episodes of mental illness is less, only about 5%.
The majority of episodes of new mental illness during pregnancy are minor conditions or neuroses. The commonest condition is depressive neurosis with anxiety, but phobic anxiety states and obsessive–compulsive disorders may also occur. In most cases, these neurotic mental illnesses resolve by the second trimester of pregnancy and there seems to be no added risk of these women developing postnatal depression.
The outlook is different for those women who begin their pregnancies with chronic neurotic conditions. Their illness is likely to continue throughout pregnancy and may be exacerbated during the third trimester into the puerperium.
Minor mental illness is more likely to occur in the first trimester of pregnancy in women who have marked neurotic traits in the premorbid personality. It also tends to occur in women who have a history of neurotic disorders and in those with social problems, such as marital tension. Other predisposing factors include a history of previous abortion and the possibility of the present pregnancy being terminated (Wilson et al 1996). Women with a poor obstetric history or those who have undergone extensive infertility treatment may exhibit signs of increased anxiety in early pregnancy.
The onset of minor mental illness later in pregnancy, usually during the third trimester, is less common than in the first trimester. When it occurs at this stage in pregnancy, however, the risk of the woman developing postnatal depression is increased (Forman et al 2000).
Major mental illnesses include bipolar disorder, severe depression and schizophrenia. The risk of a woman developing a new episode of one of these conditions in pregnancy is lower than at other times in her life. When women with a history of major mental illness become pregnant, there is no particular increase in the risk of a relapse during pregnancy if they are well stabilized and their illness is in remission. Although the risk of major mental illness is reduced in pregnancy, it is greatly increased in the first 3 months after delivery.
There is growing emphasis on the development of the public health role of the midwife, with promotion of mental wellbeing representing an area where the midwife can make a valuable contribution (DH 2007). The midwife has a responsibility to provide holistic care, meeting the physical, psychological and emotional needs of all women. There should be an emphasis on promoting emotional and psychological wellbeing for all women, not just those perceived to be at risk. Ideally, all women should be treated with sensitivity during pregnancy and enabled during meetings with the midwife to reveal and discuss any issues that may predispose them to impaired mental health.
A midwife has a special relationship in a woman’s lifetime; s/he has a privileged position in which s/he is able to ask direct and intrusive questions regarding a woman’s fertility and sexual history. This is a trusting and a confiding relationship in which the midwife begins to feature strongly in a woman’s life history (Ch. 12), entrusting her body to the midwife and allowing her to care for her developing fetus.
Kirkham (2000) acknowledges the exclusivity of this relationship and identifies themes such as trust, friendship, purpose and the place of self within this dynamic context (Ch. 12). In no other professional relationship is there such a potential for influencing change than between midwife and childbearing woman.
Some women will live within a culture where there is no recognition of minor depressive illness or anxiety states (Wilson et al 1996). Any attempt to enquire whether the woman is symptomatic may be restricted by other family members who associate impaired mental health only with major psychotic illness to which there is shame and stigma attached (Oates 2001). The midwife should recognize that presentations of ongoing minor physical disorders and concerns about the pregnancy may be the only way the woman can express her feelings. To ensure that all women receive adequate support and help, independent, trained interpreters should be available for women whose first language is not English and every attempt must be made to see the woman unaccompanied.
Taking a comprehensive history at the beginning of pregnancy is vital to assess risk, review and plan care around any deterioration of mental and psychological health. Emotional lability during pregnancy is expected; however, the midwife should make ongoing assessments throughout. NICE (2007:6) recommend a universal and continuous enquiry approach:
At a woman’s first contact with services in both the antenatal and postnatal periods, healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask questions about:
Other specific predictors, such as poor relationships with her partner, should not be used for the routine prediction of the development of a mental disorder.
At a woman’s first contact with primary care, during her booking visit and postnatally (usually at 4 to 6 weeks and 3 to 4 months), healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask two questions to identify possible depression.
A third question should be considered if the woman answers ‘yes’ to both of the initial questions.
Although NICE (2007) do not specifically advise against using screening tools such as the Edinburgh Postnatal Screening Scale (EPDS) (see below) or the Hospital Anxiety and Depression Scale (HADS) or the Patient Health Questionnaire-9 (PHQ-9), caution is advised (see website). Assessment tools should only be used as part of a subsequent evaluation for the routine monitoring of outcomes and only by appropriately trained health professionals (NICE 2007).
It is essential that an accurate history is taken and any reported current or past mental illness is adequately investigated and assessed. This should be done with extreme sensitivity to eradicate any fears the woman may have of discrimination (Robinson 2002). If the woman is under the care of a GP, psychiatrist, community psychiatric nurse or psychologist, attempts should be made to work collaboratively within this team to ensure the woman’s whole needs are met.
The majority of minor illnesses will resolve spontaneously by the second trimester of pregnancy. The woman will require support, counselling, reassurance and information communicated in a caring, intelligible way. Psychotropic drugs are rarely necessary or prescribed at this stage of pregnancy. Instead, therapy to help the woman relax and reduce her anxiety seems to be effective. Midwives may be involved in counselling and supporting these women and teaching relaxation techniques. Sometimes a social worker is also required to help tackle social issues which may be the cause of the problem.
Women with a history of single episodes of major mental illness in the past but who have been well for some time are usually advised by their psychiatrist to stop their medication before conception and remain off the medication particularly in the first trimester (NICE 2007). An assessment should be made by a specialist service, usually consisting of a perinatal psychiatrist and specialist midwife/mental health nurse.
Whilst there is no significant risk of relapse during pregnancy for this group of women, there is a marked risk of developing a puerperal psychosis during the first 3 months after delivery (Cox 1986). Measures should be put in place to monitor and assess for deterioration postnatally (Bick et al 2002). This should be in collaboration with specialist perinatal psychiatric services.
The Confidential Enquiry into Maternal Deaths (Lewis 2004 & 2007) using the Office for National Statistics (ONS) linkage data indicates that suicide is the current leading cause of maternal death (indirect category). There is a misconception that women who live within socially deprived situations suffer a greater risk of mental health problems; in contrast, CEMACH highlighted that the following characteristics were risk indicators:
Therefore, the suicide profile of childbearing women is significantly disparate to that of the non-pregnant population. The risk of deterioration is significantly elevated in the last trimester of pregnancy and the first 12 weeks postpartum, when both suicide and infanticide should be considered. Though rare, most cases of infanticide where there is evidence of serious maternal mental illness will be associated with a suicide attempt or successful suicide (Marks & Kumar 1993).
CEMACE (previously CEMACH) recommend that women with a history of severe depression or psychotic disorder be referred to a specialist perinatal mental health team and an appropriate care plan developed, aiming to support the woman through pregnancy and minimize the risk of severe postnatal disorder (Oates 2004). Where a woman is under the care of a psychiatrist when pregnancy is diagnosed, there should be careful liaison between the obstetrician, midwife and mental health team to ensure that the woman’s care is seamless and holistic, and that appropriate management plans are made to maximize the outcome for mother and baby. This is especially relevant when deciding upon the woman’s ongoing and future drug regimen. Additionally, Oates (2000) recommends care is best delivered under the auspices of a managed network approach, whereby those women who are at greatest risk of relapse receive care from specialist service providers.
This is a condition where excessive anxiety is experienced on most days. Symptoms are described as: a fast heart rate, palpitations, feeling sick, tremor, sweating, dry mouth, chest pain, headaches, nausea, tachypnoea. GAD develops in about 1 in 50 people at some stage in life. Slightly more women are affected than men and usually it first develops in the early 20s. The most effective treatment is considered to be cognitive behavioural therapy (CBT).
This is an anxiety disorder and is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress.
OCD is a common mental health condition that affects 2% of the population. It is characterized by obsessive thoughts that cause anxiety. This leads to rituals or repetitive actions. Examples of compulsions include excessive hand washing, cleaning, counting, checking, touching, arranging, hoarding, measuring, excessive neatness, and repeating tasks or actions (NICE 2005a).
This is a normal reaction to an extraordinary event where the individual experiences intense terror and fears for his or her life. It is reported from survivors of road/air accidents, military combat, physical, emotional and sexual abuse, terrorist attacks, hostage situations and being diagnosed with a life-threatening illness (NICE 2005b). Childbirth is now recognized as a situation that may trigger a PTSD response and this might not have been recognized from past pregnancies but may present in a subsequent pregnancy. PTSD symptoms include flashbacks and nightmares, avoidance, numbing of emotions and hyperarousal.
The prevalence of bipolar disorder at the onset of pregnancy has not been estimated and there are no age-related data for childbearing women (Lewis 2004). Estimates would suggest that it is likely that approximately 2 per 1000 pregnancies occur in women with chronic schizophrenia and approximately the same number in women with pre-existing bipolar disorder. These women are likely to be in contact with secondary psychiatric services (Wilson et al 1996).
There are a growing number of women with pre-existing psychotic and affective disorders who will suffer a relapse in their illness during or after pregnancy. It is estimated that 2 per 1000 live births will fall into this category (Wilson et al 1996).
There are no data for the prevalence of schizophrenia in women of reproductive age group. General figures suggests that around 1 in every 100 people are affected. It affects men and women equally and seems to be more common in city areas and in some minority ethnic groups. It is rare before the age of 15, but can start at any time after this, most often between the ages of 15 and 35. Estimates would suggest it is likely that approximately 2 per 1000 pregnancies occur in women with chronic schizophrenia. Schizophrenia is characterized by hallucinations, hearing voices, delusions, loss of insight and depression. Suicide is common in people diagnosed with schizophrenia.
Self-harm, also known as self-injury, is a common behaviour and is more likely to affect young women than men; up to 10% of 14–16-year-olds have self-harmed. A prevalence is noted among young ethnic females and other discriminated groups. It is a way of coping with extreme emotional distress and is secretive in its manifestation. Some expressions of self-harm are: cutting, gouging, burning, scratching, purging, eating disorders and hair pulling (NICE 2004a).
These are characterized by a fear of being fat and out of control with food, which ultimately has a detrimental impact on the health of the individual. Girls and women are 10 times more likely than boys and men to suffer from anorexia or bulimia. Prevalence is estimated to be about 1 in 150 girls. Women with bulimia nervosa are prone to unplanned pregnancy, in part because vomiting reduces the efficacy of oral contraceptives. Some of the effects of eating disorders are:
It is increasingly evident since the global growth of social drug consumption and the incidence of substance abuse that the general mental health of the population has suffered. Mental diagnoses such as bipolar disorder and personality disorders are increasing; theories suggest that social drug use is one of the main reasons and therefore this factor will increase the number of women at risk presenting during pregnancy.
There is good evidence to suggest that during the postnatal period all women are at increased risk of developing a mental illness and for those women who are already diagnosed with a severe mental illness, rates of relapse increase profoundly and they will therefore require specialist services (Lewis 2007).
These conditions are not exclusive and constitute a range of problems with which women may present when pregnant. The midwife’s role must be to recognize the problems, risk assess the woman’s current mental wellbeing and refer to the appropriate health professional or specialist service; the midwife must continue to work within the multidisciplinary team whilst continuing to offer support and guidance to the woman so that she receives normal midwifery care throughout her childbearing experience.
Some women find childbirth a fulfilling experience, but for others it is the most traumatic experience of their life (Niven 1992). The anticipation and unpredictability of birth can cause women anxiety and in some cases extreme distress. In most cases apprehension is normal; however, if the worry is all-consuming and the woman overwhelmed by these emotions, she is more likely to experience heightened pain levels and discomfort.
The experiences of labour and birth for those women who have longstanding fear of hospitals and associated procedures, such as needle phobia, are likely to be more difficult. In these situations it is important that the midwife understands and helps the woman plan her care around these anxieties to avoid further trauma.
Women who have experienced traumatic life events are much more likely to have issues with control and pain. Examples of this are women who were abused as children, survivors of rape/sexual abuse, and women who have experienced violent relationships (Gutteridge 2001).
There is increasing awareness that events around the time of birth can seriously affect a woman’s mental and pyschopathological wellbeing (Laing 2001, Pantlen & Rohde 2001). Women have reported experiencing intense fear, helplessness and a loss of control when recalling their birth experiences. One study found that women who suffered an adverse birth experience were likely to develop trauma symptoms associated with post-traumatic stress disorder (Creedy et al 2000), described as ‘extreme psychological distress following exposure to a traumatic and threatening experience’ (Lyons 1998:93).
A detailed history should be taken for all women and risks identified in relation to pre-existing mental health problems and psychological disorders. Monitoring of mood and anxiety levels throughout pregnancy is by using the questions recommended by NICE (2007). A discussion should take place with the woman to identify the source of her concerns and a plan formulated for the birth which should be acceptable to her. This must be communicated to the maternity team and documented clearly so that when a woman comes into hospital she does not have to negotiate with her caregivers (Bloom 2002). Problems may arise where there is doubt about a woman’s capacity to consent to or refuse treatment. Where a woman’s capacity is questioned, a supervisor of midwives should be involved and appropriate legal advice should be sought (see Ch. 9). The primary aim should always be to act in the woman’s best interests and as her advocate.
Support during labour is vital; this could be the woman’s birthing partner but should also consist of continuous midwifery input and support. Throughout the birth it is important that the woman understands and is kept informed; she should be asked for consent prior to any procedures. Following the birth it is important to consider the woman’s reaction to the event and any signs of emotional distress noted and documented. Postnatal debriefing following a ‘difficult’ birth is generally discouraged although explanations about procedures and events may be a natural part of the woman’s way of coming to terms with the birth (NICE 2007). However, there is a growing body of opinion that women would benefit from a form of postnatal debriefing to help reduce the psychological morbidity experienced by many women following pregnancy and childbirth (Lavender & Walkinshaw 1998, Pantlen & Rohde 2001).
If the woman’s reaction and anxieties appear to be severe, she should be referred to specialist psychiatric services for an assessment and possible treatment. It is important that the midwife works together with any other health professionals in supporting the woman and her baby during recovery.
The reported incidence of depression after childbirth is between 10% and 15% of women (Cox et al 1993, Kumar & Robson 1984), but, when questioned, many midwives and women report a higher incidence. The actual cause of depressive illness following childbirth is unknown but is thought to be multifactorial, a combination of biological, psychological and social factors. Rarer forms of psychiatric illness, such as psychoses, affect even fewer women but are dramatic in effect and impact.
Biological reasons include genetic make-up, gynaecological and obstetric problems (Stein et al 1989), parity and maternal age, the hormonal changes which occur in the early puerperium, and the appearance and behaviour of the baby. The mother may experience a reactive depression if her baby dies or is born with a congenital abnormality, particularly if previously undiagnosed. Psychological factors may include the woman’s early relationship with her parents, personality development, acceptance of her sexuality and the ability to accept dependence (Cox 1986). Women who display anxious or obsessional traits in their personality, or appear too controlled and compliant have a greater risk of developing postnatal depression. Another symptom is anomie, which is a painful feeling of inability to experience love or pleasure. These mothers often feel that they do not or cannot love their babies but their baby is obviously lovingly handled and cared for by the mother.
The previous psychiatric history of the woman (and her family) has been found to be a risk factor in many cases. The consistent finding of epidemiological studies carried out to date is that the major factors of aetiological importance are psychosocial in nature (Murray & Cooper 1997). The occurrence of stressful life events and lack of personal support from family, partner or friends have consistently been found to raise the risk of postnatal depression (Levy & Kline 1994, Stein et al 1989).
The midwife has the opportunity to assess mood changes and adaptation to parenthood, often knowing the woman before the birth. This relationship is vital and the information the midwife has will often be the first step in identifying a problem. There are tools that may assist in confirming the presence of depressive and anxiety symptoms that may be used to confirm the midwife’s suspicions. Using questions recommended by NICE (2007) at every contact visit is important. If the midwife has confidence in her skills to use other assessment tools, there are several commonly used.
The Edinburgh Postnatal Depression Scale (EDPS) has been developed for the diagnosis of postnatal depression (Cox & Holden 1994) (see website). It is a simple, self-rating, 10-item scale which was designed to be used at about 6 weeks postpartum, but can also be used at other times, including the antenatal period, for high-risk women (Clement 1995). Scores for individual items range from 0 to 3 according to severity, and the total score is the sum of the scores for the individual items. Women who score 12 or more on the scale are likely to be suffering from depressive illness. Referral for further assessment and treatment should then be offered. Initially the midwife’s responsibility is to detect the symptoms, and refer the woman for specialist support.
Because of the difficulties associated with detecting postnatal depression within other cultures, a Punjabi version of the EPDS has been developed which has proved to be successful in trials to date (Clifford et al 1999).
Where midwives have been trained to deliver evidence-based postnatal advice and support, based upon the woman’s description of symptoms, rates of postnatal depression have been shown to be reduced (MacArthur et al 2002). Women at risk of postnatal depression will require particularly close observation in the postnatal period.
Pregnancy is a time that both women and health professionals accept as emotionally labile. The change of hormones in early pregnancy and again after the birth gives way to emotional ebb and flow, with some women more prone than others. However, it is fair to say that some degree of emotional instability is normal and should be explained as such to women and their families.
It is important to distinguish between the normal mood and emotional changes that occur following the birth, known as ‘baby blues’ which is a period of tearfulness and mood lability. This transition lasts a matter of days and affects more than 50–80% of all women, especially primigravida (Romito 1989). The condition typically presents between 2 and 4 days after birth and symptoms include tearfulness, irritability, mood instability, headache, tiredness and oversensitivity (Hannah et al 1992). The woman needs the opportunity to talk about her feelings, and her physical discomfort, which should reduce, as the condition frequently coincides with breast discomfort. In most cases the condition is self-limiting but studies have found that women who suffer from this condition are more likely to go on to develop postnatal depression (Beck et al 1992, O’Hara & Zekoski 1988, O’Hara et al 1991).
This is considered to be any non-psychotic depressive illness of mild to moderate severity within the first year following childbirth. Prevalence rates range between 10% and 28% and it affects women from all cultures, ethnic backgrounds and socioeconomic groups. However, for many women, up to 75%, their illness will begin in the antenatal period and may go undetected. Some features of postnatal depression are low mood, poor sleep pattern, loss of appetite, tearfulness, anxiety, sense of failure, guilt, shame and isolation. The most common time for detection is around 4–6 weeks postnatally (Cox et al 1993). Early recognition is critical for effective intervention measures and reducing morbidity. The response to treatment and prognosis is good if detection and support is initiated early.
PTSD is an adjustment, anxiety or dissociative disorder following exposure to a traumatic event, either as a victim or witness (real or perceived). Whilst PTSD in the general population is better acknowledged, there remains some scepticism around its incidence and childbirth.
Although it is difficult to imagine that such an extreme reaction can be caused by childbirth, a normal life event, it is the perception of the woman that is the critical denominator. Some of the triggers that may precipitate a stress reaction have been identified as:
The trauma experienced during childbirth has many causative factors that are entirely perceptual for the individual woman; however, the work of Kendall-Tackett & Kaufman-Kantor (1993) identified that there are significant outcomes that will occur:
The ICD-10 classification of mental and behavioural disorders (WHO 1992) stipulates that trauma symptoms should include re-experiencing of the event(s) by flashbacks and/or nightmares. The individual may also be hypervigilant and experience physical and emotional ‘numbing’; avoidance of triggers that may cause distress is common. Symptoms often present after weeks and may persist for years, if not recognized and treated, followed by depression and suicide attempts.
This is regarded as a serious mental illness during the perinatal period, consistently affecting 2 per 1000 women. It is a psychotic illness and requires immediate psychiatric intervention and expert support. Severe episodes of the ‘baby blues’ may lead to postnatal depression, and untreated depression may develop into a major depressive psychosis (Cox 1986).
Characteristics of the illness are rapid onset (usually within the first postnatal week), hallucinations, mood swings, loss of contact with reality, intrusive thought processes and loss of inhibitions (Kendell et al 1987).
One explanation for the development of puerperal psychosis is the major change which occurs in the levels of the steroid hormones at this time, especially the drop in oestrogen (Wieck 1989). It is thought that high-risk patients develop a hypersensitivity of the central D2 receptors and that this may be related to the effect of the drop in the oestrogen level on the dopamine system. Another theory is that the condition is related to the fall in progesterone levels which occurs after delivery (Dalton 1985).
Psychosocial and obstetric factors are also thought to be possible causes of puerperal psychosis. Those who appear to be at higher risk include:
Reflective activity 69.2
You are preparing to transfer home a woman who had her baby by emergency caesarean section 3 days ago. She appears agitated, unsettled and is reluctant to care for her baby. On further communication she appears disturbed, unable to hold eye contact and finds it difficult to answer your questions. Some of her responses to your questions concern you. See the website for points you may consider.
To minimize the risk of harm to the fetus or infant, drugs should be prescribed cautiously for women who are planning a pregnancy, pregnant or breastfeeding. As a result, the thresholds for non-drug treatments, particularly psychological treatments, are likely to be lower than those set in NICE clinical guidelines on specific mental disorders, and prompt and timely access to treatments should be ensured if they are to be of benefit.
Discussions about treatment options with a woman with a mental disorder who is pregnant or breastfeeding should cover:
When prescribing a drug for a woman with a mental disorder who is planning a pregnancy, pregnant or breastfeeding, prescribers should:
Conclusion
All women must be cared for with sensitivity, and encouraged to explore their own feelings in a safe and supported way. They should be confident that their care will be non-prejudiced and that there will be no stigma associated with disclosure of previous mental illness. Adequate resources must be made available to ensure the woman receives the care appropriate to her needs. There is a growing recognition amongst midwives of the value of self-reflection. Midwives caring for women with profound emotional disturbances may reflect on their own life experiences, identifying a personal need for support.
Initially midwives should be encouraged to discuss any areas of difficulty with their supervisor of midwives, but ultimately they will only be able to offer holistic woman-centred care if they are emotionally well themselves (Ch. 12). It is essential that employers recognize the potential stress midwives may be under when caring for women with profound problems and ensure that an adequate level of non-judgemental support exists for staff as well as for women using the service (Hammett 1997).
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