Postnatal mental health and post-traumatic stress

As we have discussed, psychological problems post-natally may be as common as physical symptoms, and maternal postnatal mental health has an important impact on the well-being of the woman, her infant and her family. Postnatal psychological morbidity can be associated with a range of factors including earlier life experiences and mental health problems, poor levels of postnatal support and traumatic birth experi-ences (Robertson et al. 2004; Leigh & Milgrom 2008). Therefore, at each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with everyday matters. Women and their families/

partners should be encouraged to tell their healthcare professional about

any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern (NICE 2007).

Healthcare professionals should be alert to women’s mental health problems in the postnatal period, including the onset of new disor-ders such as postnatal depression (PND), puerperal psychosis, post-traumatic stress disorder and panic disorder and relapse of other psychotic illnesses, such as schizophrenia. Women with existing diag-noses should be identified during admission and care plans for postnatal management adhered to, based on their current mental state and risk of relapse (NICE 2007).

We have noted that depression following childbirth is common, well known and has been widely researched and debated. Postnatal post-traumatic stress disorder (PN PTSD) or ‘birth trauma’ (Beck 2004), which refers to a disorder that can occur in women following the experience or witnessing of life-threatening events in childbirth has increasingly attracted the attention of public health researchers, but is less widely known among health professionals providing postnatal care. In the United Kingdom, an estimated 6–10% of women present with clinical symptoms of PTSD following childbirth. When PN PTSD develops, its symptoms may start soon after childbirth or be delayed for months. The symptoms may persist for a long time and result in other problems such as PND, although the two disorders have different origins. Both require early diagnosis, specialised care and treatment. General symptoms of PTSD include the following (Diagnostic and Statistical Manual of the American Psychiatric Association 1994):

•

Persistent re-experiencing of the event by way of recurrent intrusive memories, flashbacks and nightmares

•

Avoidance of anything that reminds them of the trauma, which can lead to emotional detachment or numbing

•

‘Hyperarousal’ symptoms – irritability, difficulties with sleeping and concentrating

Women can feel traumatised by labour regardless of the mode of birth.

However, invasive obstetric procedures such as emergency Caesarean sections, labour inductions and instrumental vaginal births are more likely to be perceived as traumatic and are associated with PTSD.

postnatal debriefing for at-risk women has been suggested as a way of preventing both PTSD and PND, although evidence of its effectiveness is lacking (Rowan et al. 2007). The term debriefing has been much discussed in recent midwifery literature, but is poorly understood and is often used by midwives interchangeably with other concepts such as postnatal review, counselling or support. Additionally, each approach requires more research to assess effectiveness. Psychological debriefing is an intervention that was developed with the aim of helping

people to cope with a traumatic event, initially used in situations such as war and disaster, and later extended to other forms of trauma. Rose and Tehrani (2002, p. 3) describe the psychological model as generally involving ‘a slow sequential exposition of the event’ with the aim of achieving cognitive restructuring while recognising grief. The principle is to revisit and recount emotional responses and sensory experiences during the event as well as retelling of the facts of it, with the idea that a ‘ventilation’ of emotional responses will be therapeutic.

Rose and Tehrani (2002) note that, while such an approach was widely assumed to be beneficial, this has been debated, and research on effectiveness has confirmed questions about the approach. Such complex subjects and interventions are difficult to research, particularly where interventions studied may vary in quality and approach, and may be applied to different kinds of trauma (Ormerod 2002). However, it has been suggested that early interventions of this type may be superimposed on or may even interfere with a natural recovery process, may medicalise normal distress or replace individuals’ own means of coping with traumatic experiences, or even that the arousal at this early stage may serve to re-traumatise the individual (Ormerod 2002). The recommendation of NICE guidelines, consequently, is that debriefing should not be routinely offered, or offered within a month of a traumatic experience. After 1 month, those individuals who may be vulnerable to PTSD can be identified at this stage and offered appropriate review, counselling or debriefing (Department of Health 2001; NICE 2007).

The psychological debriefing approach is not necessarily equivalent to review or counselling by midwives or obstetricians following a trau-matic birth, but with limited research available on maternity care, the advice regarding timing of review should be followed. The recom-mended timing also relates well to the woman’s need for a period of rest and recovery following childbirth. This also indicates the poten-tially long-term nature of the need for postnatal support, and value of a model of postnatal care that can allow midwives to assess women’s individual needs and continue care for a month if required (MacArthur et al. 2002). Two of the studies included in the Cochrane Review of debriefing were focused on maternity care (Lavender & Walkinshaw 1998; Small et al. 2000) and the reviewers noted that the approaches in these studies were somewhat different, in being more ‘patient-led’ and delivered by midwives, so may not have shared the full characteristics of a ‘psychological debriefing’ approach. Additionally, neither study looked at PTSD symptoms per se. Clearly, further research is needed on the subject of postnatal interventions relating to birth traumas, but mid-wives should be aware that a number of women may suffer damaging symptoms of PTSD, in addition to those who suffer from better-known problems such as depression, should therefore be asking women about their emotional health following childbirth and be equipped to offer

advice or referral if needed. Gamble and Creedy (2004), in a review of counselling-type interventions after distressing birth experiences, note that further research is needed to investigate different types of coun-selling and their effects, and also, that interventions are provided in a context of inadequate postnatal support for most women, including limited opportunities for midwives to listen to women talk about their birth experiences and how they are feeling.

Conclusion

This chapter has discussed the types of morbidity that women com-monly experience after childbirth, including physical and psychological problems. We have noted that the rates of symptoms of morbidity are high and that problems are often under-reported as women may feel embarrassed or that they should not ‘bother’ health professionals with minor problems. However, even relatively minor problems may have an important impact on the quality of a woman’s life and her ability to care for and enjoy the time with her new baby. Maternal mental health problems have been shown to have a major impact on the development of infants, and a negative impact is not confined to those with the more major and acute psychological morbidities such as puerperal psychosis (Beck 1995).

Within this context, midwives face the challenge to strike a good balance in offering care and support to women – to provide reassurance and take a positive approach, and also to take the potential impact of postnatal morbidity seriously and offer adequate care, referring women for more specialist care when needed.

Reassuring women that some of the longer term morbidity follow-ing childbirth may be difficult to treat and that it might not resolve completely but in general be alleviated with information, discussion, support and reassurance from a knowledgeable individual could result in women feeling better about themselves.

We have also discussed the variability and changes in the ways in which postnatal care is provided. In many countries, domiciliary postnatal care is not provided routinely, leaving the onus on women to visit healthcare facilities if they experience problems. While routine services are not always beneficial, the considerable evidence of under-reporting of postnatal morbidity and its potentially negative impact on women’s quality of life and well-being suggests that there are particular advantages to providing domiciliary care. The importance of this is likely to have increased in the United Kingdom and in many other countries where lengths of hospital stay post-natally have declined considerably in the recent past. Additionally, studies of women’s views of maternity care show that women value postnatal care at home highly

and are generally more satisfied with this than with the care in hospital (Dowswell et al. 2001). In a situation where time and resources for care are limited, the most optimal care is likely to be provided by flexibly offering care around women’s and families’ needs, such as the model of care assessed in MacArthur and Bick’s trial of woman-centred care packages. Some women are able to cope well after birth, suffer few health problems or are able to draw on their own sources of informal support, and therefore may not need frequent or intensive postnatal care by midwives, while others will need and benefit from greater support from midwives. Taking a woman-centred approach will support midwives in being able to provide appropriate forms and levels of care.

Key implications for midwifery practice

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It is very common for women to experience a number of postnatal health problems. Most commonly reported physical morbidities are back pain, urinary or faecal incontinence, perineal pain, intercourse prob-lems, breast probprob-lems, haemorrhoids, constipation and headaches.

•

Although women may need reassurance that many health problems are common, they should be offered adequate care and attention to these problems and their impact on women’s and families’ lives acknowl-edged.

•

Women often do not report their symptoms, so midwives need to be observant and proactive in asking about each woman’s well-being and responding to problems.

•

Although the value of routine physical checks has been questioned, midwives cannot assume that women will report all problems, and suf-ficient attention should be given to perineal care and healing.

•

Psychological problems are also common after birth and may have a major impact on the future well-being of the woman and her family.

Midwives should ask women about their mental health as well as their physical well-being, and be aware of appropriate forms of support and referral.

•

A more women and family-centred approach to postnatal care is needed.

Points for reflection on your practice:

In providing postnatal care, how far are you able to give women the level and type of care that they need?

What influences this?

In community settings, do you conduct selective visits, and if so, how far is the pattern of visiting based on assessment of the individual woman and family’s needs?

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