Fundamentals of Midwifery: A Textbook for Students (122 page)

No future for the kids without me, so better I take them with me.’

The majority of depressive illness in the perinatal period will be mild to moderate as defined in Table 13.3. The word mild is perhaps deceiving as this level of PMI can still cause significant distress to women. If left untreated there are implications for the fetus, obstetric outcomes and effects on the development of the child in the short and long term. Depression during late pregnancy is associated with a significant increase in the use of epidural analgesia, caesarean section, instrumental deliveries and increased rates of admission for the neonate to intensive care (Chung et al. 2001). Apart from inflicting distress on the mother, depression undermines the marital relationship and an association between a mother’s depression and the subsequent report of depression in her partner have been demonstrated (Scottish Intercollegiate Guidelines Network [SIGN] 2002). Further maternal depressive symptomology at any time, but particularly antenatally, has been identified as a risk factor for a child’s wellbeing (Louma et al. 2001) in both emotional and cognitive terms (Hay and Kumar 1995; Murray et al. 1991), particularly when associated with other risk factors such as poverty (Murray and Cooper 1997). NICE (2007) recom- mends psychological therapies managed within a primary care setting, for the management of

Sadness, irritability, anxiety, apathy, anhedonia

Inappropriate guilt, inattention, poor

concentration,

memory disturbance Delusions

Sleep, appetite and libido disturbance,

loss of energy, fatigue,

vague pains, headache, constipation

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Withdrawn, irritable, tearful

Loss of job, relationship break- down, child protectioin.

Key symptoms of depression.

Symptoms of the different levels of depression

Low mood, tearfulness, reduced interest or enjoyment but able to function.

A number of depressive symptoms and difficulty in functioning.

All the above, along with early morning waking, feeling worse in the morning, significant weight/appetite loss, marked disinterest in life, suicidal thoughts other risk issues.

Severe depression with hallucinations, delusions or other psychotic experiences.

mild to moderate depression with generally good results observed. Pharmacological treatments should obviously be used with caution due to potential effects on both mother and the devel- oping fetus.

Major depressive illness is more likely to occur in the postnatal period, but clearly can have a significant impact on a woman, her baby and her wider family during a major life transition. Onset can be as early as 2–4 weeks and be clearly evident by 4–6 weeks postnatally. However for the majority of cases presentation usually occurs between 8 and 12 weeks postnatally and can be enduring. Some women who develop this condition will have no previous history. However, there is an identified increased risk from women with a previous personal or family history of severe depression, either during or outside the perinatal period. Women with a known history have a significant risk of reoccurrence in subsequent pregnancies. Treatment for severe

depression is no different to treatment outside of the perinatal period, but speedy resolution is clearly important to optimise maternal recovery and promote the cognitive, emotional and social development of the child. Treatment often consists of antidepressant therapy combined with psychotherapy as recommended by NICE (2007), which if timely can enable a full recovery. Women who suffer severe depression are, however, at increased risk of suffering depression, outside of the childbearing context.

Anxiety can have a negative effect on pregnancy; including a higher incidence of obstetric complications including placental abruption, premature labour, low Apgar score and low birth weight (Crandon 1979, Cohen et al. 1989), with pregnancy specific anxieties linked to an increased risk of spontaneous abortion (Neugebauer et al. 1996). Antenatal stress and anxiety has also been demonstrated to have a programming effect on the fetus with enduring effects until at least middle childhood, that may well persist into adulthood (O’Connor et al. 2002). A level of anxiety is of course normal in pregnancy and as with depression there are physical symptoms of pregnancy that may mimic those of anxiety (Hadwin 2007). For healthcare profes- sionals, what is important is to differentiate between pathological anxiety and normal anxiety. Whilst some concerns about the health of the baby, her own health and adaptation to parent- hood are essentially normal; generalised thoughts of anxiety about other aspects of life may not be so (Hadwin 2007). Assessment needs to also consider whether the experience outweighs the woman’s coping strategies and whether such symptoms are unusual (Hadwin 2007). See Figure 13.2 for symptoms of generalised anxiety disorder (GAD).

The question whether anxiety and depressive orders are separate entities has been a contro- versial issue (Gorman 1997). Clark and Watson (1991) introduced the idea that anxiety and depression each have distinct features but also share a common dimension, called general distress or negative effect. This co-morbid relationship between anxiety and depression in pregnant women has been demonstrated (Da Costa et al. 2000) and recognition of mixed

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Dizziness Sweating

Dry mouth

Stomach pains

Undue worry Feeling tense or nervous

Poor concentration

Negative thoughts

Difficulty staying or falling asleep Restless sleep

Restlessness headaches,

tremors

inability to relax chest pain or constriction

Symptoms of generalised anxiety disorder (Hadwin 2007).

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anxiety and depression is important as this is thought to be one of the most common presenta- tions both generally (Tyrer 2001) and in maternity (Raynor and England 2010). More so than the presentation of anxiety and depression individually and Hadwin (2007) suggests that health professionals need to bear this in mind when women present with symptoms that do not neces- sarily meet the diagnostic criteria of an individual condition. What is important is not necessarily diagnosis

but recognition of the signs and symptoms a woman is experiencing and appropriate response.

Panic attacks may sometimes happen with GAD, but normally would manifest in individuals experiencing generalized arousal (Hadwin 2007). An increase in panic attacks following birth has been demonstrated (Cohen and Noncas 2005). However, some authors feel it is the severity of symptoms that are more significant (Hadwin 2007). Symptoms of panic disorder include intermittent episodes of panic or anxiety where the individual take action to avoid these feel- ings. These spontaneous episodes start suddenly, rise rapidly and can last from minutes to up to an hour. Physical symptoms include palpitations, cheat pain, sense of choking, churning stomach, dizziness, feelings of unreality, detachment from oneself and fear of impending dis- aster (WHO 2004). Women may seek to avoid the places where attacks have occurred, which may be significant if attacks have occurred in care settings. Support is therefore critical and healthcare professionals need to promote both self-confidence and self-efficacy to manage symptoms. It is worthy of note that some physical factors may aggravate panic disorder includ- ing hyperthyroidism, hyperventilation, sleep deprivation, caffeine, alcohol, cannabis and chest pain (March and Yonkers 2001).

The onset of OCD or the worsening of symptoms has been associated with childbirth (NSPCC 2013), and pregnancy is a recognised risk factor for triggering OCD (Abramowitz 2003; Kalra et al. 2005). The prevalence of perinatal OCD is not well-defined, and some authors suggest that the relationship between OCD and pregnancy is coincidental, although it can be common with other disorders such as depression (Hadwin 2007), with the concomitant risk of misdiagnosis. Studies have suggested it affects around 3% of new mothers (NSPCC 2013). Possible explana- tions are hormonal and stress-related and whilst symptoms vary in the perinatal period, women’s obsessions and compulsions are more likely to focus on the baby (NSPCC 2013; Hadwin 2007). Often thoughts focus on fears of harming the baby which may lead to excessive checking; however morbid thoughts are not uncommon in early motherhood and form part of the transi- tion to motherhood. It is also accepted that most people will experience obsessive or intrusive thoughts at different times in their lives (Hadwin 2007). Clearly, however OCD can significantly interfere with women’s wellbeing, their experience of pregnancy, and parenting and healthcare professionals can recognise and discuss these behaviours to promote appropriate referral and care packages.