Fundamentals of Midwifery: A Textbook for Students (123 page)

PTSD emerges from the experience of an exceptionally distressing event and is defined by 3 key factors that are experienced for at least one month (see Box 13.5).

PTSD can recur or worsen in childbirth and has been shown to be higher in the pregnant population than the adult female population as a whole (Seng et al. 2009). The experience of being pregnant is thought to trigger symptoms of these disorders, in vulnerable women such as those who have experienced childhood abuse (NSPCC 2013) or following a previous stillbirth

Box 13.5 Signs of PTSD‌

Intrusion of thoughts, memories, flashbacks in which the person seems to re-experience the distressing event and nightmares.

Avoidance of reminders, situations or events, emotional numbness or blunting, detachment.

Increased arousal, for example hypervigilance, irritability, insomnia, impaired concentration.
Box 13.6 Women at risk of serious mental illness

Women who have a previous history of bipolar illness or a psychotic episode in early life, who are well and not in contact with psychiatric services. They may not be at risk in pregnancy, but are at an increased risk postpartum. Requires a proactive management plan and awareness of early risk and identification.

Women who have had a previous or recent episode and are stable but are medicated. There isrisk of relapse in pregnancy if women stop their medication. Expert advice on medication anda proactive management plan is essential.

Women with a chronic SMI with complex social needs, symptomatic and medicated. Usually these women will be in contact with psychiatric services. Effective multidisciplinary joined-up working is critical to ensure effective care planning.
293(Turton et al. 2001). It is thought that PTSD can also be triggered by childbirth with links posited between a traumatic birth and PTSD, with women particularly at risk after an emergency cae- sarean section or admission of their baby to NICU (Joint Commissioning Panel for Mental Health 2012).
Serious mental illness (SMI)
Schizophrenia and bipolar disorder affect only a small proportion of the general populationwhich is reflected in the perinatal population, with risk being most elevated in the postnatal period (Raynor and England 2010). Oates describes three groups of women (Raynor and England 2010; Box 13.6).Pre-pregnancy counselling can be extremely helpful, but is clearly challenging when many pregnancies are unplanned. It should not be assumed that women with an SMI will be easier to identify and sensitive questioning is key to identification, assessment and effective referral.
Puerperal psychosis (PP)
Whilst the numbers of women suffering puerperal psychosis (PP) are relatively small, the con- sequences can be a devastating for women and their families, including suicide, infanticide (Spinelli 2004) and subsequent puerperal and non-puerperal psychiatric episodes (Robertson et al. 2005). PP has an acute onset, within the first four weeks after giving birth (Cantwell and Cox 2006) and is characterised by delusions, hallucinations, bizarre behaviour and mood lability (Heron et al. 2008).Women who have a history of bipolar disorder have been identified as particularly vulnerable (Brockington 1996; Jones and Craddock, 2001). Familial factors play an additional role (Jones
Box 13.7 Other identified risk factors for PP

Poor socioeconomic circumstances

Pregnancy complications/shorter gestation

Birth complications/caesarean section

Female baby

Marital status

Stillbirth

Longer labour with associated sleep deprivation/night-time birth294
and Craddock 2001; 2002). A personal history of PP predisposes approximately 57% of women to experience another episode after a subsequent pregnancy (Robertson et al. 2005). However, primipara women are consistently reported to be at greater risk of experiencing PP than mul- tiparous (Blackmore et al. 2006), with some suggestion that older first time mothers might be at greater risk (Nager et al. 2005). Childbirth itself is a risk factor for PP, albeit a small one (Nager et al. 2005) and episodes can occur ‘out of the blue’ to women without previous psychiatric history (Heron et al. 2012). Box 13.7 highlights other risk factors for PP.The key theoretical explanations for the aetiology of PP remain genetic, biochemical and endocrine (NICE 2007). The presentation of PP is acute, florid and women deteriorate rapidly, hence hospitalisation is often required (Doucet et al. 2011) and recommended (NICE 2007). Early recognition and prompt treatment can facilitate the resolution of the florid features of PP, but risk of relapse remains high in the early weeks. Whilst there is often a perception that women with PP present a risk to their baby, this is more likely to be through neglect rather than active harm to the baby. The mother–baby interaction will improve as the mother recovers (Raynor and England 2010). Longer term prognosis is good, although women often pass through a period of depression and anxiety during recovery. There is a risk of relapse in a subsequent pregnancy and outside the puerperium. Recent exploratory work highlights that symptoms of stress–vulnerability experienced during pregnancy and/or birth and aspects which might influ- ence those symptoms, such as a woman’s early environment and experienced levels of expressed emotion may facilitate consideration of a psychological account of the development of PP. This may present future opportunities to develop antenatal interventions (Glover et al. 2014).
Care provision
Effective service provision for PMI, requires joint working between mental health services, mid-wifery and obstetrics, acute care, primary care, children’s services, paediatrics and the voluntary sector (NSPCC 2013). Joint working within or across organisations must be facilitated by effec- tive communication and provide a seamless perspective to care. It is noteworthy that despite a 7-year time-lag since publication of the NICE (2007) guidelines, support for women with PMI remains spasmodic and lacking across the UK and it remains a lottery whether women get access to services and the right help (Jomeen and Martin 2014). Whilst some areas have special- ist services, mental health specialist midwives and voluntary sector services; the Patients’ Asso- ciation (2011), reported that 64% of local authorities do not have a PMH commissioning strategy, highlighting this as a critical issue. The government has recently pledged to ensure specialist midwives in each trust to deal with PMI; however unless this is supported by adequate services the risk of the service users‘dropping out’ through gaps in the system will remain a reality. Localstrategies need to prioritise the development of pathways of care for women with PMI at all levels, which are critical to optimise care for women and their families, but are also essential to support practitioners to confidently and proactively identify and assess women’s PMHP and needs (Jomeen et al. 2013).
Further reading activityFor further reading on what a good service looks like see the following report:Joint Commissioning Panel for Mental Health (2012)
Guidance for commissioners of perinatal mental health services
. JCP-MH: London [available online] http://www.jcpmh.info/good-services/ perinatal-mental-health-services
Key points

PMI is a key public health issue.