Postnatal Post Traumatic Stress Disorder (PTSD) and Birth Trauma #DayofLight

This is a part 2 of a reproduction of a research paper I wrote on postnatal mental health as part of my Developing Doulas course. I’m posting this on my blog now as part of the #DayofLight

What is PTSD?

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events. PTSD can develop immediately after someone experiences a disturbing event or it can occur weeks, months or even years later. PTSD can develop in any situation where a person feels extreme fear, horror or helplessness. 9

Postnatal PTSD (PN-PTSD) is PTSD that develops after birth.10

Birth Trauma is a term used both for PN-PTSD, but also for women who may have some symptoms of PTSD after birth, but may not fulfil the clinical criteria for a PTSD diagnosis. 10

PN-PTSD can affect fathers, and other birth companions, as well as the new mothers. 10

Postnatal PTSD can occur alone or in addition to the symptoms of PND.1 However, the 2 illness are distinct and need to be treated individually. Many women with PN-PTSD are wrongly diagnosed with PND, given treatment that is unlikely to help and may be given inappropriate advice by healthcare professionals, such as being told to “try and move on with their lives” or that they should be grateful for having a healthy baby. This kind of reaction can actually exacerbate feelings of guilt and isolation and worsen symptoms. 10

What are the signs and symptoms of PTSD?

The symptoms of postnatal PTSD can develop straight after the birth or months afterwards1.

The symptoms of PTSD include:

  • Persistent re-experiencing of the event through recurrent instrusive memories, flashbacks and nightmares1 10
  • Panic attacks1
  • Sleeping problems1
  • Lack of emotions 1
  • Severe irritability or anger1
  • Avoidance of anything that reminds them of the traumatic event(s). 10
  • Hyper-vigilance (feeling jumpy or needing to be on their guard all the time). 10 In new mothers, this may present as being unable to leave the baby at all.

What causes PTSD?

Postnatal PTSD may result from a traumatic birth, a fear of dying or the baby dying or life threatening situations1. What may be considered a traumatic birth can cover a wide range of situations and what one mother may find traumatic, another mother in a similar situation may not. Traumatic births may be related to a very long or painful labour1, a very fast labour, an emergency or problematic delivery1 and/or other factors10.

For some women, Birth Trauma may be triggered by factors other than sensational or dramatic events. For example, feelings of loss of control, loss of dignity, hostile attitudes of staff around them or the absence of informed consent to medical procedures can contribute to Birth Trauma developing. 10

Mind, the mental health charity, state that the impact of difficult labours and births leading to PTSD has been under-estimated, as people may feel that the baby is adequate compensation for the trauma and that new mothers will soon forget the ordeal in the joy of motherhood; but a traumatic

childbirth may impair a new mother’s relationships with both her baby and her partner.8

The Birth Trauma Association states that risk factors for the development of PN-PTSD include “a very complicated mix of objective (e.g. the type of delivery) and subjective (e.g. feelings of loss of control) factors”10. They include:

  • Lengthy labour or short and very painful labour
  • Induction
  • Poor pain relief
  • Feelings of loss of control
  • High levels of medical intervention
  • Traumatic or emergency deliveries, e.g. emergency caesarean section
  • Impersonal treatment or problems with the staff attitudes
  • Not being listened to
  • Lack of information or explanation
  • Lack of privacy and dignity
  • Fear for baby’s safety
  • Stillbirth
  • Birth of a damaged baby (a disability resulting from birth trauma)
  • Baby’s stay in SCBU/NICU
  • Poor postnatal care
  • Previous trauma (for example, in childhood, with a previous birth or domestic violence)

How is PTSD treated?

The NICE Guidance on Antenatal and Postnatal Mental Health6 recommends that single-session formal debriefing focused on the birth should not be routinely offered to women who have experienced a traumatic birth. However, this is usually an option available to those women who specifically request it. Independent options for debriefing are also available, for example, with an independent midwife.

The NICE Guidance on Antenatal and Postnatal Mental Health6 does recommend that maternity staff and other healthcare professionals should support women who wish to talk about their experience, encourage them to make use of natural support systems available from family and friends, and take

into account the effect of the birth on the partner.

For diagnosed cases of PTSD, NICE recommends psychotherapy as the first treatment to try for PTSD. In some cases, medication may also be used.11

Treatments include:

  • Watchful waiting, involving carefully monitoring symptoms. This may be recommended in cases of PTSD where symptoms are mild or have been present for less than 4 weeks after the traumatic event (or birth).11
  • Psychotherapy, involving seeing a trained mental health professional, a psychotherapist, who will listen and help the person affected come up with effective strategies to resolve their problems.11 The Birth Trauma Association Expert Board member, Psychologist Dr Susan Ayers, advises that PN-PTSD is best treated by psychotherapy.10
  • Cognitive Behavioural Therapy (CBT), a type of therapy that aims to help you manage your problems by changing how you think and act. Trauma-focused CBT uses a range of psychological treatment techniques to help you come to terms with the traumatic event. It is appropriate if the symptoms of PTSD are severe and develop within one month of a traumatic event and/or if the person affected still has PTSD symptoms within three months of a traumatic event.11
  • Eye movement desensitisation and reprocessing (EMDR), a relatively new treatment that has been found to reduce the symptoms of PTSD. EMDR involves making side-to-side eye movements while recalling the traumatic incident. It works by helping the malfunctioning part of the brain (the hippocampus) to process distressing memories and flashbacks so that their influence is reduced.11
  • Medications, such as the antidepressants paroxetine or mirtazapine may be considered for treating PTSD in adults. However, these antidepressants will only usually be used if the person affected:
    • chooses not to have trauma-focused psychological treatment.
    • cannot start psychological treatment due to a high risk of further trauma.
    • has gained little or no benefit from a course of trauma-focused psychological treatment.
    • has severe depression or hypersensitivity that significantly affects their ability to benefit from psychological treatment

Antidepressants can also be prescribed to reduce any associated symptoms of depression and anxiety and to help with sleeping problems.11

It is possible for PTSD to be successfully treated many years after the traumatic event occurred, which means it is never too late to seek help. 11

How could PTSD be avoided?

Birth is unpredictable and there is no way to guarantee that it will go the way a mother (or father) wants or expects and the traumatic element of some births might be unavoidable – e.g. in the case of a stillbirth. However, many of the factors that can contribute to the development of PN-PTSD could be dealt with, or had their risk reduced.

Antenatal education about birth and support with developing birth preferences that consider not just the ideal situation, may reduce a couple’s feeling that they have lost control, no matter how the birth develops. The antenatal education would ideally cover the decision making process in a medical environment – for example, the use of the BRAIN (What are the Benefits? What are the Risks? What are the Alternatives? What does your Instinct say? What if you do Nothing?) technique for considering options – so that the mother or couple feel able to make informed decisions that take their choices into account, even if things develop beyond what they had considered antenatally.

Continuous support, during pregnancy, labour/birth and then postnatally is likely to have a part to play and Doulas could potentially have a real impact here. There is considerable evidence that continuous support during labour may have the following benefits, many of which are reducing the risk of factors that could contribute to the development of PN-PTSD. With continuous support during labour/birth, women are:

  • more likely to have a spontaneous vaginal birth (fewer inductions). 12
  • less likely to have painkilling drugs or an epidural during birth. 12 In research studied, this was not due to a lack of these options, suggesting that the women had better pain control.
  • less likely to report dissatisfaction. 12
  • statistically going to have a shorter labour. 12 NB. This does not mean that all labours with continuous support will be short!
  • less likely to have a caesarean. 12
  • less likely to have an instrumental vaginal birth. 12
  • less likely to have a baby with a low 5-minute AGPAR score. 12 Although the research does not specifically state this, it is possible that the chance of baby needing a SCBU/NICU stay (which is one factor that can contribute to the development of PN-PTSD) is reduced.

Research has found that continuous support was most effective when provided by a woman who was neither part of the hospital staff nor the woman’s social network (i.e. A Doula). 12

Other, less medical, factors that may contribute to the development of PN-PTSD – such as impersonal treatment or problems with the staff attitudes; not being listened to; lack of information or explanation; and a lack of privacy and dignity10 – may also be reduced or have their impact reduced, by having a Doula providing continuous support during labour/birth. A Doula may be experienced at dealing with medical staff and may be able to help women or couples ensure that their wishes are heard and that they are given any information they need. They may also be able to help with practical matters – e.g. finding an available bathroom if there is no privacy because all labour rooms are in use – or taking on the role of ‘doorkeeper’.

In the case of previous trauma – such as childhood abuse, rape or sexual abuse or previous Birth Trauma – being a potential factor contributing to the development of PN-PTSD, if this is raised antenatally as a concern, then a plan could be put in place to try and avoid it becoming a problem. For example, these women might want to refuse consent to all vaginal examinations, they might want to only be cared for in labour/birth by female staff members or they might want to limit the number of people in the room with them at any one time. Simple measures, such as making it clear in their birth preferences and maternity notes that all staff must knock before entering the room and then introduce themselves and wait for the go-ahead before approaching, could help women in this situation. If a woman or a couple are able to raise concerns antenatally, then a plan could be put in place with the agreement of hospital staff and if it is clear why these measures are needed, then any reasonable medical staff would hopefully concur with them. If a woman is able to raise concerns antenatally (or even pre-pregnancy), then possibly treatment for the original PTSD, such as psychotherapy, could be used during pregnancy. However, some women may be unable to talk to their healthcare providers or even their Doula about past trauma and it may not come up until the labour/birth triggers an issue.

References

  1. NHS Choices. 2011. NHS Choices: Feeling depressed after childbirth. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/feeling-depressed-after-birth.aspx . Accessed 15 Feb 2013.
  2. NHS Choices. 2012. NHS Choices: Postnatal Depression. http://www.nhs.uk/conditions/postnataldepression/pages/introduction.aspx . Accessed 15 February 2013.
  3. Dennis C-L, Creedy DK. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001134. DOI: 10.1002/14651858.CD001134.pub2
  4. NHS Choices. 2012. NHS Choices: Postnatal Depression – Symptoms. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Symptoms.aspx . Accessed 15 February 2013.
  5. NHS Choices. 2012. NHS Choices: Postnatal Depression – Causes. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Causes.aspx . Accessed 16 March 2013.
  6. NICE. 2007. Antenatal and Postnatal Mental Health: The NICE Guideline on Clinical Management and Service Guidance. http://www.nice.org.uk/nicemedia/live/11004/30431/30431.pdf . Accessed 16 March 2013.
  7. NICE. 2010. CG45 Antenatal and postnatal mental health: understanding NICE guidance. http://guidance.nice.org.uk/CG45/PublicInfo/pdf/English . Accessed 25 March 2013.
  8. Mind. 2010. Understanding postnatal depression. http://mind.org.uk/assets/0001/7313/Understanding_postnatal_depression_2010.pdf . Accessed 25 March 2013.
  9. NHS Choices. 2011. NHS Choices: Post-traumatic stress disorder. http://www.nhs.uk/conditions/post-traumatic-stress-disorder/pages/introduction.aspx . Accessed 25 March 2013.
  10. The Birth Trauma Association. What is Birth Trauma? http://www.birthtraumaassociation.org.uk/what_is_trauma.htm . Accessed 25 March 2013.
  11. NHS Choices. 2011. NHS Choices: Post-traumatic stress disorder – Treatment. http://www.nhs.uk/Conditions/Post-traumatic-stress-disorder/Pages/Treatment.aspx . Accessed 25 March 2013.
  12. Hodnett, ED., Gates, S., Hofmeyr, GJ. & Sakala, C. Continuous support for women during childbirth Cochrane Database of Systematic Reviews 2007, Issue 3.

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