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Perinatal PTSD
I recently spoke with Dr Jain, a psychiatrist based at Stanford University to explore this area of my practise.
Dr. Jain: You are a perinatal psychiatrist who specializes in treating psychological aspects of birth trauma. Can you start by talking a little bit about what a perinatal psychiatrist does and why there is a specific need for this type of expertise for pregnant women? Can you comment specifically on your work with immigrant/refugee populations who may have high rates of mental health problems to begin
Dr. Moore: Perinatal psychiatrists work with women with new onset or preexisting moderate to severe mental health diagnoses through their pregnancy and up to a year after birth.
We are community based and work with women and their families to support their mental health through this vulnerable time period. This includes regular outpatient review, community nursing support, psychological support, and expertise around prescribing medication during pregnancy and breastfeeding, alongside monitoring the developing parent infant bond.
Perinatal
There is an increased risk of suicide after pregnancy, and suicide remains one of the leading causes of maternal death in the first 42 days after birth in the United Kingdom, as highlighted by the last MBRRACE-UK release “Saving Lives, Improving Mothers’ Care – Surveillance of Maternal Deaths in the UK 2011-13.”
Perinatal disorders often develop rapidly,
I work within Tower Hamlets, a very deprived area in East London, with a young population who have higher than average numbers of children. Our population is growing rapidly, it is expected to grow by 26% over the next twenty years, and there is a high birth
50% of our referrals are Bangladeshi women, which reflects our local population. We have a hugely transient population with people moving in and out of our area, and we have women within our service from all over the world who have often been exposed to war or huge trauma. We often work with interpreters and have to be extremely mindful of the cultural and spiritual aspects of our care.
Dr. Jain: When researching this topic of Birth Trauma, I ran into some issues
Dr. Moore: You are right, there is not yet any standard diagnostic definition, and this can cause confusion as there is a significant difference between Birth Trauma and Postpartum PTSD regarding symptoms and treatment.
When a woman has a traumatic birth, I mean that there was something subjective about the birth that was traumatic. This does
Birth Trauma definitions include “a negative and disempowering physiological & emotional response to a birth” or “when an individual (mother, father, or other witness) believes the mother’s or her baby’s life was in danger, or that a serious threat to the mother’s or her baby’s physical or emotional integrity existed.” I love Rachel Yehuda’s use of the term trauma as “a watershed event, an
Common themes include feeling unheard or not listened to, a lack of compassion from medical professionals, and feeling out of control or helpless.
Around 25% of all births in the UK are identified by women as being traumatic. This really strikes me, as it is such a high rate. In fact, if we look at the annual birth rate in the United Kingdom, this means around 173,000 women are traumatized after delivering per year.
Only 1% of births in the UK result in infant death or life
One third of women present with sub-clinical trauma, and I believe it is essential to perceive trauma responses as being on a continuum.
For many women, these birth experiences will never be discussed or explored. Although women may not develop a diagnosable disorder, they will often experience significant levels of distress and symptoms may persist for many years without treatment. There is often a significant impact on women’s future
When we talk about Postpartum PTSD, we are talking about women who had a traumatic birth who then go on to develop all the diagnostic criteria we would expect in PTSD.
Around 1-6% of women who have a traumatic birth will go on to develop a diagnosable clinical episode of PTSD.
It’s also important to mention and think about birth partners who can
source: pexels
source: pexels
Dr. Jain: In your experience, what are the common pitfalls surrounding diagnosing Postpartum PTSD? How is it distinguished from the more well-known Postpartum Depression? What are the clinical markers for who is more vulnerable to developing Postpartum PTSD, and what are the associated resiliency factors?
Dr. Moore: Unfortunately, this is an issue we see time and time again in clinical practice. Many professionals know little about Birth Trauma or PTSD following birth,
If we think about the criteria needed to make a formal diagnosis of PTSD, there are clear differences in the symptoms needed to make a diagnosis of Postnatal Depression.
With Postpartum Depression we would look for core symptoms of pervasive low mood or anxiety, fatigue, and anhedonia, with possible altered sleep and appetite or suicidality.
In PTSD we would expect to see the key features of avoidance, intrusive memories, labile mood, nightmares, or flashbacks, and
Research has been carried out into what makes someone more likely to develop PTSD following childbirth. These risk factors can be thought of as those that exist before the birth; the birth itself; and the type of support and care women get after birth.
Some women will be more vulnerable to a traumatic birth because of pre-existing problems, such as women with a history of psychiatric problems or previous trauma. There is also evidence that women with a history of trauma will be more
During birth, certain complications or events may be more stressful to women than others. Broadly speaking, women are more likely to get PTSD if they have an emergency cesarean or assisted birth (forceps or ventouse), although PTSD can develop after a vaginal delivery.
Other stressful aspects of birth, such as blood loss, a long labor, a high level of pain, or a large number of interventions, are not conclusively related to getting PTSD.
Women who feel
Following the birth, support from friends and family, and possibly that from healthcare professionals, may help women resolve their experiences and recover from a traumatic birth.
Studies have also highlighted an increased risk of developing postpartum PTSD with a stillbirth, the birth of a baby with a disability resulting from birth trauma, or a baby requiring a stay in the
One of the strongest risk factors we know of is when women dissociate during birth. One woman I worked with spoke of dissociating in pregnancy and “losing all track of time” and “feeling like she was in a fog.” She believed her baby “had been born” and “taken out of the room without her consent” and felt overwhelmingly anxious, until suddenly she looked down and saw her pregnant bump and realized she was still pregnant.
The literature regarding resilience is unclear, and we still do not fully
Dr. Jain: It appears to me there are a couple scenarios of how Postpartum PTSD might occur:
A woman already has PTSD (treated or untreated) and the psychological stressors associated with pregnancy/giving birth trigger a relapse of her PTSD symptoms
OR
The actual experience of giving birth is traumatic—either the mother’s life is threatened or she witnesses a threat to the life of her
Can you speak about other scenarios?
Dr. Moore: These are the most common routes to PTSD after birth that we see; the variance is in the individual stories and responses to trauma that we hear.
I think it’s important to flag up here that the woman’s life might not actually be in danger, it is her response to events that she perceives as traumatic, so she might have a non life threatening bleed but find that traumatic or it may be the after care that is
It is important to distinguish between women who feel angry about their birth experience and have irritability and intrusive thoughts about their birth, but who lack the other symptoms of PTSD.
Subclinical symptoms are really important in my opinion and incredibly common, and these women may not have diagnosable PTSD but must still be heard and
Dr. Jain: If one does a Google search for Birth Trauma or Postpartum PTSD, it is impossible to ignore the number of self-help organizations, patient advocacy groups, and online support forums that pop up. Indeed, prevalence statistics for Postpartum PTSD from Western studies are approximately 1 to 3%. From an epidemiological standpoint, this would make it quite common. Yet Postpartum PTSD is something that receives very little attention in medical schools and psychiatry training programs. Is this a case of medical science
Dr. Moore: Absolutely!
I think at present this is a really neglected area of teaching and training whilst being something that affects thousands and thousands of women each year here in England.
My sense is that this is changing. Certainly here we are starting to see Birth Trauma being discussed and talked about, and networks of professionals are coming together to push for more training and better awareness.
It’s something that I feel really passionate about, and
Here in the UK we are really fortunate to have some amazing web forums, such as MatExp, which allows members to share best practices and knowledge. There are many
Dr. Jain: Related to this, there appear to be some very real social and systemic phenomenon that may be exacerbating the issue of Postpartum PTSD: Unrealistic images/perceptions of what birth and motherhood should be driven by popular
Dr. Moore: A question that is often asked is whether women have too high expectations of achieving a natural or drug-free birth, contributing to them being traumatized when birth does not go as expected. The answer to this is complex, but research studies point
For many women I meet there is a real lack of honest conversations about the process of
I think there is a much greater need for midwives and obstetricians to have repeated conversations with women about birth and listen to women’s fears, hopes, and preferred choices.
The issue that comes up time and time again here is a lack of continuity of care and that women often see a different midwife at each visit, which means that these discussions don’t
I personally encourage women to think in depth about their birth and the choices they may or may not like, whilst grounding any discussion in the reality of what might happen.
I personally think if women can afford it and would like it, that using an independent midwife or doula can be really beneficial and help provide a constant support and advocate throughout pregnancy and birth.
source: pexels
source: pexels
There is also no doubt that medical interventions and having a baby in the NICU play a role in trauma. There is a wealth of
In 2013, Youngblut et al looked at parent health and functioning 13 months after infant or child NICU/PICU death. Parents (176 mothers, 73 fathers) of 188 deceased infants/children were recruited from 4 NICUs, 4 PICUs, and state death certificates 2 to 3 weeks after death. Data on parent physical health (hospitalizations, chronic illness), mental health (depression, PTSD, alcohol use), and functioning (partner status, employment) were collected in the home at
Lefkowitz et al looked at the prevalence of PTSD and depression in parents of infants in the NICU, identifying 86 mothers and 41 fathers who completed measures of acute stress disorder (ASD) and of parent perception of infant medical severity 3-5 days after the infant’s NICU admission (T1), and measures of PTSD and Postpartum Depression (PPD) 30 days later (T2).
35% of mothers and 24% of fathers met ASD diagnostic criteria at T1, and 15% of mothers and 8% of fathers met PTSD diagnostic criteria at T2. PTSD symptom severity was
There is a wealth of excellent resources online for parents with babies in the NICU/Special Care Baby Unit (SCBU), such as Bliss, Headspace Perspective, and Tommy’s. These all offer a wealth of practical advice, including telephone
Dr. Jain: What psychological interventions work for Postpartum PTSD? What about preventative measures (e.g. identifying high risk women or screening programs) or debriefing interventions?
Dr. Moore: There isn’t a standardized screening program as of yet in the UK. We screen women in our service but they only represent a minority of women. One also wonders how a woman may feel about being identified as “high risk” for developing perinatal trauma, and care would need to be taken to fully explain this
Psychological interventions that work in the postnatal period include the usual trauma focused psychotherapies, like cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR), and Compassion Focused therapy approaches are also frequently used.
Debriefing can be used and can help some women but not all—it very much depends on who is doing the debriefing and how it is done. Studies into the efficacy of debriefing have not identified any clear link with it leading to
In my service we have a specialized pathway of care for women with a prior traumatic birth or those at risk, which includes regular review and having these long detailed discussions about birth. We have a specialist team of midwives who co-work cases with us to give extra support and an obstetric lead who reviews women prior to birth.
We offer informal debriefing postnatally and really take time and care to listen to women’s birth stories, and this is crucial. If needed we can then also add in specialist timely therapeutic
Dr. Jain: Finally, are there any biological or physiological factors associated with the act of giving birth itself (e.g. hormonal shifts, changes in adrenaline, cortisol, serotonin, or dopamine) that may be implicated in increasing vulnerability for developing PTSD during that particular life event?
Dr. Moore: That’s a very complex question that we don’t yet fully understand the answer to. There is as of yet little research on the
Of course I am sure your readers will know the existing literature purely relating to PTSD that suggests that lower baseline cortisol at the time of a psychological trauma may facilitate over-activation of the central CRH-NE cascade, resulting in enhanced and prolonged stress responses which could then be accentuated by poor regulation of GABA, serotonin,
My own interest lies more in the role of the HPA axis in pregnancy and after birth. Much of the literature relates to depression, but there are studies now focusing on PTSD. It is likely that prenatal
During pregnancy the maternal hypothalamic-pituitary-adrenal axis undergoes dramatic alterations, due in large part to the introduction of the placenta, a transient endocrine organ of fetal origin.
Models are suggested, such as those by Professor Vivette Glover, where the positive feedback loop involving the systems regulating the products of the HPA axis results in higher prenatal levels of cortisol and placental corticotrophin-releasing hormone.
During pregnancy we see a rapid rise in plasma estrogen and progesterone, coupled with a very
We also need to add into this discussion the literature on the role of estrogen, and its role in fear conditioning and fear extinction. Estrogen calms the fear response in healthy women and, as illustrated by the work of Kelimer Lebron-Milad, the same is true for women
Progesterone is also known to have antiglucocorticoid properties and thus interfere with the HPA axis reactivity to stress. Studies have demonstrated a higher neuroendocrine response to stress (i.e., higher cortisol levels after ACTH administration) in women during the luteal phase of the menstrual cycle, indicating that the negative feedback of the HPA axis may be somewhat affected.
Further research is
How all these strands connect is not yet fully understood, but to my mind women entering labour
The image shown is from the fabulous Forging Families group in Sheffield, an amazing resource.