Perinatal mental health

elevated levels of stress hormones and unnecessary anxiety will affect woman's psychological status Anxiety is a state of angst, worry or unease The brain plays a key role via a neurohormonal response by both the neocortex and limbic system. The ‘fight or flight’ reflex is produced when there is a threat to the self. Anxiety and fear causes the individual to become stressed, releasing stress response hormones namely catecholamines (adrenaline/noradrenaline) and cortisol

psycho-physical symptoms as hyperalertness, tension, sense of unease, restlessness, insomnia, fear and forgetfulness. Gastrointestinal upset and marked changes, dry mouth and nausea the cardiovascular system, e.g. sweating, palpitations, tachycardia, shortness of breath, dizziness

Examples of anxiety disorders such as obsessive– compulsive and phobic anxiety Fear of giving birth (tocophobia) The fear of childbirth in the presence of tocophobia increases catecholamine levels, which can affect the frequency, strength and duration of uterine contractions.

Triggering factors for developing tocophopia: domestic abuse communication difficulties previous traumatic birth experience poor socioeconomic status lack of social support null parity longer duration of labor pre-existing mental illness

Soreness and pain being experienced from perineal trauma will affect libido ‘good’ mothers are those who are happy and fulfilled ‘bad’ mothers those who are unfulfilled, anxious or distressed are ‘ill’ ,This may lead to feelings of isolation, inadequacy and confusion. Normal emotional changes during pregnancy ambivalence to positive and negative emotions

E motional changes during labour Fear of the unknown Fear of technology, intervention and hospitalization fear and anxiety about pain Concerns about the wellbeing of the baby Fear of death a fear of lack of privacy

Postnatal ‘blues’ The postnatal ‘blues’ 50–80% of women depending on parity The onset typically occurs between day 3 and 5 postpartum, but may last up to 1 week or more, The main features are mild and may include: labile emotions (e.g. tearfulness, despair, irritability to euphoria and laughter

The actual etiology is unclear but hormonal influences (e. g The actual etiology is unclear but hormonal influences (e.g. changes in estrogen, progesterone and prolactin levels) increased emotionality appears to coincide with the production of milk in the breasts. self-limiting and will resolve spontaneously, assisted by support from loved ones

nightmares, panic attacks or ‘flashbacks’ Symptoms of PTSD nightmares, panic attacks or ‘flashbacks’ Avoidance especially of issues relating to pregnancy/birth Sleep disturbances Irritability or angry Anxiety/depression obstetric distress after childbirth appears to be directly linked to the stress, fear and trauma of birth

Types of psychiatric disorder The term ‘mental health problem’ is commonly used to describe all types of emotional difficulties from transient and temporary states of distress, often understandable, to severe and uncommon mental illness. It is also used frequently to describe learning difficulties, substance misuse problems and difficulties coping with the stresses and strains of life. It is therefore too general and too non-specific to be of use to the midwife

Psychiatric disorders are conventionally categorized into Serious mental illnesses These include schizophrenia, other psychotic conditions , bipolar illness and severe depressive illness. Previously, these conditions were called psychotic disorders. Mild to moderate psychiatric disorders These were previously known as ‘neurotic disorders’. These include non-psychotic mild to moderate depressive illness, mixed anxiety and depression, anxiety disorders including phobic anxiety states, panic disorder, obsessive–compulsive disorder and post- traumatic stress disorder.

Learning disability used to describe people who have a lifetime evidence of intellectual and cognitive impairment, developmental delay

The majority of postpartum onset psychiatric disorders are affective (mood) disorders. However, symptoms other than those due to a disorder of mood are frequently present. Conventionally three postpartum disorders are described: the ‘blues’ puerperal (postpartum) psychosis postnatal depression. The ‘blues’ is a common dysphoric, self-limiting state, occurring in the first week postpartum

Mild postnatal depressive illness This is the commonest condition following childbirth, Risk factors unsatisfactory marital or other relationships inadequate social support. older, educated and married for a long time problems conceiving previous obstetric loss high levels of anxiety during pregnancy. stressful life events such as moving house, family bereavement, a sick baby

Clinical features tearful, difficulty coping complains of irritability and a lack of satisfaction and pleasure with motherhood. Symptoms of anxiety, a sense of loneliness and isolation dissatisfaction with the quality of important relationships Affected mothers frequently have good days and bad days difficulty getting to sleep and appetite difficulties, both over-eating and under-eating.

Relationship with the baby Lack of pleasure in the baby, combined with anxiety and irritability marked irritability and even overt hostility towards their baby that the infant is at risk of being harmed.

Management Early detection and treatment is essential for both mother and baby psychological social support active listening from a health visitor

Antipsychotic drugs All psychotropic medication passes across the placenta and into the breastmilk. an alternative, non-pharmacological treatment Fetal and infant elimination of psychotropic medication is slower and less than adults and their central nervous systems more sensitive to the effects of these drugs

Antidepressants  Tricyclic antidepressants imipramine, amitriptyline and clomipramine (Anaframil)

Newborn babies of mothers who were receiving a therapeutic dose of tricyclic antidepressants at the point of birth are at risk of suffering from withdrawal effects (jiferiness, poor feeding and on occasion fits). Consideration should be given to a gradual reduction of the dose prior to birth.  

Selective serotonin reuptake inhibitors (SSRIs) (e.g. fluoxetine (Prozac) Continued use of SSRI medication during pregnancy has been associated with pre- term birth, reduced crown–rump measurement and lower birth weight.

Atypical antipsychotics The use of olanzapine in pregnancy increased risk of gestational diabetes The continued use of lithium throughout pregnancy is associated with an increased risk of fetal hypothyroidism, diabetes insipidus, fetal macrosomia and the ‘floppy baby’ syndrome (neonatal cyanosis and hypotonia). woman will require increasing doses of lithium in later pregnancy to maintain a therapeutic serum level

Succide

Breastfeeding Lithium should not be used in breastfeeding result in infant lithium toxicity, hypothyroidism and ‘floppy baby’ syndrome. sodium valproate is now the mood stabilizer of choice   Continued use of anticonvulsants throughout pregnancy is associated with an increased risk of neuro-developmental problems in the child. They should also take folic acid. transdermal oestrogens are effective in treating postnatal depression

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