Part A: Pregnancy, childbirth, puerperium: the psychological context Stress/anxiety Pregnancy, labour and the puerperium are normal life events, yet they are periods in a woman's life when her vulnerability exposes her to a significant amount of stress and anxiety. Stress and anxiety are the psychopathology of humans' existence and a part of normal human emotion. A degree of stress during pregnancy is both essential and normal for the psychological adjustment of pregnant women.

elevated levels of stress hormones and unnecessary anxiety will affect woman's psychological status

Anxiety is a state of angst, worry or unease triggered by an event where there is an uncertain outcome, such as a written examination or when important decisions have to be made.

. 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 Stress and anxiety therefore have a cognitive, somatic, emotional, physiological and behavioral component.

Anxiety disorders, are a group of mental illness that cause marked distress, that they disrupt normal function, overwhelm or impair the individual's ability to lead a normal life. Examples of anxiety disorders such as obsessive– compulsive and phobic anxiety

elevated levels of stress hormones during the antenatal period having the potential to lead to deleterious effects on the fetus persistent antenatal anxiety acting as a possible precursor to maternal mental illness postpartum

there are many factors in women's lives that can impact on their happiness and affect their emotional health and wellbeing.

Fear of giving birth (tocophobia) The fear of childbirth approximately 5–20% of pregnant women within Western society are fearful of childbirth

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

in the presence of tocophobia increases catecholamine levels, which can affect the frequency, strength and duration of uterine contractions. This can affect women's satisfaction with their birth experience and lead to maternal distress.

Transition to parenthood Postnatally, parents may find coping with the demands of a new baby, e.g. infant feeding, financial constraints, adjustments and role changes diverse emotional responses from mother ranging from joy and elation to sadness and exhaustion.

Fatigue, pain and discomfort Disturbed sleep is inevitable with a new baby. Establish breastfeeding older women women who are recovering from a caesarean section Had a long and difficult labour/birth twins higher multiples.

Soreness and pain being experienced from perineal trauma will affect libido Role change/role conflict Having a baby especially the first child, leads to a significant shift in a couple's relationship

a sense of social isolation. strong relationships The dynamics of relationships with family members are also altered

Communication Effective communication during pregnancy and the puerperium is essential. poor communication is associated with women's dissatisfaction with their care.

The ideology of motherhood Instead of feeling elated by motherhood some women experience displeasure, feelings of unhappiness and feel dismayedالفزع

grieve. ‘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.

Midwives have a pivotal role to play in assisting women and their partners to prepare for the physical, social, emotional and psychological demands of pregnancy, labour, the puerperium and, perhaps more importantly, parenthood

Social support poor socioeconomic circumstances are particularly vulnerable to mental health problems and need additional help and support.

of the traditionally defined postnatal period of the traditionally defined postnatal period. The restructuring of postnatal care means there is now a social expectation that midwives will respond flexibly and responsively to women's emotional needs on an individual basis (Brown et al 2002; DH 2004, 2007a, 2007b; NICE [National Institute for Health and Clinical Excellence] 2006). This calls for skilled multidisciplinary and multi-agency

collaboration as well as effective teamwork, acknowledges Social support need to help woman

Normal emotional changes during pregnancy, labour and the puerperium varied emotions during the different trimesters of pregnancy. fluctuations between ambivalence to positive and negative emotions.

No r m a l e m o t io na l cha ng e s dur ing pr e g na ncy Box 25.1 No r m a l e m o t io na l cha ng e s dur ing pr e g na ncy First trimester pleasure, excitement, elation ambivalence emotional lability (e.g. episodes of weepiness exacerbated by physiological events such as nausea, vomiting and tiredness) increased femininity

Second trimester a feeling of wellbeing, especially as physiological effects of tiredness, nausea and vomiting start to abate a sense of increased attachment to the fetus; the impact of ultrasound scanning stress and anxiety about antenatal screening and diagnostic tests -increased demand for knowledge and information as preparations are now on the way for the birth

Third trimester loss of or increased libido altered body image psychological effects from physiological discomforts such as backache and heartburn anxiety about labor (e.g. pain) anxiety about fetal abnormality, which may disturb sleep or cause nightmares increased vulnerability to major life events such as financial status, moving house, or lack of a supportive partner

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