Effective Perinatal Care (EPC) 1 Perinatal mental health

8C-2 Effective Perinatal Care (EPC) Case study You are visiting a mother called Amal is in the first postpartum week; she feels persistently guilty and negative towards herself, cries easily and feels tired and agitated. You are visiting a mother called Amal is in the first postpartum week; she feels persistently guilty and negative towards herself, cries easily and feels tired and agitated. 1. What might she be suffering from? 2. What other symptoms would you ask her about, to confirm your diagnosis? confirm your diagnosis? 2

8C-3 Effective Perinatal Care (EPC) The psychological context of pregnancy and the puerperium Stress/anxiety  Pregnancy 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 anxiety and stress.  Stress during pregnancy is both essential and normal for the psychological adjustment of pregnant women.  Conversely, elevated levels of stress hormones and unnecessary anxiety will stretch coping reserves, and could prove crippling.

8C-4 Effective Perinatal Care (EPC) The psychological context of pregnancy and the puerperium Stress/anxiety  there are many factors that contribute to unhappiness in women's lives and affect their emotional health and well- being.  Understanding the root cause and expression of mental distress in women is complex as the social circumstances into which women live and children are born play a major role in their health and well-being.

8C-5 Effective Perinatal Care (EPC) Neurotransmitters Serotonin : Serotonin : –Inhibits stress response –Regulates sleep –Pain sensitivity –Sexual functioning –Appetite Diminished serotonin – result of stress? Diminished serotonin – result of stress?

8C-6 Effective Perinatal Care (EPC)

8C-7 Effective Perinatal Care (EPC) Transition to parenthood -Postnatally, parents may find coping with the demands of a new baby, e.g. infant feeding, financial constraints, the whole process of lifestyle adjustments and role changes, a real strain. -For new mothers, this will involve diverse emotional responses ranging from joy and elation to sadness and utter exhaustion.

8C-8 Effective Perinatal Care (EPC) Who is at risk? –Difficult labor or unexpected outcome –Fatigue, pain and discomfort –Disturbed sleep –Twins or higher multiples –Breastfeeding –C-section –Change in libido

8C-9 Effective Perinatal Care (EPC) Role change/role conflict –Having a baby, and particularly the transition to parenthood that accompanies the first child, leads to a significant shift in the couple's relationship. Social networks are disrupted, especially those of the mother and the quality and quantity of social support such networks can and do provide.

8C-10 Effective Perinatal Care (EPC) Communication –Effective communication during pregnancy and the puerperium is essential. Yet poor communication is still the single most common factor that is associated with women's dissatisfaction with their care.   Being provided with adequate information will serve to: diminish women's anxiety levels and allay emotional distress facilitate choice enable women to maintain control over decision- making.

8C-11 Effective Perinatal Care (EPC) The ideology of motherhood Motherhood, it is thought, ensures that a woman has fulfilled her biological destiny, confirms a woman's femininity and raises her status in society, but without financial gain. Motherhood, it is thought, ensures that a woman has fulfilled her biological destiny, confirms a woman's femininity and raises her status in society, but without financial gain. Instead of feeling elated by motherhood some women experience displeasure, feelings of unhappiness and feel dismayed or even disappointed in their role as new mothers. Instead of feeling elated by motherhood some women experience displeasure, feelings of unhappiness and feel dismayed or even disappointed in their role as new mothers. The ideology of motherhood is therefore an assumption and a paradox with inherent dichotomies as the woman strives to be ‘super mum, super wife, super everything’

8C-12 Effective Perinatal Care (EPC) Facts about Motherhood I will fall in love with my baby immediately. I will fall in love with my baby immediately. Being a mother will complete me. Being a mother will complete me. Having a child will strengthen our relationship. Having a child will strengthen our relationship. Having a child will keep him around. Having a child will keep him around. Mothering is natural. Mothering is natural. Breastfeeding is natural, and it will be easy. Breastfeeding is natural, and it will be easy.

8C-13 Effective Perinatal Care (EPC) Social support During periods of stress, supportive and holistic care from midwives will not only assist in promoting emotional well-being of women, but will also help to ameliorate threatened psychological morbidity in the postnatal period. Women who are socially isolated or who have poor socioeconomic circumstances are particularly vulnerable to mental health problems and need additional help and support.

8C-14 Effective Perinatal Care (EPC) Definition Psychiatric disorders are relatively common after childbirth and may include: postpartum ‘blues’, postpartum depression (PPD), and postpartum psychosis.

8C-15 Effective Perinatal Care (EPC) Spectrum of disorders Depression/Anxiety Depression/Anxiety Obsessive/Compulsive Disorder Obsessive/Compulsive Disorder Panic Attacks Panic Attacks Post-traumatic Stress Post-traumatic Stress Bipolar Bipolar Postpartum Psychosis Postpartum Psychosis

8C-16 Effective Perinatal Care (EPC) Postnatal Blues Occurs in about 80% of mothers Occurs in about 80% of mothers Onset 1st week, lasts up to 3 weeks Onset 1st week, lasts up to 3 weeks Mood instability, weepiness, sadness, anxiety, lack of concentration Mood instability, weepiness, sadness, anxiety, lack of concentration Treatment supportive Treatment supportive Not considered part of the spectrum of perinatal mood disorders Not considered part of the spectrum of perinatal mood disorders

8C-17 Effective Perinatal Care (EPC) Depression and/or Anxiety Incidence: 15-20% of new mothers Symptoms: Excessive worry or anxiety Excessive worry or anxiety Irritability, short temper Irritability, short temper Feeling overwhelmed by responsibilities, difficulty making decisions Feeling overwhelmed by responsibilities, difficulty making decisions Sad mood, feelings of guilt, fear, phobias Sad mood, feelings of guilt, fear, phobias Hopelessness Hopelessness Sleep disturbances (insomnia or hypersomnolence), fatigue Sleep disturbances (insomnia or hypersomnolence), fatigue

8C-18 Effective Perinatal Care (EPC) Somatic symptoms without apparent cause Somatic symptoms without apparent cause Discomfort around baby Discomfort around baby Lack of feelings towards baby Lack of feelings towards baby Loss of focus and concentration Loss of focus and concentration Loss of interest and pleasure Loss of interest and pleasure Changes in appetite – significant wt gain or loss Changes in appetite – significant wt gain or loss

8C-19 Effective Perinatal Care (EPC) Obsessive-Compulsive Disorder Incidence: 3-5% of new mothers Risk factors: Personal or family hx OCD Symptoms: –Intrusive, repetitive and persistent thoughts or mental pictures –Thoughts often about harming the baby –Tremendous sense of horror and shame –Behaviors to reduce anxiety and protect baby –Counting, checking, cleaning, other repetitive behaviors

8C-20 Effective Perinatal Care (EPC) Panic Disorder Incidence: 10% of postpartum women Risk Factors: Personal or family hx of anxiety or panic disorder Personal or family hx of anxiety or panic disorder Thyroid dysfunction Thyroid dysfunctionSymptoms: Episodes of extreme anxiety Episodes of extreme anxiety chest pain chest pain Sensations of choking, smothering, dizziness Sensations of choking, smothering, dizziness

8C-21 Effective Perinatal Care (EPC) Hot or cold flashes, trembling, tachycardia, numbness or tingling Hot or cold flashes, trembling, tachycardia, numbness or tingling Restlessness, agitation, irritability Restlessness, agitation, irritability During attack, may fear she is going crazy, losing her mind During attack, may fear she is going crazy, losing her mind Panic attack may wake her up from sleep Panic attack may wake her up from sleep Excessive worry or fear (incl. fear of another panic attack) Excessive worry or fear (incl. fear of another panic attack)

8C-22 Effective Perinatal Care (EPC) Posttraumatic Stress Disorder Posttraumatic Stress Disorder Incidence: up to 6% of postpartum women Risk factors: Past traumatic events Symptoms: Recurrent nightmares Recurrent nightmares Extreme anxiety Extreme anxiety Reliving past traumatic events (sexual, physical, emotional, childbirth) Reliving past traumatic events (sexual, physical, emotional, childbirth)

8C-23 Effective Perinatal Care (EPC) Bipolar Disorder Incidence: no data Risk factors: personal or family hx of bipolar disorder Symptoms: Mania – racing thoughts, high energy and little sleep, compulsive activity Mania – racing thoughts, high energy and little sleep, compulsive activity Depression Depression Rapid and severe mood swings Rapid and severe mood swings

8C-24 Effective Perinatal Care (EPC) Postpartum Psychosis Incidence: % Onset usually 2-3 days postpartum Onset usually 2-3 days postpartum 5% suicide and 4% infanticide rate 5% suicide and 4% infanticide rate Risk factors: Personal or family hx psychosis, bipolar, schizophrenia Personal or family hx psychosis, bipolar, schizophrenia Previous hx postpartum psychosis or bipolar episode Previous hx postpartum psychosis or bipolar episode

8C-25 Effective Perinatal Care (EPC) Symptoms: Visual or auditory hallucinations Visual or auditory hallucinations Delusional thinking Delusional thinking Delirium or mania Delirium or mania Very obviously psychotic Very obviously psychotic

8C-26 Effective Perinatal Care (EPC) Medical Management ACOG/APA guidelines (2009) ACOG/APA guidelines (2009) –Psychotherapy –Pharmacotherapy –Individualized plan of care –Consider continuing medications during pregnancy to avoid risk of relapse (bipolar, psychosis, severe depression)