Childbirth at Risk

1. Childbirth at Risk The Perinatal and Intrapartal Period

2. Describe the mental illness that women are at greatest risk for during the perinatal period Critically assess and evaluate the cluster of sx indicative of the most prevelant mental illness in women Explore the nurse’s role

3. Flying Below the Radar Screen: Mental Illness in the Perinatal Period • Describe the mental illness that women are at greatest risk for during the perinatal period • Critically assess and evaluate the cluster of sx indicative of the most prevelant mental illness in women • Explore the nurse’s role

4. Care of the Woman at Risk Because of Psychological Disorders • Prevalence of psychological disorders of adults in the U.S. is 26.2% • 44 million women meet the diagnostic criteria for mental illness in any given year. • Represents 4 of the leading 10 causes of disability in the U.S. • Alteration in thinking, mood or behavior

5. PMAD Perinatal mood and anxiety disorders • Depression • Anxiety or Panic Disorder • OCD • PTSD • Psychosis • Bipolar These disorders can affect people at any time during their lives. However, there is a marked increase in prevalence of these disorders during pregnancy and the postpartum period.

6. Risk Factors for PMADs • Previous PMADs: family history, personal history, symptoms during pregnancy • History of Mood Disorders: Personal or family history of depression, anxiety, bipolar disorder, eating disorders or OCD • Significant Mood Reactions to hormonal changes: puberty, PMS, hormonal BC, fertililty treatment.

7. PMAD Risks • Endocrine Dysfunction: hx of thyroid imbalance, fertility issues, diabetes • Social Factors: inadequate social, familial, or financial support • Teen pregnancy

8. It’s not all about Hormones…. • Biological/Physiological risks • Psychological risks • Social/Relationships • Myths of Motherhood

9. Myths of Motherhood • Getting pregnant • Becoming a mother • Being pregnant • Labor & Delivery • Breastfeeding • The baby sleep all the time • Superwoman/wife/mother • Happy all the time • Media images

10. Postpartum Psychological & Physiological Changes • Focus on baby/forming attachment • Fatigue/sleep deprivation • Loss of freedom, control, and self-esteem • Hormonal changes • Birth not going as expected • Learning new skills • Role transitions • Dreams and expectations

11. Psychological and Physiological Changes of Pregnancy • All about the new mom • Hormonal changes • Prenatal classes • Preparing for parenthood • Dreams and expectations • Watching the “Baby Channel” • Not always happy, “glowing time” • Planned vs. unplanned

12. Why Moms Suffer in Silence • Stigmas associated with mental illness • Barriers to treatment • Shame

13. Effect on Labor • Unable to concentrate/process info from healthcare team • May begin labor fatigued or sleep deprived • Labor process may overwhelm the woman physically & emotionally-no energy • May appear irritable or withdrawn due to inability to articulate feelings of hopelessness or “unworthiness of motherhood”

14. Why should we care about PMADs? Tragic consequences Affecting Society: • Marital problems/divorce • Disability/Unemployment • Child neglect & abuse • Developmental delays/behavioral problems • Infanticide/Homicide/Suicide P. Boyce, University of Sydney Hospital, Nepean Hospital, Penrith NSW Australia

17. Myths About Postpartum Depression • It’s only postpartum and it’s only depression • It means I don’t love my baby/want to kill my baby • It’s all about crying • Andre Yates drowned her 5 kids • It’ll go away on its own • Anxiety and depression don’t happen during pregnancy • Physical/Mental Illness

18. PMAD (Perinatal Mood and Anxiety Disorders) • Depression and Anxiety Disorders can occur anytime in pregnancy or the first year postpartum • PMAD is a new term replacing the narrow definition of PPD.

19. PMADs : Underdiagnosed and Under-treated • Depression/Anxiety in Pregnancy: It is estimated that 15-20% of pregnant women will experience moderate to severe symptoms of depression and/or anxiety • Postpartum Depression: Approximately 15% (Marcus, 2009)

20. Exacerbating Factors for PMADs • Complications in pregnancy, birth, or breastfeeding • Age-related stressors: adolescence perimenopause • Climate Stressors: seasonal depression or mania • Perfectionism/high expectations/”Superwoman syndrome”

21. Possible Exacerbating Factors • Pain • Lack of sleep • Abrupt discontinuation of breastfeeding • Childcare stress/Marital stress • Losses-miscarriage, neonatal death, stillborn, selective termination, elective abortion • History of childhood sexual abuse

22. Possible Exacerbating Factors • Culture shock – career vs motherhood • Who’s the dad? • Death of someone close • Building a new home or moving

23. Barriers to Treatment • Distinguishing normal adjustment versus depression • Absence of education, screening, and diagnosis • Absence of professional education and treatment knowledge • Symptoms denied, ignored or minimized

24. More Barriers • Social and cultural expectations • Stigma of mental illness • Myths of motherhood • Shame, embarassment • Lack of information and advocacy • Cost of treatment and medications • Fear of medications • Transportation • DENIAL

25. Depression • More women are affected than men • CNS imbalance in serotonin & other neurotransmitters • Unable to process information • Unable to concentrate • Fatigue, sleep deprivation • Overwhelmed by labor process • Unworthy of motherhood • Hopelessness

26. Perinatal Depression Syndrome • Sadness, crying • Suicidal thoughts • Appetite changes • Sleep disturbances • Poor concentration/focus • Irritability and anger • Hopelessness and helpless • Guilt and shame

27. Perinatal Depression – SX(continued) • Anxiety • OVERWHEMED • Lack of feelings toward the baby • Inability to take care of self or family • Loss of interest, joy, or pleasure • “This doesn’t feel like me.” • Mood swings

28. Baby Blues: the Non-Disorder • Affects 60-80% of new moms • Symptoms include crying, feeling overwhelmed with motherhood, being uncertain • Due to the extreme hormone fluctuations at the time of birth • Last no more than 2 days to 2 weeks • Acute sleep deprivation • Fatigue

29. Postpartum “blues”Not a mild form of depression • Features: tearfulness, lability, reactivity • Predominant mood: happiness • Peaks 3-5 days after delivery • Present in 50-80% of women, in diverse cultures • Unrelated to stress or psychiatric history • Posited to be due to hormone withdrawal and/or effects of maternal bonding hormones

30. Anxious Depression • High co-morbidity between depression and anxiety symptoms in perinatal women. (Moses-Kolko EL et al. JAMA 2005; 293: 2372-2383 & Anderson L et al, American Journal Obstetrics & gynecology 2003; 189: 148-152)

31. Depression/Anxiety in Pregnancy • Rates vary by studies – up to 51% in low SES women (average is 18%) • Depression During Pregnancy, Overview Clinical Factors, Bennett, H. et al., Clinical Drug Investigations 2004: 24 (3): 157-179

32. Anxiety Symptoms • Agitated • Excessive concern about baby’s or her own health • Appetite changes-often rapid weight loss • Sleep disturbances (difficulty falling/staying asleep) • Constant worry • Shortness of breath • Heart palpitations

33. Anxiety Disorders • Panic disorder, OCD,PTSD, generalized anxiety disorder, phobias • Cause a wide range of sx in the laboring woman: terror, SOB, CP, weakness, faintness, dizziness (exclude other dx) • Labor may trigger flashbacks, avoidance behavior, anxiety sx. • Severe sx to vague feeling “something is wrong”

34. Panic Symptoms • Episodes of extreme anxiety • Shortness of breath, CP, sensations of choking or smothering, dizziness • Hot or cold flashed, trembling, rapid heart rate, numbness or tingling sensations • Fear of going crazy, losing control or dying • Beyond the Blues by Indman and Bennett (2006)

35. OCD: Classic Symptoms • Cleaning • Checking • Counting • Ordering • Obsession with germs, cleanliness • Checking on baby • hypervigilence

36. OCD: Sx • Intrusive, repetitive thought-ususally of harm coming to baby • Tremendous guilt and shame • Horrified by these things • Hypervigilence • Moms engage in behjaviors to avoid harm or minimize triggers. Educate mom that thought does not equal action.

37. Perinatal PTSD • An anxiety disorder after a terrifying event or ordeal in which grave physical harm occurred or was threatened. “It’s in the eye of the beholder.” Beck, CT (2004). Birth Trauma: In the Eye of the Beholder, Nursing Research, 53, 28-35.

38. Postpartum PTSD Themes • Perception of lack of caring • Feeling abandoned • Stripped of dignity • Lack of support and reassurance • Poor communication • Moms feel invisible • Feeling powerless • Betrayal of trust • Don’t feel protected by staff • Do the ends justify the means? • Healthy baby justifies traumatic delivery?

39. PPPTSD Postpartum Hemorrhage Emergency C/S Any birth complication for mom or baby Previous PTSD Previous Sexual Abuse

40. PTSD: SX • Intrusive re-experiencing of a past traumatic event-anxiety attacks with flashbacks • “emotional numbing” • Hyperarousal/hypervigilence

41. PTSD due to traumatic labor & delivery • Incidence • Full PTSD in 0.2% - 3% of birth • Partial symptoms in about 25% of birth Creedy et al 2000: Czamocka et al 2000, Mounts K. Screening for Maternal Depression in the Neonatal ICU. Clinical Perinatology 2009; 36: 137-152.

42. PTSD due to traumatic labor & delivery: resultant problems • Avoidance of aftercare • Impaired mother-infant bonding • PTSD in partner who witnessed birth • Sexual dysfunction • Avoidance of further pregnancies • Exacerbation in future pregnancies • Elective c/s in future pregnancies

43. PTSD in NICU moms • Risk factors: • Neonatal complications • Lower gestational age • Greater length of stay in NICU • Stillbirth • Prominent symptoms: • Intrusive memories of infant’s hospitalization • Avoidance of reminders of childbirth

44. Perinatal Psychosis • “It was the seventh deadly sin. My children weren’t righteous. They stumbled because I was evil. The way I was raising them they could never be saved. The were doomed to perish in the fires of hell.” Andrea Yates, mother of Noah, John, Luke, Paul and Mary

45. Psychosis: Prevalence • 1-2 in 1,000 postpartum women will develop PPP • Of those women:5% suicide 4% infanticide Onset usually within first 3 weeks after delivery

46. PPP: Sx • Delusions (eg baby is possessed by a demon) • Hallucinations (eg. Seeing someone else’s face instead of the baby’s face) • Insomnia • Rapid mood swings • Waxing and waning (can appear and feel normal for stretches of time between psychotic symptoms

47. Bipolar Disorder • Higher risk of suicide • Women with a previous diagnosis of bipolar depression are at greater risk for developing a mood disorder in the postpartum period • Postpartum psychosis is more common in women with bipolar disorder: 20 out of 30 postpartum women with bipolar disorder experience a psychotic episode. 70% of women with bipolar disorder will relapse within the first 6 months postpartum

48. Clinical Therapy • Provide support • Decrease anxiety • Orient to reality • Sedatives/analgesia (decrease pain may decrease psychological sx) • Psychiatric support

49. Can PMADS Be Prevented “…Prevention is the great challenge of postnatal illness because this is one of the few areas of psychiatry in which primary prevention is feasible.” Hamilton and Harberger (1992)

50. Primary Prevention Model • Risk factors are known • Feasible to identify high-risk mothers • Screening is inexpensive and educational • Many risk factors are amenable to change • Known effective, reliable treatments exist