Traumatic Childbirth and Postpartum Posttraumatic Stress Disorder

This chapter on posttraumatic stress disorder (PTSD) in the postpartum reviews the disorder that may occur following: a traumatic birth during which the mother is injured: postpartum medical problems such as hemorrhage or the occurrence of a defect or medical complications in the newborn. Symptoms of PTSD include nightmares, intrusive thoughts, flashbacks, hypervigilance, avoidance of triggers, depressed mood, and a pessimistic view of the future. It is important to screen for PTSD after a traumatic birth as women often hesitate to come forward as they feel ashamed, lack insight into symptoms, lack support, or fear reproach. It is essential to attend to any residual physical trauma or pain following the delivery. Cognitive-behavioral therapy is the treatment of choice. Medication may be helpful including selective serotonin reuptake inhibitors and prazosin to help educe nightmares.

Postpartum Psychosis

This chapter on postpartum psychosis notes that the risk of postpartum psychosis in the general population is very rare at less than 1%. In a mother with a known history of schizophrenia, this risk increases to 25%. Psychotic symptoms appearing postpartum may also be evidence of a bipolar disorder. The presence of elevated mood, increased activity levels and energy, poor sleep, and a family history of manic episodes all increase the likelihood that a bipolar disorder is present. Women with a personal or family history of a bipolar disorder are at an elevated risk of developing a mania or depression with psychotic symptoms postpartum. Postpartum psychosis due to any cause is a psychiatric emergency and treatment should be initiated early and aggressively to ensure the safety of mother and infant. Hospitalization and/or separation of the baby and mother may be necessary. The use of medication to treat schizophrenia or bipolar disorder during pregnancy may decrease the risk of a postpartum psychosis. With appropriate postpartum medication and support, the majority of women experiencing postpartum psychosis recover well and the risk of recurrent psychotic symptoms can be greatly reduced.

Disorders of Attachment

This chapter on disorders of attachment addresses the causes and consequences of impaired attachment between mothers and their fetuses or infants. Mothers’ feelings of attachments for their babies generally begins during pregnancy, grows with quickening, and continues after the delivery. Women who have an unwanted pregnancy or who suffer from anxiety, depression, or a psychotic disorder during pregnancy may feel detached from the developing fetus. Postpartum, it is important to assess for these disorders as well as a painful, traumatic delivery, as they may continue to interfere with attachment. Generally, treatment of the underlying disorder allows the woman to begin bonding with the baby. This chapter describes how to recognize and manage factors that may be interfering with attachment. Working with the mother and the baby can assist in building bonds.

Postpartum Personality Disorders

This chapter on personality disorders in the postpartum reviews the impact on the well-being of the mother and the infant if the mother suffers from a pre-existing personality disorder. Borderline personality disorders may have a negative impact on the new mother’s ability to form a healthy relationship with the infant and may become frustrated easily frustrated if the infant doesn’t obey. Women with dependent personality disorders may feel needy, helpless, and indecisive and therefore feel overwhelmed with motherhood. New mothers with paranoid personality disorders feel generally distrusting and suspicious. They may reject the health-care worker’s advice, thereby putting the infant at risk. Working with the mother–infant dyad is essential.

Postpartum Depression

Postpartum depression occurs in about 9% to 16% of women following delivery. It is often missed because the symptoms may overlap with what women commonly experience after having a baby such as fatigue. It occurs all over the world and those who have support may be at an advantage. The causes are thought to be a combination of genetic, hormonal, and psychosocial ones and women who have had a previous depression are at particularly high risk although many psychosocial factors may also place her at risk. Clinicians must rule out medical contributions and ensure the safety of both mother and baby. Treatment is essential as the consequences affect the entire family. Both psychotropic medications, with considerations for breastfeeding, as well as psychotherapy are effective. Community resources can be used to increase support. Although there remains an increased risk for future depressive episodes, the majority of women recover well with treatment.

Eating Disorders in the Postpartum Period

The chapter on eating disorders in the postpartum addresses the issues of mothers who have anorexia nervosa or binge eating disorders. Women with anorexia nervosa may become particularly upset about the weight gain that comes with pregnancy. Extreme dieting may make them weak and have problems focusing on the baby’s needs. Warning signs include dieting that is associated with decreasing weight goals, increase in criticism of one’s body, social isolation, amenorrhea, and purging. They may also restrict the nutrition of their baby. Women with binge eating disorder may suffer secretly as they may not have abnormal weights. Hiding away to binge may interfere with care of the infant.

Postpartum Anxiety

This chapter focuses on anxiety disorders presenting in the postpartum. Symptoms include ruminative, excessive worried thoughts that are minimally decreased with reassurance and support, an inability to relax, feelings of tension, worry the baby’s health, feeling overwhelmed with caring for the baby, and insomnia due to intrusive worried thoughts and inability to relax. Depressive symptoms can occur secondary to feeling anxious. Women with a history of an anxiety disorder have an elevated risk of developing these symptoms postpartum. Support and encouragement for family is important. Medications such as a selective serotonin reuptake inhibitor and short-term use of a benzodiazepine may be required. Relaxation techniques, mindfulness-based stress reduction, and cognitive-behavioral therapy may all be helpful. Lack of treatment may result in postpartum depression, impaired mother/infant bonding and impaired infant/child development.

Prevention of Postpartum Disorders

This chapter on prevention of postpartum disorders reviews the factors that can decrease the risks of developing a postpartum psychiatric disorder. The primary risk for postpartum or perinatal depression is a personal history of depression during or after a previous pregnancy. Maintenance during pregnancy of treatment for a pre-existing mental health disorder is essential. Building support networks is also important. Ensuring good health practices during the postpartum such as getting adequate exercise, eating well, and exposure to light can all be helpful. Sleep is an important component in reducing risks. Working with a partner who can help with some overnight bottle feeding can also be very beneficial.

Postpartum Adaptation: Normal, Baby Blues, Baby Pinks

This chapter on postpartum adaptation/baby blues describes the transient symptoms of sadness, tearfulness, irritability, and insomnia know as the “baby blues” experienced by 50% to 80% of new mothers. This is not a sign of depression but, rather, the consequences of the massive bio-psycho-social changes that occur after the birth of a child. No specific treatment other than education and reassurance is required. Most often these symptoms resolve spontaneously within the first 2 to 3 weeks. Occasionally, they continue and develop into a major depression so women should be reassessed within the first 6 weeks postpartum to ensure the symptoms have cleared.

Risk Factors for Postpartum Disorders

This chapter on risk factors for postpartum disorders describes how the postpartum period is a time in women’s lives when they are at an especially high risk for developing mental health problems. The massive hormonal changes experienced after birth can interact with other risk factors to result in a postpartum disorder. Poor sleep due to infant care can exacerbate these vulnerabilities. There are many factors that may increase the risk of developing a postpartum disorder. Depression or anxiety during pregnancy, a personal or family history of a psychiatric disorder, current stressors, and lack of social supports may all increase the risk of developing a postpartum depression or anxiety disorder. Women with a history of bipolar disorder are particularly at risk for developing a depression or manic episode postpartum. Recognition of factors that may predispose women to the development of a postpartum disorder can allow preventative factors to be put in place.