The purpose of this project is to identify factors and describe evidence-based interventions for women at risk for the development of PTSD in the postpartum period. The following aims will be addressed in this project:
Aim 1: to recommend assessment tools to assist in the identification of those at risk for PTSD postpartum.
Aim 2: to identify interventions to implement in the event that the mother is found to be at risk for PTSD.
Aim 3: to identify strategies to improve care provided to mothers to lessen the development of PTSD postpartum.
Through this project women who deliver via C-section and are at risk for PTSD will be identified and appropriate interventions will be recommended to improve the overall outcomes of both the mother and the newborn
Methods:
A literature review was undertaken utilizing the following databases: Cochrane Library; PsychInfo; CINAHL; Pubmed; Medline; and Google Scholar. The search terms postpartum PTSD; traumatic childbirth; C-section; and continuous support were utilized. Both quantitative and qualitative publications were integrated in the current review. A total of fourteen articles were included, containing one systematic review, two randomized control trials (RCT), one quasi-experimental study, seven non-experimental studies, two meta analyses, and one mixed methods study.
Results:
Symptoms
Mothers experiencing PTSD in the postpartum period were found in the literature to exhibit symptoms of intrusion: flashbacks and nightmares regarding their childbirth. Arousal: difficulty sleeping, irritability, and difficulty concentrating. Avoidance: memory loss of the events during childbirth and avoiding places, activities, or people that are reminders of the traumatic experience (Simpson et al., 2017; Garthus-Niegel, et al., 2017). The literature also revealed that PTSD has long term effects such as decreased maternal and infant bonding, decreased breastfeeding rates, a fear of future pregnancy, and avoiding prenatal care in future pregnancies (Simpson et al., 2017; Bryanton et al., 2008; Baas et al., 2017).
Risk Factors
The literature identified multiple factors which increase the likelihood of postpartum PTSD. Some of these risk factors include mothers with a history of previous trauma or sexual abuse, pre-existing mental health disorders, fear of childbirth, diminished coping skills, and primiparas (Tomsis, Gelkopf, Yerushalmi, & Zipori, 2017; Grekin & O’Hara, 2014; Simpson et al., 2017; Baas, Stramrood, Dijksman, de Jongh, & van Pampus, 2017; Shahar, Herishanu-Gilutz, Holcberg, & Kofman, 2015). Further risk factors are uncontrolled pain during labor, not breastfeeding as long as intended postpartum, and self-blame for the procedure (Tomsis et al., 2017; Simpson et al., 2017;).
During labor, one of the main factors that contributes to the development of PTSD is the care provider. The literature identified that the unexpected nature of childbirth combined with poor care can lead mothers to view their birth experience as traumatic (Bryanton, Gagnon, Johnston, & Hatem, 2008; Grekin & O’Hara, 2014; Harris & Ayers, 2012; Reed, Sharman, & Inglis, 2017). Unfortunately, C-sections are frequently viewed as a routine intervention and its effect on mothers’ mental and emotional well-being is at times forgotten (Reed et al., 2017). Lack of communication about the procedure can lead to feelings of hopelessness, lack of control, humiliation, shock, feeling violated and dehumanized during labor. These feelings have all been found to increase the risk of PTSD postpartum (Simpson et al., 2017; Reed et al., 2017). In addition to the care provider, low support during labor was identified as a leading factor in the development of PTSD. In fact, lack of support greatly increases the likelihood that a mother will negatively perceive her birth experience (Tomsis et al., 2017; Simpson et al., 2017).
Recommendations
Support and Education
Lack of support during C-section has been identified as a leading factor contributing to the view of birth as traumatic and subsequent development of PTSD (Simpson et al., 2017; Kewei et al., 2017; Noyman-Veksler, Herishanu-Gilutz, Kofman, Holchberg, & Shahar, 2015; Bryanton et al., 2008). Evidence based practice has found that implementing continuous nursing support for mothers undergoing C-section is effective in decreasing rates of PTSD (Simpson et al., 2017; Bohren, Hofmeyr, Sakala, Fukuzawa, & Cuthbert, 2017; Kewei et al., 2017). Continuous nursing support involves a nurse being present with the patient starting from the time a C-section is indicated, extending through the procedure, and into the postpartum period. In this role, the nurse provides more than standard nursing care and ensures effective communication regarding the procedure. The nurse serves as a liaison between the patient and the medical team, is present to answer questions, serves as a direct support person, and allow the mother to discuss her experience and any traumatic events following the procedure (Kewei et al., 2017).
Evidence based practice has also identified training for care providers as a vital intervention (Reed et al., 2017). Caregivers should be educated on the importance of constant communication and option giving during C-section, as well as the effect caregivers’ actions have on mothers (Reed et al., 2017; Grekin &O’Hara, 2014; Bryanton et al., 2008). The literature also identified that it is important for care providers to educate all mothers before the start of labor of the possibility of an emergency C-section and what to expect in the event it occurs (Bryanton et al., 2008).
Screening
Due to number of women affected by postpartum PTSD it is essential that mothers are screened following C-section. Current research identified the Posttraumatic Stress Disorder Symptom Scale-Self Report (PSS-RS) as an effective screening tool. This screen tool has shown to have internal constancy and reliability in screening women in the postpartum period who are experiencing symptoms of PTSD in accordance with the criteria of the Diagnostic and Statistic Manual of Mental Health Disorders, the fifth addition (DSM V) (Baas et al., 2017; Beck, Gable, Sakala, & Declercq, 2011). In addition to the PSS-SR, the Modified Questionnaire Measuring Attitudes About Labor and Delivery (QMAALD) has been found in the literature to be useful in the identification of women at risk for developing PTSD based on their birth experience. Questions target feelings of control, involvement in decision making, support, and contact with the infant after birth (Bryanton et al., 2008). This scale has been found to have internal consistency in measuring the perception of birth as positive or negative. The PSS-SR and the QMAALD can be provided by the nurse following C-section to determine if a woman is at risk for perceiving her birth as traumatic and to identify if a woman is experiencing symptoms of PTSD.
Treatment
Treatment methods for postpartum PTSD are under investigated and require additional research. However, symptoms of PTSD have been found to be lessened by uninterrupted skin-to-skin and breastfeeding immediately following surgery (Simpson et al., 2017). Additionally, counseling and debriefing in the postpartum period has been found to be beneficial in some cases. However, more research is needed to assess its efficacy in the treatment of postpartum PTSD (Meades, Pond, Ayers, & Warren, 2011).
Conclusion:
The prevalence of PTSD postpartum is staggering. Its subsequent effects on mothers long term makes it a variance that is crucial to address clinically. Although the literature has offered insight into the development of PTSD following C-section, it is a topic that is still not fully understood. Further research is needed to identify effective prevention and treatment strategies for mothers at risk of developing PTSD in order to better support this population.