Post-Traumatic Stress Disorder inpostpartum Patients

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2 Heidi L. Stone, MS, RNC-OB Post-Traumatic Stress Disorder inpostpartum Patients What Nurses Can Do It s 4:00 a.m. and the ambulance call comes in: Full-term pregnant female, 35 years old, first pregnancy, frank red vaginal bleeding, ETA 5 minutes. The patient arrives, diaphoretic, pale, visibly anxious and asking, Is my baby all right? Fetal heart tones are heard via Doppler at 60 beats per minute. The patient is lying in blood to her ankles, her pulse is 135, her blood pressure is 70/40, her abdomen is rigid and she denies having had contractions.

3 You direct the charge nurse to summon the on-call physician from the call room as you and the team quickly prepare her for an emergency cesarean section (c-section). Her husband arrives saying, She didn t want a c-section, we planned a natural birth. Someone quickly assures him that an emergency c- section is the safest way to deliver the baby in this situation and directs him to the waiting area. The patient is then rushed to the operative suite for general anesthesia and a stat c-section of a live infant with Apgar scores of 4 to 6. The infant continues to be hypotonic and pale at five minutes and is admitted to the neonatal intensive care unit (NICU) for intravenous fluids and monitoring. When the patient recovers from anesthesia she tells her nurse, I wanted to have a natural birth, I read all the books, I want to breastfeed, I did everything I was supposed to. Why did they make me have a c-section? Where is my baby? Why won t they let me nurse my baby? Nobody is telling me anything! Bottom Line Women who have traumatic birth experiences, and even those who merely perceive their experiences as traumatic, may be at risk for PTSD. PTSD can negatively affect mother-infant bonding. Nurses can play a key role in identifying patients at risk for PTSD. ABOUT PTSD Many nurses are familiar with post-traumatic stress disorder (PTSD) as it was first described by the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders (DSM) in The DSM IV (2000) describes exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury a person s response to the event must involve intense fear, helplessness or horror (American Psychiatric Association, 2000, p. 463). PTSD was first identified in the 1980s as symptoms resulting from traumatic events experienced or witnessed by soldiers in the Vietnam War (Beck, 2004). Since then, PTSD has been recognized in other populations, including women with anxiety or depression during their pregnancies, those with previous pregnancy losses and those with obstetric complications (Born, Soares, Phillips, Jung, & Steiner, 2006). Stressors or triggers are those events outside of the range of usual human experience Heidi L. Stone MS, RNC-OB, is a clinical assistant professor of nursing at Towson University in Hagerstown, MD. Address correspondence to: hstone@towson.edu. DOI: /j X x that would be distressing to almost anyone. Witnessing a threat of harm to one s child s life or serious threats to one s self or others is indicated as causative (Hughes, Evans, & Fainman, 2001). In identifying triggers for PTSD, nurses must consider that individual responses to experiences are dependent on prior life events and preexisting coping skills. PTSD is a complex psychiatric disorder with major depression being a comorbid condition in nearly half of all people with PTSD (Stuart & Laraia, 2005). Many clinicians find it difficult to recognize symptoms in the postpartum period, which is complicated by hormonal changes and developmental adjustments (Cashion, 2004). INTRAPARTUM AND POSTPARTUM RISKS Developmental theorist Erik H. Erikson ( ) identified important developmental tasks of young adulthood as being those of intimacy versus isolation (Berman, Snyder, Kozier, & Erb, 2008). Similarly, Robert Havighurst ( ) identified tasks of selecting a mate, starting a family and rearing children as essential to the normal development of young adults (Berman et al.). As such, childbirth accompanies a critical developmental phase when family functioning and social relationships are important to the successful mastery of developmental tasks. Women who experience childbirth with generalized anxiety, fear of the birth experience, low stress-coping capacities and/or prior psychiatric histories have been noted to be at higher risk for developing PTSD (Tham, Christensson, & Ryding, 2007). The development of PTSD in the postpartum period can have far-reaching effects, as it may interfere with normal development and role mastery (Alder, Stadylmayr, Tschudin, & Bitzer, 2006). Certain groups known to be at higher risk are those with weak social support systems, those who experience a high level of obstetric intervention, those who have experienced a (real or perceived) negative relationship with staff/caregivers and those with negative emotional responses during or directly after the birth experience (Olde et al., 2005). There is evidence of increased incidence of PTSD in women who develop altered states of consciousness during their experiences of labor and/ or delivery (Olde et al.; Kennedy & MacDonald, 2002). Such clients have minimal or unrealistic recollections of the events or the perception of time, place and person during their birth experiences. The events of the birth experience become distorted in such patients minds, perhaps due to pain or to sedatives and analgesics administered during and after birth as well as to psychological coping mechanisms, and these experiences contribute to more delusional memory than factual memory (Olde et al.). The perception of threat is a personal experience. Caregivers who have witnessed similar events with previous patients often interpret occurrences and behave as if everything is routine. Pa , AWHONN

4 In identifying triggers for PTSD, nurses must consider that individual responses to experiences are dependent on prior life events and preexisting coping skills tients and family members may be confused by such outwardly calm behavior, misinterpreting it as unconcerned (Maggioni, Margola, & Fillipi, 2006). Such an experience could be the unprepared support person witnessing forceps application or the use of a vacuum extractor or a loved one experiencing the pain associated with labor. Other examples could be giving birth to a dead fetus or a damaged or imperfect neonate, or long-planned birth plans being changed at the last minute by an emergency c-section (Tham et al., 2007). Witnesses to the childbirth, such as the patient s spouse, mother, other children, relatives and friends may be at risk for PTSD and should be included in the plan of care (Church & Scanlan, 2002). PATIENTS PERCEPTIONS Traditionally, childbirth was not suspected of being a trigger event for PTSD; however, it s now recognized that childbirth can indeed qualify as an extreme traumatic stressor (Beck, 2004) and, as such, be a contributing factor to the development of PTSD. When listening to and assessing a patient after a traumatic event, the nurse often realizes that the client s delusional memory has become her reality. Not only are those who experience an obviously traumatic birth at risk, but so are those who perceive their normal delivery as being traumatic (Maggioni et al., 2006). Patients preconceived expectations greatly impact their interpretations of the labor and delivery experience, contributing to a higher risk for PTSD among primiparas and those with inexperienced social support systems (Maggioni et al., 2006). Women whose expectations are closely aligned with their control of the situation, such as women with stringently outlined birth plans, are also identified as at greater risk for developing PTSD (Maggioni et al.; Olde et al., 2005). According to Maggioni et al., differences between a woman s expectations and her actual experience can produce adverse emotional outcomes. In the literature there are many references to the need for feeling in control. This control has been described by Maggioni et al. as that of external and internal control: External control is control over what is being done by others; internal control is control over one s own body and behaviors. Many nurses have suspected that keeping a patient well-informed by explaining procedures, rationales and what to expect will decrease a patient s anxiety. Maggioni et al. reinforce this suspicion by explaining that these interventions have a direct and positive influence on patient s birth satisfaction. Negative birth satisfaction, which leaves women with a sense of minimal control, contributes to adverse psychological outcomes (Maggioni et al.; Olde et al.). NURSING INTERVENTIONS Nurses working in intrapartum and postpartum units are ideally situated to affect both physical and psychological outcomes for all their patients. During the intrapartum, nurses should facilitate a sense of control for their patients. Nurses can empower their patients to play an active role in their labor experiences by providing them with the information they need to make informed decisions (Church & Scanlan, 2002). Czarnocka and Slade (2000) studied patients whose birth experience were less positive than expected and how often such patients and their families attempted to place blame on their nurses or doctors. Blaming others was a predictor for a higher PTSD-question- August September 2009 Nursing for Women s Health 287

5 naire score, as well as for alienation from a potential source of support during the intrapartum and postpartum periods. Nursing care during the intrapartum is not limited to fetal monitoring and documenting assessments of uterine activity and fetal status at the recommended frequency. The Association of Women s Health, Obstetric and Neonatal Nurses (AWHONN) recommends one-to-one nursing care during active labor and promotes the development of a trusting, supportive nurse-patient relationship as well as the facilitation of early recognition of maternal or fetal problems and intervention. These interventions are not limited to the physical aspect of care, but should include such interventions as ongoing educational and psychological support and assessment, as well. Early recognition of precursors to PTSD, such as acute stress reaction (ASR) appearing dazed, experiencing reduced levels of consciousness or agitation and withdrawal (Church & Scanlan, 2002) will be recognized by the nurse who is intimately involved with knowing her patient. Highly anxious patients may need more frequent reassurances from their nurse that the situation is not life-threatening (Ayers, McKenzie-McHarg, & Eagle, 2007). In the early postpartum period, nursing interventions such as encouraging and allowing the patient to verbalize her perceptions of the birth experience and reviewing and clarifying the situation with her may be useful as therapeutic prophylaxis against the development of PTSD (Church & Scanlan). Trustful support is a term used by Cigoli, Gilli, and Saita (2006) in describing the reassurance many woman need during the reproductive part of the life cycle. When interpersonal family dysfunction exists, there is may be a lack of ability or willingness on the part of family members to provide the support and reassurances that the patient may need (Cigoli et al.). In such situations, the roles of intrapartum and postpartum nurses, who have established trustful relationships with the patient, are essential to the patient s well-being. Cigoli et al. identified such need for support by the nurse in their analysis of studies of patients with PTSD. During the vulnerable intrapartum period, the nurse establishes this relationship and, ideally, can continue it into the postpartum period by providing the support and reassurances lacking in the traditional familial system of support. Even in situations where the family is intact, the relationship of the intrapartum nurse can continue into the postpartum period through clarification and support Box 1 Examples of Open-Ended Questions Tell me about your birth experience. It sounds like things didn t go as anticipated. How did this experience compare to what you had expected? What was the best (or worst) part of this experience for you? 288 Nursing for Women s Health Volume 13 Issue 4

6 Not only are those who experience an obviously traumatic birth at risk, but so are those who perceive their normal delivery as being traumatic to not only the patient but to her family as well through visits on the postpartum unit or follow-up phone calls. The intrapartum nurse can transfer this relationship to the postpartum nurse by providing clear and concise information in report regarding the patient s birth experience and her reactions. This communication is an essential component in the identification and follow-up of at-risk patients. ASR is a transient psychological reaction that often follows a traumatic event and is a known precursor to PTSD (Church & Scanlan, 2002). Birth partners may be affected and should be included in the nursing support and education in the postpartum period (Cigoli et al., 2006). Partners should be given information to help them recognize not only symptoms of postpartum depression but also of ASR, and should be encouraged to seek help for their partners and/or themselves as appropriate (Cigoli et al.). Nurses on antenatal units should consider the establishment of support groups involving clinical social workers and/or psychologists who have special knowledge of cognitive behavioral therapy and PTSD, as well as some advanced understanding of the childbearing experience (Ayers et al., 2007). Information about the availability of such support services should be made available to all clients as part of their routine discharge teaching. PTSD is a psychiatric diagnosis made by qualified psychiatric practitioners. Actual PTSD will not be evident until after discharge from the acute care facility or birth center, as symptoms consisting of re-experiencing the event, avoidance of reminders and hyper-arousal must be present for one month for diagnosis (American Psychiatric Association, 2000). Recognition and identification of clients at risk will promote continuity of care and early referral for treatment (Ayers & Pickering, 2001). Most women demonstrate normal adaptation, whereby they process and reconstruct the childbirth experience with their loved ones and with their nurses (Reynolds, 1997). This therapeutic process has been implicated in a reduced incidence of birth-related stress (Alder et al., 2006). Nurses can use open-ended questioning (see Box 1) to assess their patients birth experiences and identify patients with perceived negativity, which may put them at increased risk for developing PTSD (Alder et al.). However, identification is not enough; the nurse must communicate the patient s issues to the managing physician or midwife. As mentioned previously, these concerns should also be included in nurse-nurse report/communications and documented in discharge reports as well. If facility protocols for referrals are in place, these should be initiated, as untreated PTSD may lead to altered maternal-infant bonding, avoidance of social interactions and relational difficulties (Alder et al. 2006). While initial care and assessment may identify some of those at risk, follow-up screening is recommended at the sixto eight-week postpartum visit. Most practitioners traditionally have relied on the Edinburgh Postnatal Depression Scale as a screening tool for postnatal depression. This tool alone is insufficient to identify patients at risk for PTSD. There is evidence that PTSD can develop in the wake of resolving postnatal depression (Ayers et al., 2007). Wilson and Keane (2004) note several symptoms that, while not specific to the postpartum patient alone, could signal the nurse to recognize a possible stress response during assessment of the postpartum patient, which might progress to PTSD (see Box 2). Early identification may decrease the intensity of symptoms and/or derail Box 2 Symptoms Signaling a Possible Stress Response Emotional numbing taking the feeling out of emotional memories Reduced awareness of one s environment Derealization and depersonalization Intrusive thoughts Insomnia Impaired concentration Avoidance behaviors Irritability Autonomic arousal, such as palpitations, hyperventilation and/or nausea August September 2009 Nursing for Women s Health 289

7 Box 3 PTSD Symptom Scale: Self-Report Version PTSD Symptom Scale: Self-Report Version (PDS; Foa et al., 1997) Participant Date Directions: Below is a list of the problems that people sometimes have after experiencing a traumatic event. Read each one carefully and fill in the number (0-3) that best describes how often that problem has bothered you in the past 2 weeks. Rate each problem with respect to the traumatic event that brought you into treatment. 0 = Not at all or only one time 1 = Once per week or less/once in a while 2 = 2 to 4 times per week/half the time 3 = 5 or more times per week/almost always Items Having upsetting thoughts or images about the traumatic event that came into your head when you didn t want them to? 2. Having bad dreams or nightmares about the traumatic event? 2a. Having these bad dreams always center on being killed? 3. Reliving the traumatic event, acting or feeling as if it were happening again? 3a. Reliving the traumatic event as if I am moving in a rewind motion? 4. Feeling EMOTIONALLY upset when you were reminded of the traumatic event (for example feeling scared, angry, sad, guilty, etc.)? 5. Experiencing PHYSICAL reactions (for example, break out in a sweat, heart beats fast) when you were reminded of the traumatic event? 6. Trying not to think about, talk about, or have feelings about the traumatic event? 6a. And when I try hard enough NOT to think about the traumatic event I feel dizzy? 7. Trying to avoid activities, people, or places that remind you of the traumatic event? 8. Not being able to remember an important part of the traumatic event? 9. Having much less interest or participating much less often in important activities? 9a. Having much MORE interest in activities that are unimportant? 10. Feeling distant or cut off from people around you? 11. Feeling emotionally numb (for example, being unable to cry or unable to have loving feelings) 11a. Feeling emotionally transparent (for example, feeling like people are unable to see me) 12. Feeling as if your future plans or hopes will not come true (for example, you will not have a career, marriage, children, or a long life)? 13. Having trouble falling or staying asleep? 14. Feeling irritable or having fits of anger? 15. Having trouble concentrating (for example, drifting in and out of conversations, losing track of a story on television, forgetting what you read)? 16. Being overly alert (for example, checking to see who is around you, being uncomfortable with your back to the door, etc.)? 16a. Being overly aware of sensations or changes in my body? 17. Being jumpy or or easily startled startled (for (for example, example, when when someone someone walks up walks behind up you)? behind you)? 17a. Being acutely aware of of smells, smells, especially body body odor? odor? Source: Nursing for Women s Health Volume 13 Issue 4

8 the prolonged stress response associated with PTSD (Ayers & Pickering, 2001). Alder et al. (2006) suggest that the PTSD symptom scale (see Box 3) be included in postpartum assessments of patients identified as high risk. The scale, while not specific to the postpartum patient, is a 17-item questionnaire designed to target severity of symptoms of PTSD. While there is no absolute positive score, risk correlates with a higher score to the responses to the questions. While it may not be feasible to administer the scale to all patients, familiarity with the types of questions will facilitate the nurse s psychosocial assessment of the postpartum patient at subsequent visits. Home health nurses, neonatal nurses and nurses working at emergency and outpatient centers where postpartum women and their infants may be seen prior to their routine postpartum visit may find familiarity with these questions especially helpful in identifying those patients with symptoms (Ayers & Pickering). CONCLUSION All postpartum women should be afforded frequent opportunities to discuss their experiences, clarify their misunderstandings and have appropriate follow-through and referrals to support services when indicated. Utilizing the tools identified and knowledge of the psychosocial aspects of the childbearing process, nurses can play a key role in identifying women at risk for PTSD during the postpartum period. Intrapartum and postpartum nurses have opportunities to intervene on behalf of their patients with referrals, education of patients and their families, and appropriate communication with other nurses and appropriate support services, whether in acute care facilities or community-outpatient settings. We have the opportunity to deeply touch and impact lives through our caring, sensitivity and astute observations and assessments of the whole patient. NWH REFERENCES Alder, J., Stadlmayr, W., Tschudin, S., & Bitzer, J. (2006). 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