Emotional midwifery support as an intervention to reduce

development of Postnatal Post Traumatic Stress Disorder

Background and definitions • Post Traumatic Stress Disorder is mind’s reaction to a traumatic event such as

actual or threatened death, serious injury, or sexual violence (American Psychiatric Association, 2013)

• In the UK:

• around 3% postnatal women would develop PTSD.

• Around 30% have some symptoms (Birth Trauma Association, 2019)

• Symptoms according to NICE(2018) guidelines:

• re-experiencing (flashbacks) • avoidance • hyperarousal (including hypervigilance,

anger and irritability) • negative alterations in mood and

thinking • emotional numbing

• dissociation • emotional dysregulation • interpersonal difficulties or

problems in relationships • negative self-perception (including

feeling diminished, defeated or worthless

What does the evidence say trust Communication as

Information

sharing

Communication as

emotional sharing

Cigoli, V., Gilli, G., Saita, E. (2006) Relational factors in

psychopathological responses to childbirth. J Psychosom Obstet

Gynaecol.;27(2):91-7.

clear

communication

Support with

anxiety

De Schepper S., Vercauteren, T., Tersago, J., Jacquemyn, Y., Raes,

F., Franck, E. (2016) Post-traumatic stress disorder after childbirth

and the influence of maternity team care during labour and

delivery: A cohort study. Midwifery. Jan;32:87-92

Perception of

midwife being in

control

Internal locus of

control

Ability to ask

questions

Ford, E., Ayers, S. (2011) Support during birth interacts with prior

trauma and birth intervention to predict postnatal post-traumatic

stress symptoms. Psychol Health. 26(12):1553-70.

Informational

support

Emotional support

Beck, T. (2006) Pentadic Cartography: Mapping Birth Trauma

Narratives. Qual Health Res.16(4):453-66.

Consent,

personalization

(opposite to

objectification)

Effective

communication

Caring

communication

Harris, R., Ayers, S. (2012) What makes labour and birth

traumatic? A survey of intrapartum 'hotspots'. Psychol Health.

27(10):1166-77

no, fear, no

dissociation,

control

clear

communication

Presence, heard,

supported

Trust and control

Can lack of control cause PTSD?

Theory of control (Walker, 2001):

• Internal locus of control is protective against PTSD (Schepper et al, 2015)

• Internal locus of control can include trust in significant others, but violation of trust makes us powerless and makes it external

• This broken trust might be a reason for very vigorous birth plans

• Examples when trust could be broken:

• lack of confidence in health care providers – ex erratic management of emergency

• lack of consent and communication

trust Communication as

Information

sharing

clear

communication

Perception of

midwife being in

control

Internal locus of

control

Ability to ask

questions

Informational

support

Consent,

personalization

(opposite to

objectification)

Effective

communication

no, fear, no

dissociation,

control

clear

communication

Perception of control: from a mad train to a rollercoaster

Emotion sharing • As you see, a range of stressors in labour lie in the area

of interpersonal communication • Requires emotional intelligence: an ability to empathize,

to understand what the other person is feeling. This skill can be developed

• In the following slides I will introduce some tools that could be useful for emotional support: namely attunement, holding and containment. They have originated in psychotherapy, but recently have been used in health and social care.

Communication as

emotional sharing

Support with

anxiety

Emotional support

Caring

communication

Presence, heard,

supported

Attunement (Rogers,1995): I hear you

• Popularized in health psychology as active listening (Sully and Dallas, 2010)

• Ensures effective communication of both information and emotions

• Facilitates feeling of security and wellbeing

• Helps to establish and maintain rapport

How:

• During the conversation listen carefully for emotional cues

• Reflect both factual and emotional information back to the woman for further development of the conversation

Almost always, when a person realizes he has been deeply heard, his

eyes moisten. I think in some real sence he is weeping for joy. It is as

though he was saying “Thank God, somebody heard me. Someone

knows what it’s like to be me”. In such moments I have had the

fantasy of a prisoner in a dungeon, tapping out day after day Morse

code message, “Does anybody hear me? Is anybody there?” And

finally one day he hear some faint tapping which spell out “Yes”.

(Rogers, 1995)

Holding (Winnicott,1953): you are all right

• Originated from observational studies on relationships between mother and child. Initially a mother fully shelters her infant from the outside stressors, completely adjusting to his/her needs. As the baby grows, the mother gradually reduces level of own adjustment, allowing the child to experience temporary frustrations and learn how to deal with stress in controlled environment.

• In practice used to convey message of safety and acceptance

• Important as in labour the woman could display range of emotions, we need to ensure she feels safe to express them

• This facilitates trust and safe environment for birth

“an environment that holds the baby well enough, the baby is

able to make personal development according to the inherited

tendencies. The result is a continuity of existence that

becomes a sense of existing, a sense of self, and eventually

results in autonomy.”

― D. W. Winnicott, Home Is Where We Start From: Essays

by a Psychoanalyst

Containment (Bion, 1962): what you feel is…

• Also studied relationships between mother and an infant or a young child. Observed how mothers help their babies to manage and process difficult emotions such as fear and anxiety.

• The child would project these emotions to the mother, the mother would process them and “return” them back to the child.

• In practice might help women to process their fillings of fear or frustration in labour and relieve their anxiety: to improve coping and assist with decision making

Patients have taught me that when I allow myself to

feel (even be invaded by) the patient’s own

unbearable feelings, and I can experience this

(paradoxically) as both unbearable and yet bearable,

so that I am still able to find some way of going on, I

can begin to ‘defuse’ the dread in a patient’s most

difficult feelings.

(Casement, 1985)

Summary

• Some women can experience postnatal PTSD. This condition could complicate postnatal recovery and negatively affect the whole family

• Some of vulnerability factors like previous mental health or intrapartum complications are inevitable; however interpersonal aspects such as perception of support could be prevented

• The midwife can reduce these stress factors by being professional, communicating clearly, attuning to the woman’s feelings and helping her to process difficult emotions.

References: 1. American Psychiatric Association (APS) (2013) Diagnostic and statistical manual of mental disorders (5th ed.) Arlington: The American

Psychiatric Publishing 2. Beck, T. (2006) Pentadic Cartography: Mapping Birth Trauma Narratives. Qual Health Res.16(4):453-66. 3. Bion, W.R. (1962b). Learning from Experience. London: Heinemann. Winnicott, D.W. (1963a). From Dependence towards Independence

in the development of the Individual. In The maturational process and the facilitating environment (Ch 7). London & New York: Karnac. 4. Birth Trauma Association (2019) Supporting Parents With Birth Trauma [online] Available at: <

https://www.birthtraumaassociation.org.uk/for-health-professional/supporting-parents-with-birth-trauma > [Accessed 21 January 2019] 5. Cigoli, V., Gilli, G., Saita, E. (2006) Relational factors in psychopathological responses to childbirth. J Psychosom Obstet

Gynaecol.;27(2):91-7. 6. De Schepper S., Vercauteren, T., Tersago, J., Jacquemyn, Y., Raes, F., Franck, E. (2016) Post-traumatic stress disorder after childbirth and

the influence of maternity team care during labour and delivery: A cohort study. Midwifery. Jan;32:87-92. 7. Fahy, K., Foureur, M., Hastie, K. (2008) Birth Territory and Midwifery Guardianship. Edinburgh: Books for Midwives 8. Ford, E., Ayers, S. (2011) Support during birth interacts with prior trauma and birth intervention to predict postnatal post-traumatic

stress symptoms. Psychol Health. 26(12):1553-70. 9. Hall (2011) ‘Containing the container’: an exploration of the mother–midwife relationship. Infant Observation: International Journal of

Infant Observation and Its Applications Volume 14, Issue 2 10. Harris, R., Ayers, S. (2012) What makes labour and birth traumatic? A survey of intrapartum 'hotspots'. Psychol Health. 27(10):1166-77 11. NICE (2018) Post-traumatic stress disorder [online] Available at: < https://www.nice.org.uk/guidance/ng116/chapter/Recommendations>

[Accessed 21 January 2019] 12. Rogers, C. (1995) A way of being Boston: Houghton Mifflin Co. 13. Sully, P., Dallas, J. (2010) Essential communication skills for nursing and midwifery. Edinburgh: Mosby Elsevier 14. Walker, J. (2001) Control and the psychology of health: theory, measurement, and applications Buckingham: Open University

15. Winnicott, D.W. (1963). From Dependence towards Independence in the development of the Individual. In The maturational process and the facilitating environment (Ch 7). London & New York: Karnac.