January 2018-February 2018 Research Update

Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units.

Arch Womens Ment Health. 2017 Dec 19. doi: 10.1007/s00737-017-0802-1

Skinner EMBarnett BDietz HP.


Vaginal birth may result in damage to the levator ani muscle (LAM) with subsequent pelvic floor dysfunction and there may be accompanying psychological problems. This study examines associations between these somatic injuries and psychological symptoms. A qualitative study using semi-structured interviews to examine the experiences of primiparous women (n = 40) with known LAM trauma was undertaken. Participants were identified from a population of 504 women retrospectively assessed by a perinatal imaging study at two obstetric units in Sydney, Australia. LAM avulsion was diagnosed by 3D/4D translabial ultrasound 3-6 months postpartum. The template consisted of open-ended questions. Main outcome measures were quality of information provided antenatally; intrapartum events; postpartum symptoms; and coping mechanisms. Thematic analysis of maternal experiences was employed to evaluate prevalence of themes. Ten statement categories were identified: (1) limited antenatal education (29/40); (2) no information provided on potential morbidities (36/40); (3) conflicting advice (35/40); (4) traumatized partners (21/40); (5) long-term sexual dysfunction/relationship issues (27/40); (6) no postnatal assessment of injuries (36/40); (7) multiple symptoms of pelvic floor dysfunction (35/40); (8) “putting up” with injuries (36/40); (9) symptoms of post-traumatic stressdisorder (PTSD) (27/40); (10) dismissive staff responses (26/40). Women who sustain LAM damage after vaginal birth have reduced quality of life due to psychological and somatic morbidities. PTSD symptoms are common. Clinicians may be unaware of the severity of this damage. Women report they feel traumatized and abandoned because such morbidities were not discussed prior to birth or postpartum.



Women’s experiences of living with postnatal PTSD.

Midwifery. 2018 Jan;56:70-78. doi: 10.1016/j.midw.2017.09.019.

Peeler SStedmon JChung MCSkirton H.


the mental health of new mothers is a public health concern as it is likely to have an impact on the mother herself, her close relationships and the behavioural and emotional health of her children. Post-traumatic stress disorder affects some women after childbirth.


the aim of this study was to explore how women were affected by the memories of a birth that they perceived as traumatic.


in this paper the authors report the qualitative analysis of interview data from seven postnatal women reporting symptoms of PTSD. Participants were recruited from a large NHS Trust in the South West of England. Thematic analysis was used to analyse interview data collected from the seven women reporting symptoms of postnatal PTSD.


complicating factors such as relationship difficulties and pre-existing health problems appeared to contribute to postnatal post-traumatic stress disorder and some women reported difficulty expressing emotions. The study findings confirm that women value good relationships with midwives during labour.


antenatal screening for personality traits such as alexithymia (difficulty expressing emotions) may be useful and midwives should be alert to current life events that may increase women’s vulnerability to post-traumatic stress disorder.



Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review.

J Affect Disord. 2018 Jan 1;225:18-31. doi: 10.1016/j.jad.2017.07.045.

Cook NAyers SHorsch A.



Approximately 3.3% of women in pregnancy have posttraumatic stress disorder (PTSD) and 4% of women postpartum PTSD. The impact of maternal PTSD during the perinatal period (from conception until one year postpartum) on child outcomes has not been systematically examined.


A systematic review was conducted to synthesize and critically evaluate quantitative research investigating the association between perinatal PTSD and child outcomes. Databases EMBASE, BNI, Medline, PsycInfo and CINAHL were searched using specific inclusion and exclusion criteria.


26 papers reporting 21 studies were identified that examined associations between perinatal PTSD and postpartum birth outcomes, child development, and mother-infant relationship. Studies reviewed were heterogeneous, with poor-to-medium scores of methodological quality. Results showed that maternal postpartum PTSD is associated with low birth weight and lower rates of breastfeeding. Evidence for an association between maternal PTSD and preterm birth, fetal growth, head circumference, mother-infant interaction, the mother-infant relationship or child development is contradictory. Associations between maternal PTSD and infant salivary cortisol levels, and eating/sleeping difficulties are based on single studies, so require replication.


Methodological weaknesses of the studies included insufficient sample size, use of invalidated measures, and limited external validity.


Findings suggest that perinatal PTSD is linked with some negative child outcomes. Early screening for PTSD during the perinatal period may be advisable and onward referral for effective treatment, if appropriate. Future research using larger sample sizes, validated and reliable clinical interviews to assess PTSD, and validated measures to assess a range of child outcomes, is needed.


Postnatal post-traumatic stress: An integrative review.

Women Birth. 2018 Jan 11. pii: S1871-5192(17)30475-4. doi: 10.1016/j.wombi.2017.12.003.

Simpson MSchmied VDickson CDahlen HG.



Post-traumatic stress disorder and post-traumatic stress symptoms following birth occur amongst a small proportion of women but can lead to poor maternal mental health, impairment in mother-infant bonding and relationship stress. This integrative review aims to examine the associated risk factors and women’s own experiences of postnatal post-traumatic stress in order to better understand this phenomenon.


Fifty three articles were included and critically reviewed using the relevant Critical Appraisal Skills Program checklists or Strengthening the Reporting of Observational studies in Epidemiology assessment tool.


Risk factors for postnatal post-traumatic stress symptoms and disorder include factors arising before pregnancy, during the antenatal period, in labour and birth and in the postnatal period. Potential protective factors against postnatal post-traumatic stress have been identified in a few studies. The development of postnatal post-traumatic stress can lead to negative outcomes for women, infants and families.


Risk factors for post-traumatic stress symptoms and disorder are potentially identifiable pre-pregnancy and during the antenatal, intrapartum and postnatal periods. Potential protective factors have been identified however they are presently under researched. Predictive models for postnatal post-traumatic stress disorder development have been proposed, however further investigation is required to test such models in a variety of settings.


Postnatal post-traumatic stress symptoms and disorder have been shown to negatively impact the lives of childbearing women. Further investigation into methods and models for identifying women at risk of developing postnatal post-traumatic stress following childbirth is required in order to improve outcomes for this population of women.



Preventing Posttraumatic Stress Disorder following childbirth and traumatic birth experiences: A systematic review.

Acta Obstet Gynecol Scand. 2018 Jan 16. doi: 10.1111/aogs.13291.

de Graaff LFHonig Avan Pampus MGStramrood CAI.



Between 9 and 44% of women experience giving birth as traumatic, and 3% of women develop a posttraumatic stress disorder following childbirth. Knowledge on risk factors is abundant, but studies on treatment are limited. This study aimed to present an overview of means to prevent traumatic birth experiences and childbirth-related posttraumatic stress disorder.


Major databases (Cochrane; Embase; PsycINFO; PubMed (Medline)) were searched using combinations of the key words and their synonyms.


After screening titles and abstracts and reading 135 full-text articles, 13 studies were included. All evaluated secondary prevention, and none primary prevention. Interventions included debriefing, structured psychological interventions, expressive writing interventions, encouraging skin-to-skin contact with healthy newborns directly postpartum and holding or seeing the newborn after stillbirth. The large heterogeneity of study characteristics precluded pooling of data. The writing interventions to express feelings appeared to be effective in prevention. A psychological intervention including elements of exposure and psycho-education seemed to lead to fewer posttraumatic stress disorder symptoms in women who delivered via emergency cesarean section.


No research has been done on primary prevention of traumatic childbirth. Research on secondary prevention of traumaticchildbirth and posttraumatic stress disorder following delivery provides insufficient evidence that the described interventions are effective in unselected groups of women. In certain subgroups, results are inhomogeneous.



Birth experiences, trauma responses and self-concept in postpartum psychotic-like experiences.

Schizophr Res. 2018 Feb 2. pii: S0920-9964(17)30767-3. doi: 10.1016/j.schres.2017.12.015.

Holt LSellwood WSlade P.


The frequency of psychotic-like experiences (PLEs) amongst new mothers is beginning to be explored but the mechanisms underlying such experiences are yet to be understood. First time mothers (N=10,000) receiving maternity care via the UK National Health Service were contacted postnatally via Emma’s Diary, an online resource for mothers. Measures assessed birth experience, trauma appraisals, post-traumatic stress symptoms, adjustment to motherhood, self-concept clarity and PLEs (in the form of hallucinations and delusions). There was a 13.9% response rate (N=1393) and 1303 participants reported experiencing at least one PLE (93.5%). Three competing nested path models were analysed. A more negative birth experience directly predicted delusions, but not hallucinations. Trauma appraisals and poorer adjustment to motherhood indirectly predicted PLEs, via disturbed self-concept clarity. Post-traumatic stress symptoms directly predicted the occurrence of all PLEs. PLEs in first time mothers may be more common than previously thought. A key new understanding is that where new mothers have experienced birth as traumatic and are struggling with adjustment to their new role, this can link to disturbances in a coherent sense of self (self-concept clarity) and be an important predictor of PLEs. Understanding the development of PLEs in new mothers may be helpful in postnatal care, as would public health interventions aimed at reducing the sense of abnormality or stigma surrounding such experiences.




Infant Ment Health J. 2018 Feb 27. doi: 10.1002/imhj.21695

S Hairston IE Handelzalts JAssis CKovo M.


Despite decades of research demonstrating the role of adult attachment styles and early mother-infant bonding in parenting behaviors and maternal mental health, these constructs have seldom been studied together. The present study aimed to investigate the relationship between attachment styles and specific bonding difficulties of mothers. In addition, as postpartum depression and childbirth-related posttraumatic stress symptoms have been associated with both constructs, we explored their possible mediation effect. One hundred fourteen mothers, 4 to 12 weeks’ postpartum, completed a demographic questionnaire, the Adult Attachment Style Questionnaire (M. Mikulincer, V. Florian, & A. Tolmacz, 1990), the Postpartum Bonding Questionnaire (L.F. Brockington, C. Fraser, & D. Wilson, 2006), the Modified Perinatal Posttraumatic Stress Disorder Questionnaire (J.L. Callahan, S.E. Borja, & M.T. Hynan, 2006), and the Edinburgh PostnatalDepression Scale (J.L. Cox, G. Chapman, D. Murray, & P. Jones, 1996), using an online survey system. As predicted, insecure attachment styles were associated with bonding difficulties wherein anxious/ambivalent attachment was associated with greater infant-focused anxiety, mediated by postpartum depression but not childbirth-related PTSD symptoms. In contrast, greater avoidant attachment style was associated with greater rejection and anger, mediated by childbirth-related posttraumatic stress disorder (PTSD), but not depression symptoms. The current study confirmed the association of different attachment styles with bonding as well as the mediating roles of childbirth-related PTSDand postpartum depression symptoms. Future psychological interventions may utilize such evidence to target interventions for bonding disorders in accordance with individual differences.



Just another ordinary bad birth? A narrative analysis of first time mothers’ traumatic birth experiences.

Health Care Women Int. 2018 Feb 23:1-43. doi: 10.1080/07399332.2018.1442838.

Murphy HStrong J.


A difficult birth experience can have long lasting psychological effects on both mother and baby and this study details 4 in-depth accounts of first time mothers who described their birth experience as traumatizing. Narrative analysis was used to record discrepancies between the ideal and the real and produced narrative accounts that highlighted how these mothers felt invisible and dismissed in a medical culture of engineering obstetrics. Participants also detailed how their birth experience could be improved and this is set in context alongside current recommendations in maternal health care and the complexities of delivering such care in UK health settings.



The impact of childbirth-related post-traumatic stress on a couple’s relationship: a systematic review and meta-synthesis


  1. Delicate,S. Ayers ,A. Easter&S. McMullen


Objective: This review aimed to identify the impact of childbirth-related post-traumatic stress disorder (PTSD) or symptoms (PTSS) on a couple’s relationship.

Background: Childbirth can be psychologically traumatic and can lead to PTSD. There is emerging evidence that experiencing a traumatic birth can affect the quality of the couple’s relationship. This is an important issue because poor-quality relationships can impact on the well-being of partners, their parenting and the welfare of the infant.

Methods: A systematic search was conducted of Amed, CENTRAL, Cinahl, Embase, Maternity and Infant Care, Medline, MITCognet, POPLINE, PsycARTICLES, PsycBITE, PsycINFO, Pubmed and Science Direct. Additionally, grey literature, citation and reference searches were conducted. Papers were eligible for inclusion if they reported qualitative data about parents who had experienced childbirth and measures of PTSD or PTSS and the relationship were taken. Analysis was conducted using meta-ethnography.

Results: Seven studies were included in the meta-synthesis. Results showed that childbirth-related PTSD or PTSS can have a perceived impact on the couple’s relationship and five themes were identified: negative emotions; lack of understanding and support; loss of intimacy; strain on the relationship; and strengthened relationships. A model of proposed interaction between these themes is presented.

Conclusions: The impact of childbirth-related PTSD or PTSS on the couple’s relationships is complex. As the quality of the couple relationship is important to family well-being, it is important that healthcare professionals are aware of the impact of experiencing psychologically traumatic childbirth as impetus for prevention and support.



Gestational and Postnatal Cortisol Profiles of Women With Posttraumatic Stress Disorder and the Dissociative Subtype.

J Obstet Gynecol Neonatal Nurs. 2018 Jan;47(1):12-22. doi: 10.1016/j.jogn.2017.10.008

Seng JSLi YYang JJKing APLow LMKSperlich MRowe HLee HMuzik MFord JDLiberzon I.



To test the hypothesis that women with posttraumatic stress disorder (PTSD) have greater salivary cortisol levels across the diurnal curve and throughout gestation, birth, and the postpartum period than women who do not have PTSD.


Prospective, longitudinal, biobehavioral cohort study.


Prenatal clinics at academic health centers in the Midwest region of the United States.


Women expecting their first infants who fit with one of four cohorts: a nonexposed control group, a trauma-exposed control group, a group with PTSD, and a group with the dissociative subtype of PTSD.


In the first half of pregnancy, 395 women provided three salivary cortisol specimens on a single day for diurnal data. A subsample of 111 women provided three salivary cortisol specimens per day, 12 times, from early pregnancy to 6 weeks postpartum for longitudinal data. Trauma history, PTSD, and dissociative symptoms were measured via standardized telephone diagnostic interviews with the use of validated epidemiologic measures. Generalized estimating equations were used to determine group differences.


Generalized estimating equations showed that women with the dissociative subtype of PTSD had the highest and flattest gestational cortisol level curves. The difference was greatest in early pregnancy, when participants in the dissociative subtype group had cortisol levels 8 times greater in the afternoon and 10 times greater at bedtime than those in the nonexposed control group.


Women with the dissociative subtype of PTSD, a complex form associated with a history of childhood maltreatment, may have toxic levels of cortisol that contribute to intergenerational patterns of adverse health outcomes.



Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy.

Br J Psychiatry. 2018 Jan;212(1):50-56. doi: 10.1192/bjp.2017.9.

Howard LMRyan EGTrevillion KAnderson FBick DBye AByford SO’Connor SSands PDemilew JMilgrom JPickles A.



There is limited evidence on the prevalence and identification of antenatal mental disorders. Aims To investigate the prevalence of mental disorders in early pregnancy and the diagnostic accuracy of depression-screening (Whooley) questions compared with the Edinburgh Postnatal Depression Scale (EPDS), against the Structured Clinical Interview DSM-IV-TR.


Cross-sectional survey of women responding to Whooley questions asked at their first antenatal appointment. Women responding positively and a random sample of women responding negatively were invited to participate.


Population prevalence was 27% (95% CI 22-32): 11% (95% CI 8-14) depression; 15% (95% CI 11-19) anxiety disorders; 2% (95% CI 1-4) obsessive-compulsive disorder; 0.8% (95% CI 0-1) post-traumatic stress disorder; 2% (95% CI 0.4-3) eating disorders; 0.3% (95% CI 0.1-1) bipolar disorder I, 0.3% (95% CI 0.1-1%) bipolar disorder II; 0.7% (95% CI 0-1) borderline personality disorder. For identification of depression, likelihood ratios were 8.2 (Whooley) and 9.8 (EPDS). Diagnostic accuracy was similar in identifying any disorder (likelihood ratios 5.8 and 6).


Endorsement of Whooley questions in pregnancy indicates the need for a clinical assessment of diagnosis and could be implemented when maternity professionals have been appropriately trained on how to ask the questions sensitively, in settings where a clear referral and care pathway is available.



There is more to perinatal mental health care than depression: Public health nurses reported engagement and competence in perinatal mental health care.

J Clin Nurs. 2018 Feb;27(3-4):e476-e487. doi: 10.1111/jocn.13986.

Higgins ADownes CCarroll MGill AMonahan M.



To explore public health nurses’ engagement, competence and education needs in relation to perinatal mental health care in Ireland.


It is estimated that 15%-25% of women will experience a mental health problem during or postpregnancy, either as a new problem or a reoccurrence of a pre-existing problem. Public health nurses, or their equivalent, are ideally positioned to support women’s mental health and improve health outcomes for the woman and baby, yet little is known about their role and engagement with mental health issues, other than with postnatal depression. The objectives of the study were to identify public health nurses’ knowledge, skills and current practices in perinatal mental health and establish their education needs.


The research used a descriptive design.


A total of 186 public health nurses completed an anonymous, online survey, designed by the research team.


While public health nurses are positive about their role in supporting women’s mental health, they lack the knowledge and skills to address all aspects of mental health, including opening a discussion with women on more sensitive or complex issues, such as trauma and psychosis and providing information to women. Those who received education reported statistically significant higher knowledge and confidence scores than those without.


Public health nurses lack the knowledge and skills required to provide comprehensive perinatal mental health care to women. Future education programmes need to move beyond postnatal depression and address the range of mental health problems that may impact on women in the perinatal period.


Without knowledge and skill among nurses in all aspects of perinatal mental health, women with significant mental health needs may be left to cope alone and lack the necessary prompt evidence-based interventions and supports.



The Perfect Storm of Trauma: The experiences of women who have experienced birth trauma and subsequently accessed residential parenting services in Australia.

Women Birth. 2018 Feb;31(1):17-24. doi: 10.1016/j.wombi.2017.06.007.

Priddis HSKeedle HDahlen H.



There appears to be a chasm between idealised motherhood and reality, and for women who experience birth trauma this can be more extreme and impact on mental health. Australia is unique in providing residential parenting services to support women with parenting needs such as sleep or feeding difficulties. Women who attend residential parenting services have experienced higher rates of intervention in birth and poor perinatal mental health but it is unknown how birth trauma may impact on early parenting.


This study aims to explore the early parenting experiences of women who have accessed residential parenting services in Australia and consider their birth was traumatic.


In-depth interviews were conducted with eight women across Australia who had experienced birth trauma and accessed residential parenting services in the early parenting period. These interviews were conducted both face to face and over the telephone. The data was analysed using thematic analysis.


One overarching theme was identified: “The Perfect Storm of Trauma” which identified that the participants in this study who accessed residential parenting services were more likely to have entered pregnancy with pre-existing vulnerabilities, and experienced a culmination of traumatic events during labour, birth, and in the early parenting period. Four subthemes were identified: “Bringing Baggage to Birth”, “Trauma through a Thousand Cuts”, “Thrown into the Pressure Cooker”, and “Trying to work it all out”.


How women are cared for during their labour, birth and postnatal period impacts on how they manage early parenthood. Support is crucial for women, including practical parenting support, and emotional support by health professionals and peers.



A Model to Predict Birth Stress in Adolescents Within 72 Hours of Childbirth.

ANS. Advances in Nursing Science [22 Feb 2018]

Anderson CA  Connolly JP 


An organizing framework for understanding adolescent birth stress in immediate postpartum does not exist. Researchers evaluated adolescent birth stress within 72 hours postpartum via a modification of Slade’s conceptual model of risk factors for posttraumatic stress (PTS). Birth stress was defined by negative birth appraisal and subjective distress. Precipitating factors pain management, partner presence, and delivery type, plus maintaining factor infant complications, predicted negative birth appraisal. Predisposing factors depression and prior trauma predicted subjective distress. Findings support utility of Slade’s modified model of PTS risk factors for identification of adolescent early birth stress and generate nursing practice and research implications.



One Response

  1. Dr Elizabeth Skinner at |

    The following paper has the wrong URL attached to it:

    Skinner EM, Barnett B, Dietz HP. Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units. Arch Womens Ment Health. 2017 Dec 19. doi: 10.1007/s00737-017-0802-1

    To download the complete paper this is the correct URL:


    Kind regards
    Dr Elizabeth Skinner [author]


Leave a Reply

Skip to toolbar