Research Update July – September 2019

Prevalence of Post-Traumatic Stress Disorder Following Caesarean Section: A Systematic Review and Meta-Analysis.

J Womens Health (Larchmt). 2019 Sep 18. doi: 10.1089/jwh.2019.7750. [Epub ahead of print]
Chen Y1Yang X2Guo C3Liao Y4Guo L1Chen W5Chen I4,6Krewski D7,8Wen SW4,6,8Xie RH1.
Background: While caesarean section (CS) can be a lifesaving intervention when performed in a timely manner to overcome dystocia or other complications, it is a traumatic event and may increase the risk of post-traumatic stress disorder (PTSD). No attempt has been made to assess prevalence of PTSD after CS specifically. This study aimed to quantify pooled prevalence of PTSD after CS through a systematic review and meta-analysis. Methods: MEDLINE, PsycINFO, EMBASE, and CINAHL were searched using PTSD terms crossed with CS terms. Studies were included if they reported the prevalence of PTSD after CS using an instrument based on Diagnostic and Statistical Manual of Mental Disorders-criteria to identify PTSD. The pooled prevalence was then estimated by meta-analysis in overall eligible studies and in subgroups. Results: Nine studies were included with a total of 1,134 postpartum women, of which 136 were identified as having PTSD. Pooled prevalence of PTSD after CS was 10.7% (95% confidence interval [CI]: 4.0-20.2). Pooled prevalence of PTSD after emergency CS (10.3% [95% CI: 1.7-24.9]) was higher than that after elective CS (7.1% [95% CI: 0.7-19.4]), but the difference was not statistically significant. Subgroup analysis showed that pooled prevalence of PTSD after CS differed according to study setting, time interval of PTSD assessment, and type of participants. Meta-regression analysis showed that study setting and type of study participants were significant sources of heterogeneity. Conclusions: Women with CS apparently have higher rates of PTSD as compared with women without CS. However, the susceptibility to PTSD appears to vary based on emergency/elective CS, study methodology, self-perceived traumatic birth, and country of study. Further targeted research is needed to elucidate the role of these factors in relationship between CS and PTSD.
KEYWORDS: caesarean section; meta-analysis; post-traumatic stress disorder; prevalence

Postnatal Debriefing: women’s need to talk after birth

British Journal of Midwifery VOL. 27, NO. 9   doi10.12968/bjom.2019.27.9.563
Jackie Baxter
Background: There is a lack of evidence of the clinical benefit of postnatal debriefing, but qualitative studies show that women value talking to a midwife after birth. However, a very small proportion of women accepted a postnatal discussion meeting at the district general hospital where the author worked.
Aim: To determine why some women need to talk to a professional after giving birth.
Method: A postal survey was sent to a sample of 447 women who gave birth during one calendar month at an NHS Trust in England. This instrument also included the impact of events scale (IES), which assessed women’s feelings in relation to their recent experience of giving birth. A total of 170 women (38%) returned the completed form.
Findings: Some women need to talk about their birth experience after they have left the hospital. Women with symptoms of post-traumatic stress (PTS), measured by a high IES, were more likely to want to talk after giving birth and more likely to rate their experience of birth negatively, compared with those with a low IES. Approximately one-third of women who responded experienced high PTS symptoms.
Conclusions: Maternity providers should consider offering a postnatal listening service to meet women’s needs in relation to understanding their experience of giving birth. This will also serve to identify women with PTS symptoms and offer further support.

Mothers’ Experiences Interacting with Infants after Traumatic Childbirth.

MCN Am J Matern Child Nurs. 2019 Aug 28. doi: 10.1097/NMC.0000000000000565. [Epub ahead of print]
Beck CT1Watson S.
PURPOSE: The purpose of this study is to describe experiences of mothers interacting with their infants after traumatic childbirth.
STUDY DESIGN AND METHODS: A descriptive phenomenological method guided by Dahlberg, Dahlberg, and Nystrom’s reflective lifeworld research was used. Women were recruited through Trauma and Birth Stress (TABS), a charitable trust in New Zealand, whose mission is to provide support for women who have experienced traumatic childbirth. Data were collected via an electronic survey. Women were asked to describe how their traumatic births impacted their caring for and interactions with their infants and any other children they may have.
RESULTS: Eighteen women representing six countries across the globe participated. Four constituents of mothers’ experiences interacting with their infants after traumatic births were identified: feelings of numbness and detachment, crying and anger, distressing cognitive changes, and limited outside social interactions.
CLINICAL IMPLICATIONS: To help women struggling with the aftermath of their traumatic birth, nurses first need to identify them. Clinicians need to be attentive to symptoms such as a withdrawn, dazed look, and appearing distanced from their infants. Prior to hospital discharge after childbirth, women should be given opportunities to share their perceptions of their birth to determine if they view it as traumatic. Interventions should be started as soon as possible in this fragile mother-infant dyad to prevent long-term consequences.

The oxytocinergic system in PTSD following traumatic childbirth: endogenous and exogenous oxytocin in the peripartum period.

Arch Womens Ment Health. 2019 Aug 6. doi: 10.1007/s00737-019-00994-0. [Epub ahead of print]
Witteveen AB1Stramrood CAI2Henrichs J3Flanagan JC4van Pampus MG5Olff M6,7.
Birth experiences can be traumatic and may give rise to PTSD following childbirth (PTSD-FC). Peripartum neurobiological alterations in the oxytocinergic system are highly relevant for postpartum maternal behavioral and affective adaptions like bonding and lactation but are also implicated in the response to traumatic events. Animal models demonstrated that peripartum stress impairs beneficial maternal postpartum behavior. Early postpartum activation of the oxytocinergic system may, however, reverse these effects and thereby prevent adverse long-term consequences for both mother and infant. In this narrative review, we discuss the impact of trauma and PTSD-FC on normal endogenous oxytocinergic system fluctuations in the peripartum period. We also specifically focus on the potential of exogenous oxytocin (OT) to prevent and treat PTSD-FC. No trials of exogenous OT after traumatic childbirth and PTSD-FC were available. Evidence from non-obstetric PTSD samples and from postpartum healthy or depressed samples implies restorative functional neuroanatomic and psychological effects of exogenous OT such as improved PTSD symptoms and better mother-to-infant bonding, decreased limbic activation, and restored responsiveness in dopaminergic reward regions. Adverse effects of intranasal OT on mood and the increased fear processing and reduced top-down control over amygdala activation in women with acute trauma exposure or postpartum depression, however, warrant cautionary use of intranasal OT. Observational and experimental studies into the role of the endogenous and exogenous oxytocinergic system in PTSD-FC are needed and should explore individual and situational circumstances, including level of acute distress, intrapartum exogenous OT exposure, or history of childhood trauma.
KEYWORDS: Childbirth; Functional neuroanatomical; Oxytocin; PTSD; Psychological; Trauma

Measuring and conceptualizing PTSD following childbirth: Validation of the City Birth Trauma Scale.

Psychol Trauma. 2019 Aug 1. doi: 10.1037/tra0000501. [Epub ahead of print]
Nakić Radoš S1Matijaš M1Kuhar L1Anđelinović M1Ayers S2.
OBJECTIVE: City Birth Trauma Scale is a recently developed scale specifically designed for evaluation of posttraumatic stress disorder (PTSD) following childbirth based on the DSM-5 criteria (Ayers, Wright, & Thornton, 2018). Previous studies showed a two-factor structure of PTSD symptoms in postpartum women; however, more complex models were not tested. This study aimed to validate the Croatian version of the City Birth Trauma Scale and determine the latent factor structure of postpartum PTSD.
METHOD: In a cross-sectional study, 603 women completed online questionnaires comprising the City Birth Trauma Scale, Impact of Event Scale-Revised (IES-R), Edinburgh Postnatal Depression Scale (EPDS), and the anxiety subscale from the Depression, Anxiety, and Stress Scale (DASS-21).
RESULTS: Confirmatory factor analysis confirmed the bifactor model of birth-related symptoms and general symptoms had an excellent fit to the data. Both subscales and the total scale showed high internal consistency (α = .92). Convergent and divergent validity testing showed high validity, especially for birth-related symptoms. Discriminant validity was confirmed with primiparous women and women who gave birth by instrumental vaginal delivery and emergency caesarean section having significantly higher scores on birth-related symptoms, but not on general symptoms, suggesting high discriminant validity of the birth-related symptoms subscale.
CONCLUSIONS: The City Birth Trauma Scale is a reliable and valid measure. Both total scale score and subscale scores can be calculated. It is highly recommended for use in postpartum population.

Posttraumatic stress disorder in partners following severe postpartum haemorrhage: A prospective cohort study.

Women Birth. 2019 Jul 13. pii: S1871-5192(18)31729-3. doi: 10.1016/j.wombi.2019.06.016. [Epub ahead of print]
van Steijn ME1Scheepstra KWF2Zaat TR3van der Post JAM3Olff M4van Pampus MG5.
BACKGROUND: Partners of women are increasingly present during childbirth and may be exposed to a traumatic experience. Since parents’ mental health issues (i.e. posttraumatic stress disorder) have been shown to increase the risk of problems in the child’s development, it is important to identify these risk factors. Partners often describe severe postpartum haemorrhage as traumatic.
AIM: Whether witnessing severe postpartum haemorrhage is a risk factor for developing posttraumatic stress disorder in partners.
METHODS: In this prospective cohort study, we compared partners of women with severe postpartum haemorrhage (≥2000 mL) and partners of women with ≤500 mL of blood loss (controls). Four weeks after birth partners were screened for posttraumatic stress disorder symptoms with a self-report questionnaire. Scores ≥11 were followed by a gold standard clinical interview to diagnose posttraumatic stress disorder.
FINDINGS: We included 123 severe postpartum haemorrhage partners and 62 control partners. Partners of women with severe postpartum haemorrhage reported higher scores than control partners (median 3.0 (0.0-7.0) vs 2.0 (0.0-4.0), p = 0.04) on symptoms of posttraumatic stress, but no significant difference in probable posttraumatic stress disorder diagnosis according to the self-report questionnaire was found. According to the clinical interview no partners were diagnosed with posttraumatic stress disorder. Severe postpartum haemorrhage was experienced as traumatic by the partners who felt excluded.
CONCLUSION: None of the partners developed posttraumatic stress disorder, revealing the resilience of young fathers. Because some partners reported severe postpartum haemorrhage as traumatic, we recommend sufficient information and support is provided during childbirth.
KEYWORDS: Childbirth; DSM-5; Partners; Posttraumatic stress disorder; Psychotrauma; Severe postpartum haemorrhage

The effects of Psychoeducation on the Traumatic Perception of the Birth Phenomenon in women with Substance-use Disorders.

Subst Use Misuse. 2019;54(12):2066-2074. doi: 10.1080/10826084.2019.1618335. Epub 2019 Jul 3.
Yalnız Dilcen H1,2Genc R3.
Objective: The present study evaluates the traumatic perception of the birth phenomenon in women with substance-use disorders (SUD) and to investigate the effects of psychoeducation on this perception. Material and Methods: The study was conducted between January and July 2017, and involved 60 women with SUD who were divided into two groups: intervention (n = 30) and control (n = 30). The study was carried out using the semi-experimental “pre-post test matched group model,” and the Traumatic Perception of Birth Psychoeducation Program (TPBPP) was applied. Results: Traumatic birth perception was found to be decreased after TPBPP was applied in four modules to women with SUD. Conclusion: TPBPP is an effective psychoeducation model in the reduction of the traumatic perception of birth in women with SUD. Keywords: Traumatic perception of birth; substance use disorder; woman

Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth.

J Obstet Gynecol Neonatal Nurs. 2019 Jul;48(4):385-397. doi: 10.1016/j.jogn.2019.02.004. Epub 2019 Apr 5.
Beck CTCasavant S.
OBJECTIVE: To synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births.
DATA SOURCES: PubMed, Scopus, and PsycINFO databases.
STUDY SELECTION: Quantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth.
DATA EXTRACTION: The final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis.
DATA SYNTHESIS: In the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women’s Relationships With Their Infants and Partners, Critical Influence ofSupport, and Debriefing.
CONCLUSION: When a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.
Copyright © 2019 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
KEYWORDS: PTSD; mixed research synthesis; posttraumatic; stress disorder; traumatic birth

The association between the degree of nausea in pregnancy and subsequent posttraumatic stress.

Arch Womens Ment Health. 2019 Aug;22(4):493-501. doi: 10.1007/s00737-018-0909-z. Epub 2018 Sep 17.
Kjeldgaard HK1,2Vikanes Å3Benth JŠ4,5Junge C6,7Garthus-Niegel S6,8Eberhard-Gran M4,5,6.
Hyperemesis gravidarum (HG) is a pregnancy condition characterised by severe nausea and vomiting during early pregnancy. The experience of HG is for many women a traumatic event. Few studies have investigated a possible association between HG and birth-related posttraumatic stress. The objective of the current study was to assess whether HG increases the risk of birth-related posttraumatic stress symptoms (PTSS). This was a population-based pregnancy cohort study using data from the Akershus Birth Cohort Study (ABC study). A linear mixed model was used to estimate the association between the degree of nausea (no nausea (n = 574), mild nausea (n = 813), severe nausea (n = 522) and HG (hospitalised due to nausea, n = 20)) and PTSS score at 8 weeks and 2 years after birth. At 8 weeks postpartum, women with HG had higher PTSS scores compared to women with no nausea (p = 0.008), women with mild nausea (p = 0.019) and women with severe nausea (p = 0.027). After 2 years, women with HG had higher PTSS scores compared to women with no nausea (p = 0.038). Women with HG had higher PTSS scores following childbirth compared to women with less pronounced symptoms or no nausea at all. After 2 years, women with HG still had higher PTSS scores compared to women with no nausea. Although the overall differences in PTSS scores were small, the results may still be of clinical relevance.
KEYWORDS: Hyperemesis gravidarum; Mental health; Nausea and vomiting; Posttraumatic stress disorder; Pregnancy

One Response

  1. Maureen Treadwell at |

    With reference to the Chen study, and at the risk of sounding like a parrot 🙂 and repeating the same message over and over again, please can researchers separate emergency caesareans from planned pre labour sections. They are entirely different. In one, (planned) birth proceeds in most cases as the woman expects in the other, emergency cs is usually not what the woman expects. In planned, the woman is normally well at commencement of birth, in EMCS, the woman may already be partially mentally and physically exhausted. Planned is carried out on a non-contracting uterus and is a simple operation, EMCS if carried out on a contracting uterus with a baby wedged deep in the pelvis can be a challenging and traumatic operation. There is NO comparison and lumping them together (even in abstracts) ends up with research that tells us very little. Sorry to sound critical and I am sure researchers have worked very hard on this projec but we make this point over and over again and feeling slightly unheard – yet everyone I speak to is making the same point!


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