In , German obstetrician Friedrich Benjamin Osiander wrote a detailed description of what he termed "puerperal mania," and recognition of the possible connection between childbirth and mental illness grew.
Applying postpartum psychosis as a diagnosis is controversial in the modern medical community, where there is some controversy over whether it is, in fact, an independent condition, or if childbirth triggers psychotic episodes in women who were already predisposed.
A study from medical doctors at the University of Pittsburgh, Western Psychiatric Institute, and the University of Massachusetts Medical School, published in the "Journal of Women's Health," proposed that postpartum psychosis was actually bipolar disorder surfacing due to a drastic change in hormone levels after delivery, quoting data that showed up to 88 percent of postpartum psychosis sufferers could be diagnosed with a bipolar or "schizoaffective" disorder.
Sabine McKellen began her career teaching English as a Second Language to adults from around the world. Manic symptoms can include having high levels of energy, racing thoughts and talking quickly.
Mania can make It very difficult for a mother to concentrate, and her moods may change in a short space of time. The depressed symptoms are quite the opposite to mania symptoms. A mother will have little or no energy, and have negative thinking about herself and life in general. Often people with depression describe feeling helpless, hopeless and worthless, and they may doubt themselves and their ability as a mother.
I became euphoric immediately after birth…I had never been SO happy, then I became manic, shopping for baby clothes and decorating the nursery, but by day 13 I had an emotional breakdown and became psychotic and suicidal. Experiencing or seeing these symptoms can be very distressing — both for the mother herself as well as for the partner and other family members.
At times like this it is important to remember that these symptoms are all part of the condition, and these can be treated and managed with the right treatment. Seeking urgent professional help from a GP, mental health service or hospital emergency department is vital. Delays in identification and treatment can result mean that treatment becomes longer and more complex, and there can be significant safety risks for both the mother and her baby.
Partners and family members are likely to have to take the lead in accessing treatment, as the condition can make it very confusing for the mother — making it difficult for her to see things in perspective.
J Reprod Infant Psychol. Neurosci Biobehav Rev. Fatimah Mohamied. View articles. Postpartum or puerperal psychosis is an acute mood disorder requiring close specialist care. It is a disorder that is rare and poorly understood, but has devastating consequences. This work retrospectively describes the case study of a young woman who suffered postpartum psychosis following the birth of her first child.
A critical appraisal of the care received follows this, focusing specifically on the postnatal period when she was most affected. It was found that critical information was not unearthed at the initial booking appointment, nor were her presenting symptoms recognised in a timely manner; detailing a need for greater training among midwives and care givers regarding early recognition and referral for postpartum psychosis.
Postpartum or puerperal psychosis is a severe mood disorder characterised by acute onset manic or affective psychosis Dias and Jones, , usually within 2 weeks after childbirth Norhayati et al, This may overlap with depression and often fluctuates before full recovery is achieved Dias and Jones, Symptoms include agitation, insomnia, and thought processes that are eccentric, deviated and disorganised, with delusions and hallucinations, the content of which revolves around the neonate's safety VanderKruik et al, Postpartum psychosis is considered a psychiatric emergency due to its high risk of suicide and infanticide Nahar et al, It also increases the risk of later developing non-gestational psychosis particularly bipolar disorder and postpartum psychosis after a subsequent pregnancy VanderKruik et al, It is the most severe mental illness of the perinatal period, defined as the period between pregnancy and 1 year after the birth Dias and Jones, With an incidence rate of births Tinkelman et al, and the reduced capacity of women to consent, conducting research and collecting data is challenging Davies, This article will explore a case of postpartum psychosis, with particular focus on care of the woman and inclusion of her partner.
This will incorporate a critical appraisal of the role of the midwife and the multidisciplinary team, including mental health professionals.
Recommendations for improved care will follow, before a conclusion of the points made and reflective questions are presented. All details are anonymised for patient confidentiality. Her male infant was born healthy with no complications, and remained with her. She was recorded as low-risk at booking and was taking ferrous fumarate for pre-existing anaemia.
She had no personal or family history of mental illness; however, a member from the mental health team later noted that she had a brother with severe learning disabilities and that she had a complicated housing situation. Although she was employed as a health professional and spoke good English, Sarah had an interpreter at booking. Her parents and family, with whom she communicated often, remained in her home country after her migration several years ago.
Her husband spoke much less English and required interpreting assistance. Antenatally, small symphysio-fundal height measurements, and an episode of reduced fetal movements caused her anxiety. After giving birth, she was discharged to community midwife care on day 1.
At day 11 the midwife noticed Sarah's strange behavioural change and advised hospital attendance but she declined. Sarah was then seen by a member of the perinatal mental health team who suspected a psychotic episode, and liaised with specialist perinatal mental health midwives and obstetricians as there was some debate over which pathway should be used for treatment.
Sarah was admitted to the postnatal ward, treated with antibiotics and paroxetine, until she was later transferred to a mother and baby unit MBU on day Postpartum psychosis includes psychoses that occur within the postpartum period de Witte et al, This can be devastating to the woman and her family Nahar et al, , due to its occurrence at a crucial time in a family's life Doucet et al, There is an associated high risk but rare incidence of suicide, filicide or infanticide Degner, Women are also noted to have a reduced relatability to the infant Doucet et al, As a result of these risks, the woman's partner can often be overwhelmed, particularly if the postpartum psychosis is not well understood, which can lead to marital disruption and can affect the parent-infant relationship Wyatt et al, The midwife is key in detecting deviations from the norm and making appropriate timely referrals to relevant specialists Cantwell et al, This leads to effective multidisciplinary team input by way of co-operative interprofessional communication Murray-Davis et al, The Nursing and Midwifery Council NMC Code NMC, concurs, stipulating the importance of prioritising the patient and protecting safety while providing sensitive, compassionate care.
Midwives have a pivotal role in advocating for the woman's wishes and being a point of contact for safety, support and continuity, particularly in cases of complex social and mental health Bayrampour et al, An example of ineffective recognition of mental decline is when Sarah's community midwife visited her at home on day Sarah was advised to go to hospital, which she declined, but the midwife failed to escalate the situation by communicating to a specialised professional, such as the specialist perinatal mental health midwife, as soon as possible.
This was not safe or dutiful practice, as monitoring for signs and symptoms of mental illness is an important midwifery role National Institute for Health and Care Excellence NICE , , particularly as early detection allows for effective postpartum psychosis management and maximises the safety of mother and infant Nahar et al, However, given the rarity of postpartum psychosis VanderKruik et al, , midwives may lack sufficient experience to confidently recognise its signs and symptoms Noonan et al, Consistent training Cantwell et al, should therefore be provided by healthcare institutions and specialist perinatal mental health midwives to raise and maintain competence Maternal Mental Health Alliance MMHA et al, However, midwives are expected to update and maintain their own knowledge NMC, Furthermore, human factors may have played a role Derickson et al, , if the midwife was scared or apprehensive to refer Sarah's disordered behaviour to a specialist, for fear of raising a false alarm and appearing inadequate.
Effective timely referral to the specialist perinatal mental health midwife, leading to robust risk assessments, could have avoided this Cantwell et al, Moreover, continuity of care throughout Sarah's perinatal experience was not provided, likely due to staff shortages; however, this probably impeded the development of a trusting relationship between Sarah and midwifery staff NMC, This may have discouraged Sarah from communicating concerns, and inhibited knowledge of Sarah's usual behaviour, hence delaying the recognition of her decline Cantwell et al, A review of postnatal notes from day 0 and at discharge on day 1 did not describe Sarah's emotional wellbeing, her adaptation to motherhood or her competence at recognising her infant's needs, and the notes were inadequate in providing an immediate postnatal baseline of her mental health.
Alternative questions Table 1 were not considered. Instead documentation encompassed Sarah's physical health and although this is important, the absence of mental wellbeing documentation NICE, implies its exclusion from midwifery care. A family history of learning disability and a challenging housing situation were discovered.
The couple rented a room in a five bedroom house along with four other couples, two of whom were recently postnatal. This may signal poverty and stress, which could lead to mental health vulnerability.
Sarah's housing situation was also a mental health risk factor as maintaining functional relationships with other families within a confined, shared space can be stressful and difficult, particularly as the home is meant to be a space of relaxation Franks et al, However, living with other families can, in some cases, be a display of effective community, where families in lower-resource settings assist each other to transition into motherhood and collectively raise children Al-Maliki et al, Sarah may not have confessed her housing situation at booking due to negative stigma Davis et al, ; therefore midwives and specialist perinatal mental health midwifes MMHA et al, need to challenge this stigma with open communication and education to prevent secrecy and misplaced shame VanderKruik et al, The mental health nurse was effective in creating a comprehensive biopsychosocial picture, which aided direction of management by highlighting risk factors Table 2 NICE, However, requiring Sarah to interpret, rather than a professional, neglected her partner's needs.
It proved futile as she repeated her own disjointed thoughts and was highly improper due to her compromised cognition Mannion and Slade, Although it was necessary to prioritise Sarah, targeting the family holistically is needed for full recovery Glangeaud-Freudenthal et al, and for prevention of long-term sequelae to the infant Thippeswamy et al, Partners of women with postpartum psychosis have been shown to experience fear, confusion and anger; and are reported to be reluctant help-seekers, which can contribute to stress and marital collapse Wyatt et al, Midwives should therefore provide affirmational support while informing and educating the family to increase understanding of the illness.
This enables all to cope with the associated stress and guides the partner to help the patient, as their support is crucial to recovery Doucet et al, The mental health nurse specialist also discovered Sarah's antenatal anxiety over the small symphysiso-fundal height and reduced fetal movements, despite normal growth scans, and a non-suspicious CTG. Although the midwives discharged Sarah with warnings to return if reduced fetal movements repeated, they did not document any reassurance given, or note her anxiety.
Considering the growing evidence that maternal stress leads to negative neonatal outcomes Zijlmans et al, , midwives here were therefore not effective in monitoring perinatal mental health risk NICE, This disregard continued in the intrapartum notes, where Sarah grew anxious at sighting thin meconium in her amniotic fluid, and midwives did not document that they informed her that this was normal in postdates pregnancies England, , or that they gave reassurance.
Midwives may have assumed that due to Sarah's background, she would have had health-based knowledge, and thereby not provided as much information or psychological support.
This violates a tenant of practice NMC, to not discriminate between patients, and to provide quality care, including information, to all. Sleep deprivation may have contributed to Sarah's development of postpartum psychosis as she was working night shifts before commencing maternity leave, which was compounded by gestational sleep disruption and postnatal insomnia.
Although no reports associate night shift work with postpartum psychosis Aiken et al, , evidence of the effect of sleep deprivation on postpartum mental illness and postpartum psychosis aetiology exists Lawson et al, Midwives did not take note of this aspect of Sarah's employment, and therefore inadequately screened Sarah's physical and mental wellbeing, both antenatally and postnatally.
This is important as the information could have alerted staff to a potential perinatal mental health risk NICE, The mental health nurse specialist performed her role well in communicating to perinatal mental health, obstetric and midwifery staff, who then orchestrated a side room in the postnatal ward for Sarah's readmission and privacy.
This was a good display of communication across multidisciplinary teams and interprofessional collaboration in the best interests of the woman Murray-Davis et al, Sarah's history was then communicated to maternity staff and a mental health nurse was stationed with her to monitor her condition and protect her safety NMC, Sarah's sister-in-law stayed throughout the readmission, caring for the infant and ensuring that Sarah continued to breastfeed Wyatt et al,
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