A personal perspective aiming to reduce postnatal illness
There are various causes of postnatal illness, however, as a mother who developed the most severe form, puerperal psychosis, I believe that there are several areas which midwives can be aware of which may help reduce the incidence for future mothers, based on my personal experience and that of other women.
Throughout the main stages of pregnancy and birth midwives should be aware of the fundamental importance of listening to women and using good communication skills. Having a pleasant personality, showing compassion, giving consistent support, being reassuring and informative are all desired qualities.
There are specific actions which greatly enhance the admission, birth, postnatal and discharge stages also. These include being patient, giving praise and support.
I feel that midwives generally do an excellent job however it can be improved upon by realising how the smallest of actions can have such a huge impact upon their patients with their infant and partner.
As a midwife you are automatically a guest at one of the most significant events of a woman’s life – the birth of her child. You are a stranger on ‘top table’ of this momentous occasion. How you respond to and treat that lady, her partner and the new infant can have tremendous impact and your actions are often remembered even years later.
I wrote about my experiences of motherhood and subsequent puerperal psychosis in my book, Eyes Without Sparkle – A journey through postnatal illness. I wanted to help and inform others who suffer from any form of postnatal illness and also to inform and educate health professionals that the smallest of actions can make a huge difference to the care and treatment of patients. In doing so I have received examples from many other women of their experiences of giving birth and following period, as they felt they had read mine and wanted to share theirs. Although we know that postnatal illness is often caused by a change in hormonal levels, I feel that there are significant steps midwives can take to help reduce the social and psychological factors which are associated with adding to the illness. Consequently, from personal stories, I would like to outline the main aspects which I believe can make a positive difference to the mental and physical health of all new mothers.
Be a good communicator
Good communication skills can never be underestimated. Always remember that although you deal with matters of birth every working day, many new mothers do not know what to expect, even if they have read the books and magazines as I had. Yet I suffered for several days after the birth due to huge lumps in my armpits – I was very worried, until a passing comment that it was my milk coming in, put my mind at ease. We need to be listened to and to be informed of many aspects – even if you know, remember that we may not. Unbiased and informed views should be offered about all aspects of pregnancy and birth, for example, the effects of different forms of pain relief. Written information in booklets or on notice boards can also prove very worthwhile. Medical notes must be accurate and passed on, especially to the health visitor. As a new mother you can feel very ignorant, inadequate and stupid about all the new skills involved. Be patient with us and encourage and praise us when we do something well, such as breast feeding. Some mothers have told me that with second babies often staff are less inclined to inform and support them, yet often they too still need it as each birth and child can be so different. Second time mums can often feel even more stupid, believing that they should automatically know what to do. Similarly, there seems to be a feeling that if you are a medical professional then you can be left to your own devices more as the attitude appears to be, ‘you should know’! Every patient should be given the same information and support, regardless of their profession, age or previous experience. Don’t make judgmental assumptions. Older does not necessarily mean wiser. It is better to be told something four times than not at all.
Enjoying being pregnant, but I had a great deal to learn.
Effective nonverbal communication is a fundamental aspect of good midwifery. A smile, a gentle squeeze of the hand or a small pat can often be tremendously important in making a patient feel confident and safe in your care. Reassurance that they and their child are going to be OK, that their mixed emotions are normal and that you understand them is vital. If you do see a new mother with the baby blues then this is even more crucial. Bear in mind that often a ‘good cry’ can be very therapeutic but within days of giving birth you can feel very guilty about needing to do this. However, having a sympathetic and reassuring ear can make all the difference in making that period pass more quickly.
Any patient basically wants to be cared for by a ‘nice’ person. When you are in the potentially vulnerable position of pregnancy you need kindness, compassion, respect and dignity. Ideally a midwife should have regular contact with the patient so a good relationship can develop over time, so that by the birth the mother is informed and confident with the staff involved. Where this is not possible an immediate rapport can be formed by being very pleasant to the patient and her partner and making them feel very special and not ‘just another one’. Smiling and showing interest in them and sharing their joys and fears are not difficult but extremely worthwhile. The staff I remember the most are those who told me a little about themselves. Appearing bored, impatient or bad tempered are not good nursing qualities and make patients feel very uneasy. Likewise poor personal presentation, chewing gum and smelling of cigarettes do not inspire confidence in staff. If a patient does do something ‘wrong’, for example, carrying her child instead of wheeling them in a crib, please tell them kindly. I was severely reprimanded for this and the sharp retort I received left me in tears for hours.
Reassure and inform
The various stages of midwifery support also have their specific areas of importance. In antenatal care reassurance and information is paramount. Consistency of staff is also vital at this time, especially if there could be concern for a greater risk of postnatal depression, e.g. as in a previous birth. If the patient sees a different midwife each appointment then a quality relationship is not likely to form and warning signs may be missed. At one of my appointments I was particularly weepy and as I saw my regular midwife she realised immediately that all was not well and a UTI was recognised and treated as a result. I needed a stay on the antenatal ward and was very frightened and worried at times of extreme pain – a reassuring voice was always appreciated, being ignored was not.
How admission at the hospital is handled is also a crucial. Again information, reassurance and support are vital. If the ward is exceptionally busy please explain that, but also reassure that help is close by when needed. It can be very disconcerting to be left for what seems like hours with no contact with staff. As a first-time mother I was extremely scared that I was losing my baby due to the pains from the UTI and more reassurance would have been appreciated. Other mothers have also reported to me of how vulnerable they feel at the admission and early labour stages as emotions are so mixed and running high.
The baby is coming!
The actual birth obviously is very significant. When all goes to plan and mother and baby are well then everyone needs to be congratulated and praised, staff included. However, if the birth is very sudden or problematic then the immediate period afterwards is critical. Similarly, if the pregnancy has been difficult then extra care and support is needed. The birth of my son was traumatic in that he was born with the cord around his neck; I had a retained placenta and postpartum haemorrhage and needed emergency surgery. Other than being told I was lucky to have survived, no-one ever talked it through with me afterwards. I spoke at the Marcé Society in Sydney in September 2008, where all the latest international research is presented on perinatal mental health. One paper looked at mothers who had suffered from PPH and the indication was that they needed extra TLC, rest and information. No one explained to me that because I had lost so much blood I would be even weaker and may have had initial problems breastfeeding, for example. My preconceived ideas of a birth had been shattered. The opportunity to talk about it at a later time would have been very beneficial. Many of the other letters I have received from ladies who developed postnatal illness also had suffered a problematic birth and likewise had not been given the opportunity to talk about it with a professional afterwards, feeling instead that they were just part of a conveyor belt system. All mothers should be counselled after the birth even if it has gone well. Confidence in staff is paramount at the birth and if there appears to be uncertainty over procedures this can cause distress, e.g. a doctor telling a student to check the sharpness of the scissors on paper prior to cutting the umbilical cord!
In the hours after delivery and emergency surgery the midwife who dealt with me was excellent. She sensitively cleaned me up on a regular basis making me feel like a pampered child, not a disgusting, bleeding creature. Every few minutes she appeared, checking all my monitors, tubes and observations with a pleasant, efficient and kind manner – just what was required. Generally midwives should also bear in mind both the mental and physical needs of the mother and child. One aspect which seems to be overlooked is to warn and prepare for the tiredness and exhaustion post- labour which can be a shock. Efforts should be made to maximise opportunities for sleep, e.g. being as quiet as possible during night shifts. Also be flexible if new mothers cannot sleep in the early hours – being offered a drink and a chat in the nursery for a short while often means you can settle much better rather than lying awake for hours. Some mothers commented to me that sometimes their other medical needs may have gone untreated or recognised, e.g. anaemia, irritable bowel syndrome or migraine, resulting in further distress. One visually impaired lady had asked for her own room to maximise her independence but was told there were none available as they were being used by NHS staff! Being encouraged to relax by listening to music, having spiritual needs met, e.g. seeing the chaplain, and being reminded to be kind to yourself are also very helpful.
General facilities on the ward also have an important role to play. Cleanliness of the bay, toilets and bathrooms is vital but I would have to argue that cleaning routines often start too early in the morning and are very disruptive to the rest of the mothers. Does the bin really need emptying at 6.30 a.m? The beds must be comfortable and extra blankets and sheets readily available. Ultimately it is how the facilities are used by the staff managing them which is important. Sensitivity at visiting times is also needed. Overlong visiting hours filled by too many noisy visitors are not conducive to hygiene or rest and should be discouraged and monitored.
Time to go home
At discharge, information giving and sharing is also important. In today’s society there is often little support at home by extended families and a new mother can feel very isolated. She needs to know who and where she can turn to for advice and help, for example, professional contacts and mums and tots groups. Medical notes must be passed on from the hospital to the community and any concerns followed up as appropriate. This is especially relevant in recognising possible factors or signs of postnatal illness developing, for example, reporting a problematic pregnancy; traumatic or sudden birth; baby blues; sensitivity and extremes of high and low mood swings. I have been told of the excellent care by midwives both in the hospitals and community but then it falls short when discharge to the community team takes over. Every effort must be made for it to continue. In particular the partner should also be considered. The trend for them to be present at the birth is not always a positive experience and if the mother goes on then to develop a postnatal illness it is very common for the relationship to break down. If concerns are demonstrated about the mental health of the mother, then it can be invaluable to talk to the partner too as they may give a more realistic opinion than the lady herself. There is a stigma attached to postnatal depression as no woman likes to feel she is a failure. It took me a long time to admit that I was finding my new life as a mother very hard and not what I was expecting. When I finally accepted I was ill, not a failure, it was a significant step on the road to recovery.
In all stages of pregnancy and birth, I feel that midwives must never underestimate the power of being a good listener. Excellent nursing does not just involve the physical care but playing a supportive and kind role can be paramount to the wellbeing of every patient, and may actually help to reduce the incidence of postnatal illness. Although there are many courses which offer training in the clinical care of patients, I feel greater improvements in the service could be made by focusing upon the human aspects of personal relationships and interaction, possibly by talking to former patients. Let us all work together to make a good service even better.
There are significant steps midwives can take to help reduce the social and psychological factors which are associated with postnatal illness.
Good communication skills are vital, especially listening and nonverbal forms, such as smiling. Always give new mothers and their partners opportunity to talk about the birth afterwards – how was it for them?
Be kind, compassionate, clean and tidy, respectful and pleasant. Support, reassure and be consistent.
Always share and give information especially upon discharge into the community care of the health visitors.
N.B. If you wish to receive information about latest research developments and examples of good practice please sign up for Elaine’s newsletter on her website at www.hanzak.com. Keep an eye on her blog as she speaks at a wide variety of pregnancy related conferences and shares the knowledge. If you have any examples which you would like to share too please let her know.
Elaine’s book, Eyes without sparkle – a journey through postnatal illness, was published in January 2005 by Radcliffe Publishing (Oxford and Seattle) ISBN 1 85775 655 X £16.95