Avoidance can extend to subsequent health care (such as not attending the postpartum checkup), sexual relationships, caring for the baby, and future pregnancies. Some women request general anesthesia and cesarean sections for future deliveries.
Arousal may intensify postpartum sleep disturbance and fatigue and may cause a mother to be hypervigilant about her baby.
Flashbacks can influence feelings about the baby, such as when the mother has repeated, vivid memories of the newborn being limp and blue after delivery, even though the infant is healthy now.
Preventive interventions that can minimize PTSD risk after labor and dshlivery include:
- explaining to women before the onset of labor that emergency obstetric interventions might be necessary
- providing adequate social support during labor and delivery
- ensuring that the obstetric staff communicates clearly with the patient
- effectively managing pain to minimize trauma.
Postpartum, it is important to screen for PTSD symptoms among high-risk women. Prompt intervention can alleviate symptoms and minimize adverse effects on the family and the mother-infant relationship.
Role of sexual abuse in perinatal PTSD. For a woman who was sexually abused as a child, even an uncomplicated labor and delivery may trigger memories, flashbacks, and emotions associated with the abuse.26 Physical sensations associated with gynecologic examinations and labor contractions may remind her of abuse-related sensations. Some women with sexual abuse histories react adversely to the loss of control and need to depend on others during labor and delivery.
Unrecognized posttraumatic reactions during labor may result in maladaptive behaviors (Table 2).26 Obstetric staff who encounter these behaviors without being aware of their origins may think the patient is oppositional or noncompliant and may regard her as an adversary to be defeated or bypassed in order to safely deliver the baby.27 The psychiatrist can minimize this problem early in labor by alerting the staff to signs of possible sexual abuse-related PTSD. These may include:
- little or no prenatal care (due to fear of obstetric procedures)
- unusual fears of needles, intravenous lines, etc.
- recoiling when touched during obstetric examinations
- insistence on female obstetric staff
- extreme sensitivity about bodily exposure.26,28
Table 4
USE OF ANTIDEPRESSANTS FOR PTSD DURING BREAST FEEDING
| Medication | Nursling dose range* | Reported nursling side effects |
|---|---|---|
| Citalopram | 0.7 to 9.0% | Uneasy sleep |
| Fluoxetine | 1.2 to 12.0% | Vomiting, watery stools, excessive crying, difficulty sleeping, tremor, somnolence, hypotonia, decreased weight gain |
| Mirtazapine | Not known | Not known |
| Nefazodone | 0.45% | Drowsiness, poor feeding, difficulty maintaining body temperature |
| Paroxetine | 0.1 to 4.3% | None |
| Sertraline | 0.4 to 1.0% | None |
| Venlafaxine | 5.2 to 7.4% | None |
| *Weight-adjusted estimated percent of mother’s dose ingested by a nursing infant | ||
Intervention. Once abuse-related perinatal PTSD is diagnosed, the interventions in Table 3 can help a woman through labor and delivery.26,28 When successful, they can turn childbirth into a healing experience that promotes the mother’s sense of accomplishment, positive association with sexuality, and a new relationship with her body.28
Breastfeeding can also trigger flashbacks and frightening emotions in a woman who was sexually abused as a child.29 She may confuse normal sensations of skin-to-skin contact with the baby or the milk ejection reflex with unpleasant sexually-linked feelings. In such cases, it may help to:
- explain the normal sensations associated with breastfeeding and normal behaviors of breastfeeding infants
- show her how to gently redirect her baby if it does something she finds uncomfortable
- identify situations that are especially difficult for her (such as nighttime feedings) and substitute bottle feeding at those times.
These measures may promote feelings of self-efficacy and help more in the long run than prematurely giving up on breastfeeding.
Prescribing to the nursing woman. When prescribing medication for PTSD in a breast-feeding woman, minimize potential infant side effects by choosing agents that produce relatively low drug levels in breast milk (Table 4).30-34 Sertraline—the first medication to receive Food and Drug Administration approval for treating PTSD—is recommended during breastfeeding.35
Pregnancy loss. Although the prevalence of PTSD in response to miscarriage or stillbirth is unknown, some women clearly develop PTSD after pregnancy loss. The degree of associated physical trauma—and of social and professional support—influence anxiety levels in response to miscarriage36 and may also influence the likelihood of developing PTSD. Pregnancy loss after the first trimester may be more likely to result in PTSD than earlier loss, and subsequent pregnancies may exacerbate PTSD symptoms. In one study, spontaneous fetal loss after the 18th week of gestation led to high rates of PTSD symptoms in a subsequent pregnancy and up to 1 year postpartum.37
Asking a woman how she wants to grieve her pregnancy loss and helping her in that process may minimize her risk of subsequent PTSD. Couples counseling may help in some cases, as each partner may have a different grieving style.