Part 7 (1/2)

with sore nipples, then you will feel less able to cope with the practical and emotional demands of your baby. Consequently, it's important not to a.s.sume that what you are feeling is normal: check things out with your midwife and see if there are other solutions. You may need iron supple-ments for your anaemia, or to try a different position such as lying down to feed or you may need the midwife to help you with latching the baby onto the nipple.

The emotional recovery of the mother and father Avery wide range of feelings and experiences can be considered a'normal'

reaction to having a baby. For many parents there is an initial period of elation when they finally become a family and when they explore their new baby. For others the experience may be different: more uncertain or overwhelming particularly where there are any concerns over the health of the baby or the mother.The first couple of days can, however, be something of an emotional roller coaster with most new mums shedding a few tears at some point.

The first few hours may be a time when the anxieties of the pregnancy and about the labour are over and the new arrival is safe and well, bringing much relief. There may be feelings of elation about becoming a family and possibly a sense of achievement from having survived the labour and producing a healthy baby, especially if he seems fairly settled.

More negative feelings often stem from problems that occurred in the labour, the emerging relations.h.i.+p with the baby and feelings of being overwhelmed by the responsibilities of becoming a parent. Sometimes too it can be difficult to accept things not being as you had expected: perhaps to do with labour, perhaps to do with your partner, the gender of the baby, the temperament of the baby or how close you do or don't feel to him.

It is probably misleading to separate out physical and psychological recovery since the two have such strong effects on each other. However, emotional recovery is part of all of the areas we have talked about: how well the baby is feeding, his patterns of sleeping and how easily he seems to settle. Emotional recovery from the labour itself may be very rapid for some women as it becomes lost in the new preoccupations of looking after the baby. However, for some the thoughts of the labour just do not go away and can be quite preoccupying in these early days. Sometimes these problems can be resolved simply by the mother (and father too where appropriate) being allowed to recount and discuss their feelings about what happened in labour and to get explanations from the professionals 124 about why things happened as they did. Generally hospital settings do not facilitate this type of approach.You may be in a shared room with nowhere to talk privately and more than likely no one is particularly available to sit and talk with you. A recent government directive has recognised that all new mothers should be encouraged to 'debrief' but psychological work always needs the right time and the right place and therefore this may not always take place.

Whether you feel great or awful initially, this doesn't necessarily last.

This can be emotionally a very turbulent time. Your initial high may disappear: suddenly the baby needs feeding or starts crying, physical discomfort may kick in as the effects of any drugs wear off.Your tiredness may suddenly overwhelm you just as the baby decides to wake up for feeding. Your partner and or visitors may have gone home for the night and you may find yourself left holding the baby and uncertain of what to do. This may be the first night you have spent in a hospital or away from your partner.The care and support of those around you are crucial at this time. In some non-western societies women are given much more s.p.a.ce to get to know their new baby and learn to be a mother without having to return to the demands of the rest of her life.

How do new dads feel?

The stereotype of the role of the new father is that of informing the expectant relatives about the new arrival and then leaving the mother to recover while he 'wets the baby's head' with the well-wishers. Probably most partners today want to remain much more involved with the mother and baby than might have been true in the last century. However, the idea of acting as a buffer to the outside world does still remain important. The partner can therefore dissuade visitors if they are not wanted or contact them when support from them is needed.The partner can organise the situation for the return home or, if necessary, he can just stay supporting and encouraging the mother.

Of course, these issues concern the recovery of the mother. The new father too may be experiencing his own reactions to the labour or fears about being a father and what that means. He may feel very uncertain about holding the baby and avoid doing so if he feels that the mother is doing a good job or if she keeps telling him how to do it. He may have mixed feelings towards the baby too especially if the mother only has time for the baby. There is evidence that being present at birth increases likelihood of bonding with the baby, however, the father may also feel shocked and overwhelmed by what has happened.

'Baby blues', post-natal depression and post-partum psychosis 125 So, to summarize, a range of reactions can take place over the first few days and are all part of recovering from labour and the negotiation of the early tasks of parenting. Sometimes, however, these early problems might be a reflection of more complex problems to follow.

'Baby blues', post-natal depression and postpar tum psychosis : complicated reactions to having a baby The types of reaction that we have talked about so far are not unusual reactions after having a baby. So when do these reactions mean something more or turn into something more serious? It is something of a dilemma whether or not to get into'categorising' women's reactions to having a baby.

Many would argue that all women experience a sense of loss of their former self and life and a deterioration of the quality of their relations.h.i.+p (where they are in one). So maybe all of these reactions should be thought of as post-natal sadness and all women should be ready to experience some difficult times. One of the reasons for making some distinctions is that different types of problem may need different types of solution. Postnatal depression has been shown to have far-reaching consequences for both the mother and her child so if we can prevent it from happening or alleviate it more quickly, then this has positive consequences for all of the family. When suffering from emotional distress people naturally have questions about what is happening to them. How long will this last?

Should I be taking any medication? All these questions are difficult to answer but are somewhat easier if we try to draw definitions between different types of problem.

Therefore, it can be helpful to think of three types of reaction after having a baby that do need to be distinguished from each other. The first is 'baby blues', the second, is post-natal depression, and the third is post-partum or puerperal psychosis. Post-natal depression (PND) will be covered in the next chapter, as it would not be an appropriate way to describe someone's initial emotional response to having a baby. PND develops more gradually over time. Baby blues and puerperal psychosis are usually seen in those early days. In looking at the statistics it is clear that baby blues is extremely common, PND is experienced by about one in ten women and puerperal psychosis by only about one in every thousand new mothers.

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Baby blues ?

What is it?

'Baby blues' refers to a period of low or changeable mood occurring in the first or second week of having a baby. It is something of a dilemma as to whether to put baby blues in a section looking at complicated reactions to having a baby since it is really quite difficult to separate this from the normal feelings and reactions already talked about.

Most women feel tearful, frustrated or overwhelmed at some point in those first couple of days. Baby blues isn't an illness or even a proper psychiatric diagnosis, it is simply a way that people have tried to describe unpleasant feelings that occur shortly after having a baby and tend to resolve in a few days.

How common is it?

Statistically it is very common and levels of 50^80 per cent of new mothers are said to experience baby blues (Kendell et al., 1981). The reason for perhaps labelling baby blues is to differentiate between this and postnatal depression. Baby blues refers to those reactions that occur around the first week after having a baby and tend to disappear in a couple of days. If you are feeling sad and tearful in those first few days, you are not post-natally depressed but if there are issues generating these tears, then they need to be looked at carefully, otherwise this might be an indication that post-natal depression could develop.

What causes it?

Very often feeling tearful or anxious can be after a poor night's sleep or it often coincides with your milk 'coming in' (which can be painful and make feeding more difficult).You may be very emotionally fragile, laughing one moment and crying the next.Trivial matters may provoke an argument or there may be anxiety type symptoms such as confusion or forgetfulness.

These reactions tend to be short-lived and after a couple of days or a good night's sleep, things settle down.

One of the reasons for trying to describe a syndrome is because researchers can then look to see what might be causing these problems.

There is research to look at whether baby blues is hormonally generated, whether it is linked to certain types of personality or, for example, poor experiences in labour. Not surprisingly there is not one clear reason why Baby blues ?

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this happens. Giving birth is such an all-encompa.s.sing experience; it can be physically and psychologically strenuous or sometimes traumatic, you have to learn to look after your baby, accept a totally new routine, deal with feeding anxieties and come to terms with a whole new ident.i.ty. This process is obviously unique for every parent and consequently we should concentrate on the individual difficulties that the new mother is experiencing rather than looking for a single explanation.

Does it need treatment?

The fact that these experiences are not 'serious' in the medical sense does not mean they shouldn't be taken seriously. It is important for those around the mother to try to understand her particular concerns and problems. If this is a lack of sleep issue, then what can be done to help her catch a few more hours? If this is to do with anxieties about feeding, then perhaps more support from the midwife is needed. Or it may be that there is someone else such as a friend with children or one of the grandparents who can provide some perspective on the situation. Often women may fear that they are going mad. One woman confided to me that after two sleepless nights in hospital she kept seeing her (deceased) mother every time she closed her eyes to go to sleep. She had to ask the midwives to feed the baby that night so that she could recover. She was just very tired.

It is important that the partner makes the midwife aware if he is concerned about how the mother is feeling or behaving, since he is the better judge of the mother's reactions. The midwife may not have met the mother before and may not know that someone is 'not themselves'. These early problems may be the roots of longer-term difficulties if not dealt with now.

Davina's story Davina and Mike had been very excited about the arrival of their baby, which they had planned to have at home. Davina had been healthy throughout pregnancy and in her job as a solicitor was used to being in control of what was happening to her. She had read a lot about home births and felt prepared. Davina, however, did not go into labour spontaneously and eventually agreed to come into hospital to be induced. Despite a lot of pain and anguish Davina's labour did not progress and despite attempts to speed up the contractions after 24 hours the baby became distressed and had to be delivered by Caesarean 128 section. Davina and Mike were delighted that they had a healthy baby girl and things seemed to go well initially with feeding. On her last day in hospital Davina waited all day to see the paediatrician and Mike eventually left to buy some food for their return home. When Mike returned Davina was in floods of tears and had apparently told the midwife that she wanted to discharge herself. She refused to wait to see the paediatrician and Mike was concerned that he shouldn't take her home in this emotional condition. They did go home but Davina did not feel better, becoming concerned then that the baby had not been seen by a doctor and was now crying and difficult to settle. Eventually Mike had to call out the GP and after a rea.s.suring visit from him, Davina went to bed and woke feeling much happier. In the next few weeks they were both able to reflect on the stresses and disappointments that had led to Davina's tears.

Puerperal or post-partum psychosis Very few books on pregnancy and childbirth will have a section on puerperal psychosis.This is possibly because it is so rare, affecting only around 1^2 mothers in every thousand. Probably there is a feeling that discussing it might frighten prospective mothers unnecessarily. There used to be a similar att.i.tude to post-natal depression: that it was best not mentioned to mothers. This leaves problems somewhat shrouded in mystery and women who do have these problems are left to feel shameful about what has happened.

So what is puerperal psychosis?

Again, this is a condition that usually develops very rapidly after the baby is born. It may initially look like just the normal emotional struggles after having a baby. The mother may seem very anxious or agitated or tearful but, rather than subsiding, usually these symptoms escalate very rapidly.

There are many different ways that these problems may present but quite quickly it becomes clear to those around the mother that her mental state is quite severely affected.What may start off as a fairly trivial anxiety about the baby may rapidly develop into an unshakeable delusion. For example, an initial concern about the baby's features may develop into an idea that the baby is a devil.The symptoms can be very varied but usually there is an initial 'manic' or excitable phase. The mother's ideas may be racing, her Baby blues ?

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behaviour may be very hurried and inappropriate, for example, she may pick up the baby in a way that alarms those around her. (Almost all new parents worry about how to hold a baby but if you watch them picking him up, they will do it with great caution, adjusting their position in response to the baby or to the advice of others.) Her speech may be rapid and full of confused ideas and contradictions. She may become extremely paranoid about those around her and feel that they wish her or the baby harm.

The term psychosis is used to describe illnesses that are made up of delusions, hallucinations and often extreme paranoia. The symptoms in puerperal psychoses tend to be like those of manic-depression and more rarely schizophrenia. Alternatively the mother may just present as very depressed and unresponsive. Again it is important to emphasise that puerperal psychosis is extremely rare. If the mother has a history of serious mental illness, then both staff and family may have been alerted to the possibility of these problems in pregnancy.

Clearly, this can be very upsetting for partners and relatives who just cannot understand what is happening. These symptoms may initially be seen as just baby blues but it is their failure to resolve and their escalation that should alert everyone to their seriousness.

What causes it?

There is not really s.p.a.ce in this book to cover this issue in depth. Like most psychological problems, a combination of genetic, biological, environmental and social factors has been studied. It is worth emphasising again that these types of illness are extremely rare. Also there are different factors involved depending on whether this is the first time that you have been ill or whether you have a history of (psychotic) mental illness. Where a woman has a history of manic-depression or schizophrenia she is more at risk for developing these problems. However, it is more likely that under these circ.u.mstances your doctors will monitor your pregnancy more closely and it may be that medical treatment is commenced shortly after the baby is born in order to prevent puerperal psychosis taking place.

How is it treated?

Puerperal psychosis needs immediate psychiatric intervention. Women will usually need to go into hospital to be a.s.sessed and monitored. They 130 will usually need drug treatment and intensive support around caring for the baby. The relatives too will need support and information. A GP or a visit from the community midwife cannot provide this level of support.

Because the presentation of post-partum psychosis is so dramatic, usually the services respond very quickly. Often the problems develop before the mother has left hospital, within hours of the birth.

What about the future?

The two main questions that parents have following these experiences are: How long will it take to recover? And, will it happen again if we have more children? To answer these questions a distinction needs to be made as to whether this is the first illness or a recurrence of previous problems.