Academic literature on the topic 'RC0321 Neuroscience. Biological psychiatry. Neuropsychiatry ; RG Gynecology and obstetrics'

This thesis presents two papers. The first is a systematic review of the literature exploring the relationship between perinatal paternal mental health difficulties and child outcomes in preadolescence. Eighteen papers were reviewed. The review found fairly consistent evidence for internalising and externalising problems and mixed evidence for socio-emotional and cognitive difficulties and child temperament. More research is required regarding mental health in fathers during this period more generally as well as how preadolescent child outcomes may be affected. The second paper is an empirical study exploring whether perfectionism was related to experiences of postnatal distress (depression, anxiety and OCD) in first time mothers and whether this relationship could be explained by antenatal maternal orientation. Furthermore, whether the strength of any relationships were affected by participants’ experience of becoming a mother. Eighty-four women completed questionnaires during their third trimester of pregnancy and fifty-nine six-to-twelve weeks after birth. A relationship between socially prescribed perfectionism and postnatal depression and anxiety was observed. Antenatal maternal orientation did not mediate this relationship. Mental health in pregnancy, the impact of sleep deprivation, feelings of control and powerlessness, perceived relationship with baby and levels of social support predicted depression, anxiety and OCD in the postnatal period.

In the first part of my PhD I explored the link between childbirth and mood disorders in a retrospective sample of over 1500 parous women with mood disorders, recruited as part of ongoing molecular generic studies. Around two thirds of participants reported at least one episode of illness during pregnancy or the postpartum. Women with bipolar I disorder reported an approximately 50% risk of a perinatal major affective episode. Risks were lower in recurrent major depression and bipolar II disorder at around 40%. The majority of perinatal episodes occurred within 4 weeks of childbirth. Episodes of mania or psychosis had an earlier onset than those of depression. For bipolar II disorder, onsets of psychiatric episodes were more spread out over the perinatal period with more onsets in pregnancy and later in the postpartum. Moreover, childbirth did not seem to be a specific trigger for the majority of perinatal episodes of bipolar II disorder. Primiparity was associated with postpartum mania/psychosis and unipolar postpartum depression in women who experienced their first lifetime episode within 6 weeks postpartum. My findings raise the possibility of a relationship between postpartum mood disorders and other disorders influenced by parity, such as pre-eclampsia. In the second part of my PhD I designed and piloted a prospective study aimed i) to replicate and ii) to extend the findings on the retrospective sample, exploring the influence of a range of variables on the vulnerability to develop an episode of severe illness in pregnancy or the postpartum. Over 14 months of recruitment 19 women completed the follow-up assessment. To capture the clinical complexity of bipolar disorder in pregnancy and the postpartum period very large scale longitudinal studies are needed. These studies must be based on a strong collaboration with the NHS.

The vision for maternity services focuses on women-centred care with choice, control and promoting normality at its centre, thus emphasising the need to empower women to make choices and decisions regarding their care in labour and birth. Some women will choose the medical model of care, however others prefer to be in control and choose to use non-pharmacological alternatives for pain control in labour such as Transcutaneous Electrical Nerve Stimulation (TENS). TENS has enabled the provision of non-invasive, mobile, self-controlled pain relief for women in labour and is used extensively by women in the UK who, when asked, assess it favourably and say they would use it again. Currently the available literature on TENS fails to consider individual women’s experiences of using TENS for labour and birth, this study therefore seeks to redress this balance. Set in the south of England, the study uses Interpretative Phenomenological Analysis (IPA) in order to explore the experiences of twenty purposively selected women, who were interviewed to expose their in-depth experiences of using TENS for pain control in labour and birth. The analysis of the verbatim transcripts revealed comprehensive findings ensuring an idiographic focus along with making claims for the larger group of women. In this study women used TENS as part of a combination of more natural pain control or as a ‘sole’ form of pain control for labour and birth. TENS was recognised as being part of a wider strategy for the maintenance of control in labour and normal birth for women. A super-ordinate theme of ‘control’ emerged from the data particularly relating to ‘internal control of self’, ‘external control of others’ and ‘control of the TENS machine’. Women’s positive experiences were enhanced by remaining mobile, using drug free pain control, being knowledgeable, having partners’ and midwives’ support, being distracted from their pain and trusting in TENS. By uncovering a group of women’s in-depth experiences of using TENS for pain control in labour and birth this study has filled a “gap” in the knowledge base. In addition, the findings suggest that TENS was identified as an ‘enabling mechanism’ for the women in order to be in control of a normalised birth. Women were able to maintain their independence, make decisions and actively take part in their pain control using TENS.

Volume 1: Research component There are three papers contained in this volume, all concerned with maternal mental health problems in the perinatal period. The first is a review that examines the existing literature on eating disorders in the perinatal period. It examines prevalence, symptomatology levels across the perinatal period and factors associated with development and remission from eating disorders in the perinatal period. The second paper is a report of research, carried out by the author, investigating obsessive compulsive disorder, bonding and meta-cognitions in new mothers. It specifically examines whether bonding is impaired in new mothers with OCD when compared with mothers who have no symptoms of OCD, a subject that has not been investigated in previous research. Both papers have been prepared for submission to Archives of Women‟s Mental Health. The final paper is a public domain paper describing the literature review and empirical papers and has been used to disseminate the findings of the research amongst participants, mother and baby organisations and mental health professionals. The appendices contain information regarding ethical approval, measures used and instructions to authors from the Archives of Women‟s Mental Health. Volume 2: Clinical component This volume contains five clinical practice reports (CPR) submitted during the doctorate course. These reports reflect the training of the course and the work completed over the three years of the course. CPR 1 and 2 were conducted during a child and adolescent placement. CPR 1 describes a doctor phobia in a five year old girl, formulated from a behavioural and a systemic perspective. CPR 2 reports a single case experimental design study on a narrative intervention for sleep difficulties in a nine year old boy. CPR 3 describes a qualitative service evaluation of a waiting list initiative and changes to the referral system to a Psychological Therapies Service within an adult mental health service. CPR 4 is a case study of a CBT intervention for a client with OCD in a specialist adult service. The abstract of CPR 5, a presentation on a CBT and narrative intervention for anger in a woman with a learning disability in an inpatient setting. The names and identifying details have been changed or removed from these reports to protect anonymity.

Background: The scope of postpartum pelvic dysfunction and perineal trauma is under-researched. Instrumental vaginal delivery or 3rd/4th degree tears were recognised risk factors for pelvic/perineal dysfunction; caesarean delivery was not implicated. Aims: • To analyse obstetrical/biological factors associated with pelvic dysfunction after caesarean or non-instrumental vaginal delivery • To compare these associations between groups after determining frequencies • To evaluate severity of pelvic/perineal dysfunction, including quantifying maternal perception of the psychosocial impact Participants and Methods: 284 primiparae (184 caesarean, 100 vaginally delivered) had domiciliary, in-depth medical interviews using structured and open questioning. Results: Caesarean (elective, emergency) vs. vaginally delivered were compared: Stress incontinence manifested in 60/184 (33%, 33%) vs. 54/100 (54%), anal incontinence in 94/184 (53%, 50%) vs. 44/100 (44%), dyspareunia in 50/184 (28%, 27%) vs. 46/100 (46%), haemorrhoids in 3/184 (2%) vs. 5/100 (5%) and double incontinence with dyspareunia in 33/284 (14%, 10% vs. 12%). Sixty sustained perineal trauma. Delivery mode and non-labour factors were predictors. Severity was evaluated by devising a psychosocial measure tailored to maternal functioning. New faecal incontinence necessitated continuous perineal protection in two pre-labour caesarean and one vaginally delivered mother. Severe dysphoria was associated with incontinence (p=0.038, OR 2.334, CI 1.049, 5.192), dyspareunia (p=0.005, OR 2.231, CI 1.272, 3.914) and post-caesarean wound problems (p=0.022, OR 3.620, CI 1.203, 10.896). Incontinence impaired leisure activities (p=0.036, OR 2.165, CI 1.051, 4.463) and employment (p=0.023, OR 1.912, CI 1.093, 3.345); caesarean mode affected social-networking (p=0.018, OR 2.438, CI 1.166, 5.099) and employment (p=0.031, OR 1.967, CI 1.064, 3.636). Conclusions: Pelvic/perineal dysfunction was: ▪ Predicted by caesarean or non-instrumental vaginal delivery, with anal incontinence being more prevalent post-caesarean ▪ Comparable following elective or emergency caesarean ▪ Associated with severe and quantifiable biopsychosocial maternal morbidity.