Maternal Post-Birth Well-being Assessment / Self Assessment / De-briefing

[Julie Doula]

Hello everyone,

I thought I would start a new thread from the one started by Janet when she shared about her first birth experience, which then led to discussion about the need for proper post-birth de-briefing.

It seems like some women do get a chance to de-brief because they are blessed with sensitive careproviders who understand the art of listening. Long may that prosper, there's nothing else like it. Any "tool" we developed would only be a weak imitation of the real thing: humane compassion.

But since the need for maternity reform is increasingly apparent (to nearly everybody except perhaps Tony Abbott), perhaps a document of some sort might be a useful tool or guideline - a way to get caregivers thinking along those lines, and a way to help birthing women assert their voice and feel like they've been heard.

I would like to hear everyone's ideas on what you'd want to see included in such an assessment or feedback form. Some people have had them - what bits did you like and what else needs to be added?

Quote (Yael):

"I think hospitals should all have mandatory birth debriefings before discharge, it is such an 'ordeal' (in a good way, i just can't think of the right word), to go through, i think everybody no matter what their experience should discuss it."

Quote (Caro):

"Perhaps you should come up with something to introduce to *after care* so to speak. IT could actually cut down on women getting pnd and other after birth issues"

Quote (Flowerchild):

"I had an independent midwife with my first birth and as part of her practice she had a feedback sheet - this was helpful for me especially as I had some issues with the way she conducted herself in my labour. I was able to express myself on paper and for my feelings to be heard. For my next two births I had a birth centre birth and as part of my midwife's practice in that centre she had a debrief session about a week after the birth.... With my fourth I had my own midwife again and it was/is the practice of that private hospital to have feedback sheets AND the midwife also conducted a debrief with me."

I've asked TABS in NZ if they have any such thing. They have a Birth Review (that didn't happen with either of my births in NZ so it must be more recent) and there is a PTSD diagnostic tool based on this from the DSM-IV:

The DIAGNOSTIC CRITERIA for POST-TRAMATIC STRESS DISORDER
(DSM-IV)


A. The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others

2. The person’s response involved intense fear, helplessness or horror.
Note: In children, this may be expressed instead by disorganised or agitated behaviour.

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions.

2. Recurrent distressing dreams of the event.

3. Acting or feeling as if the traumatic event were recurring (includes dissociative flashbacks episodes, including those that occur on awakening or when intoxicated).

4. Intense psychological distress at exposure to internal or external cues that s symbolise or resemble an aspect of the traumatic event

5. Physiological reactivity on exposure to internal or external cures that symbolise or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma

2. Efforts to avoid activities, places or people that arouse recollections of the trauma

3. Inability to recall an important aspect of the trauma

4. Markedly diminished interest or participation in significant activities

5. Feelings of detachment or estrangement from others

6. Restricted range of affect (e.g. unable to have loving feelings)

7. Sense of foreshortened future ( e.g. does not expect to have a career, marriage, normal life span).

D. Persistent symptoms of increased arousal (not present before the trauma) as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating

4. Hypervigilance

5. Exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B,C & D) is more that one month

F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Specify if: Acute; if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if: With Delayed Onset; if onset of symptoms is at least 6 months after
the stressor.

I think we might look at creating an maternal assessment questionnaire, which could be responded to by both caregivers and mothers (and fathers - who can also be affected by birth trauma), which also provides for general Birth Review/de-briefing of any birth, not just births that are experienced as traumatic - since we know that there is such a need to process any birth, even the blissful ones - every birth is a huge, impactful event.

(We'll probably find that Sheila Kitzinger has already done it! Maybe we can ask her about it - I hear she is coming to Australia in November ....)

[Snowy Love]

I have no suggestions, but wanted to say its a brilliant idea. I was feeling really off from about day 3 to day 5 when DH & I just talked through everything that happened - helped get it straight in my head & DH filled in blanks in my memory, but it would have been a hell of a lot better to have talked to one if the midwives together on day 2 or 3.

[Ca Plane Pour Moi]

It's a good idea, but if we are lucky enough to get a care provider who actually cares, what then? I mean, what will they do? Knowing what my care was like (and what my family is like when I tried to discuss this with my mother), just tell me I should be grateful he's alive and get over myself - or tell me it's normal. It's four months ago and I'm still having the nightmares and can't stop crying or honestly feel my son is mine.

[Julie Doula]

Ryn, I'm so sorry to hear that. What you're feeling is important and valid. You really need to talk it through in order to process it and come to terms with it - and that need is totally normal and healthy. It is your birth right.

In England, Sheila Kitzinger is doing great work around birth trauma. She has just published "Birth Crisis". If you Google "Sheila Kitzinger" and then click on 'Birth Crisis" on her website, you'll find the names and contact details of women in England who are manning a telephone hot-line that women can call in order to receive support and the chance to de-brief. It says,

"Contacting the Birth Crisis Network

If you need to talk about a birth experience which haunts you, do phone one of the following:
If you are not in their region, they may pass you onto someone else in the Birth Crisis Network, not listed here."

[Karina]

I think this would be a great idea. No one came to talk to me about how I felt about Claires birth. All that happened was that just as I was leaving thr delivery suite to go to the post natal ward, my midwife asked if I was happy with the way her birth went. I was not in any state to talk about it then and there and my mind was still going 'omg i just gave birth'... In hindsight, i wish someone had come to talk to me about how I was feeling, but at the time while i was in hospital it was not something I even thought of. I went home and the next day had the blues and couldnt stop crying. Even DH wasnt too interested in talking about Claires birth and just sort of said yeah or really short responses to everything I told/asked him. Claires birth was not really traumatic, but it was still an event that I felt I needed to debreif afterwards kwim.
so yeah i think it would be a great idea for mums to be able to have someone sit down with them and just debreif afterwards.

[Ca Plane Pour Moi]

Thank you Julie, I will do that this afternoon.

[Pandora]

I think its a great idea. Its unfair that so many women don't have this opportunity, or many do not know they have it.

I was lucky enough that my MCHN was a midwife at my hospital, and was present for DS' birth, so knew exactly what happened and was very encouranging as far as birth debrief went. My trauma happened pre-birth, and she was excellent with that as well.

So I would say it should include events leading up to the impending birth and how these were handled, especially for post dates births like DS'

[Julie Doula]

it should include events leading up to the impending birth and how these were handled, especially for post dates births'

Good point! Yes.

[Julie Doula]

This is what we have so far:

"Birth Review

The opportunity to de-brief after your birth, with a supportive listener, is an important part of the birth process. It is really the “4th Stage of Labour”. Any birth is an intense, impactful experience – regardless of whether it was experienced as straightforward or traumatic. The need to process this huge experience in one’s life is felt by most women. In New Zealand and most other countries, such a de-brief is a mandatory part of maternity care. In New Zealand, it is called a Birth Review.

We believe that a woman’s own perceptions, opinions, responses and feelings about her birth experience are valid, significant and extremely important for improving and optimizing maternity care in this country.

This is your Birth Review. You may use this document to trigger thoughts and ideas if you wish, or if you prefer, you can toss it in the rubbish and do it your way. Please feel free to use other paper, or make your responses verbally – do whatever is helpful for you.

The first part is about your experience of birth and the impact on you.

The second part offers you an opportunity to give feedback to relevant care givers and services and make suggestions for improvements."



If this was your birth review, what questions would you like to see on it?

[Berry]

Hi Julie,

I heard that a new initiative which I think came in recently involves screening every woman giving birth for PND. I think that is fantastic as it is hugely prevalent yet so often hidden, overlooked or the woman herself doesn't acknowledge it.

I would love to see ante-natal screening too as I think pregnancy involves huge hormonal and emotional shifts and pre-natal depression is common, is frequently linked with feelings about the birth and post-natal feelings, and would best be addressed sooner rather than later.

Re my suggestions for a post-birth de-briefing or questionnaire - would like it to include assessment of depression, options for ongoing support - list of contacts and support groups and reading materials, exploration and support re bonding with baby, assistance with establishing breastfeeding and routines, and general discussion of birth process, obstetric and hospital experience.

[Julie Doula]

Great suggestion, Berry - a list of all local sources and resources for PTSD/PND support, BF support plus helpful reading and websites, would be great to include.

This is one of the tools used for assessing PND - what do you think everyone?

"Can you identify with any of the following? Often? Sometimes? Rarely? Never?

1. I have been able to laugh and see the funny side of things.

2. I have looked forward with enjoyment to things.

3. I have blamed myself unnecessarily when things went wrong.

4. I have been anxious or worried for no good reason.

5. I have felt scared or panicky for not very good reason.

6. Things have been getting on top of me.

7. I have been so unhappy that I have had difficulty sleeping.

8. I have felt sad or miserable.

9. I have been so unhappy that I have been crying.

10. The thought of harming myself has occurred to me."

[Berry]

I think the PND assessment tool is good but would also want to do an exploratory and open-ended interview re supports the woman has and is likely to access, from her partner, own extended family, in-law relationships, MCHN, groups such as new mother's group and local playgroups. The woman should be able to direct the session around what she feels is important and is impacting her. I think the better the awareness a mum has of the importance of supportive buffers like mothers' groups and the more inclined she is to utilise them, the less likely she is to spiral into depression.

[AnyDream]

Julie, I answered the Edinburgh Depression scale a million times and none of the questions on it even remotely identify whether there has been a trauma experienced, hence my PTSD went undiagnosed until about 2 years later when a GP named it.

The things that indicate the trauma to me was - the inability to recall large chunks of what happened (I literally blanked it out for several months), and also a total dissociation from my body from the waist down (I was literally unable to touch myself for weeks afterwards). There was also a weird time thing where I stopped being able to track time at all, even something simple like eating a sandwich would take nearly an hour and I'd have no idea that much time had passed. The biggie though, was once I finally came out of denial, I remembered that I'd left my body and gone to a place of death and had to chose whether to live or not. Whether or not this actually happened (and the Dr I saw last week happily labelled it a psychotic episode to fit his own world view) the important thing about this event was that I believed that I wasn't going to make it out of there alive. When I finally told a few ppl about my experience, several of them sort of laughed at me, like how could that possibly be. So I'm not really sure how you would go building questions that cover the entire spectrum of "normal" debriefing right through to the really severe cases.

BTW, my baby was three days old before any of the nursing staff asked me how I was feeling. I had already identified a previous instance of reactive depression (at my admittance interview) so god only knows what deficit in care was going on at that hospital.

[Julie Doula]

Julie, I answered the Edinburgh Depression scale a million times and none of the questions on it even remotely identify whether there has been a trauma experienced, hence my PTSD went undiagnosed until about 2 years later when a GP named it.

That's what I thought, too Marydean. I don't think I would find that PND questionnaire that helpful. Especially not for actual PTSD.

The following is based on the diagnostic tool for PTSD from the DSM IV. Would you have found such a questionnaire helpful as a catalyst for talking abour your feelings, experiences, needs and ways to meet those needs?

(Thank you everyone for some excellent input and suggestions.)

"Can you identify with any of the following? Often? Sometimes? Rarely? Never?

* I experienced a traumatic event/events during/surrounding the birth which involved actual or threatened injury or threat to my physical integrity or my baby’s physical integrity

* The trauma keeps coming back to me in one or more of the following ways:

- I keep having thoughts, memories, flash backs or strong feelings about the birth or events surrounding the birth, often when I didn’t want to think about it

- I have disturbing dreams or day dreams about the birth or events surrounding the birth

- I sometimes act out or feel as if it was happening again, especially at times when I am half asleep or in my sub-conscious.

- I feel distressed when something reminds me of the traumatic things that happened – something little triggers a memory and then I feel upset.

- When the memories are triggered, I feel so upset I react physically – such as changes to breathing or heart rate, sweating, feeling dizzy, feeling sick or a getting a head ache.

* I try to avoid anything that could remind me of the trauma or trigger flash backs in one or more of the following ways:

- I avoid thoughts, feelings, or conversations associated with the trauma

- I avoid activities, places or people that arouse recollections of the trauma

- I am unable to recall an important aspect of the trauma, there’s some things I just don’t remember.
- I’ve lost interest in doing things I used to enjoy and invest energy in

- I feel detached and estranged from some people

- I feel numb or detatched from my body or parts of my body

- I feel emotionally numb and less able to laugh, get excited or have loving feelings.

- I can’t imagine a future life for myself anymore. I can’t see ahead.

* I feel tense and on edge, like I’m always on guard. I wasn’t like this before. I’ve experienced:

- Difficulty falling or staying asleep

- Irritability or outbursts of anger, feelings of rage

- Difficulty concentrating

- Hypervigilance

- Exaggerated startle response. Just little things can give me a fright or set me off.

* I’ve been having these symptoms for a while now.

* I feel it has been affecting my sleep, my relationships and my daily functioning. It’s not like me.

* I started feeling this way straight away after the event that I found traumatic.

* The shock was delayed a few days before I started having these feelings.

* I have had these feelings for less than three months / more than three months.

* I feel these symptoms are getting diminishing over time / worsening over time.

* Are there any other symptoms you are experiencing not mentioned above, or anything you want to elaborate on?

* Has anything helped you find relief, or is anything helping you manage?

* Is there anything that you think would help you, that you are having difficulty obtaining?"

I feel that one main goal in putting together an assessment like this is to prompt care providers to focus more on "and how is the MOTHER feeling???" - not to make women feel that they are being rated or assessed on how well they are or are not doing. Maternity services should be consumer driven like any other service, and to give women as consumers a way to assert their voice and for our feedback to be validated and heard is why such an assessment may be helpful in our current climate. I would hate for mothers to feel that they, or their ability to cope with the massive challenges of birth, is the thing under assessment.

I am one of those women who had "manageable" births. My experience of trauma, and of that trauma being dismissed, comes from non-birth related incidences. I understand that each person's experience of our widely varying birth experiences is unique and everyone's own perspective is significant and valid.

[Berry]

Hi Marydean - I can relate to that dissociation from body in a way; I was petrified giving birth the first time (natural birth), it made me feel like my body was totally out of my control, brought back a traumatic memory, and I never touched or looked at my stitched episiotomy post-birth. "In shock" was listed on my medical record re giving birth; no mention of anything else emotional or any checks (that I know of) in the hospital of my emotional state.

[Ca Plane Pour Moi]

I think a de-brief should make it clear that it won't affect the stay in hospital - I'd have lied my head off to get out of there. And the PND check mentioned there, it's easy to just give the "correct" answers. I mean, I didn't sleep in hospital because I had a new baby, it was when I was at home and he started sleeping that I had troubles with upset sleep fom nightmares.

I think women should be asked if the midwives/Obs at their birth did anything against their wishes. For me, pushing drugs and not letting me take the monitor off. That can impact this sort of thing and it's not something a mother will feel is her fault IYSWIM. Or if she has been treated with kindness and respect by ALL her carers, even post-natally, not just in the birth.

ETA: Marydean, I agree - having your own mother saying you're being melodramatic when you say you're having problems with not being able to remember those early days with the baby because they've been blanked out, you are having birth nightmares and are still in shock... you need a support network as Berry said and you need a support network that won't just fob you off.

[AnyDream]

I think a de-brief should make it clear that it won't affect the stay in hospital - I'd have lied my head off to get out of there. And the PND check mentioned there, it's easy to just give the "correct" answers.

I agree, Ryn!

Also, I don't know what it is in our culture that makes some ppl think it's just a case of "getting over it". How can any woman know what another woman experienced - just because some ppl find birth painful but bearable (possibly in a well supported environment) doesn't mean it's that way for everyone!!! And there's some sort of value judgement wrapped up in there too, like if you didn't cope ok with birth (no matter how hard or easy it was) then that reflects on you as a person in some way. Because it's supposed to be this "normal" experience.

[AnyDream]

Julie, yes those questions are a lot more on the mark, especially the questions that deal with numbness and dissociation. For example, I had enormous difficulty talking to my DD for months. I could sing to her, but I couldn't chat to her about everyday things the way most mothers do. There are months and months of entries in my journal about this one thing, I was convinced I was a terrible mother, not that I'd had this traumatic experience and what I was experiencing was dissociation!

However I'm not sure that a questionnaire immediately after birth would have caused me to identify the problem. It was some months later that i noticed that I didn't seem to be coping the way other new mums were, and that my energy hadn't returned. I also experienced a lot of fatigue and pain (not related to sleep deprivation as I was getting a lot of sleep) it was more of a drained feeling like I just didn't have any energy.