Post partum disturbance …

1)mental

POSt

ill&

Mai slim NI Al

occurre”ce

syndromes noted

in

%temture

date from

behavioral

literature

Moda”

of such

1848

with

and lactation has historical

since Hippocrates’~‘. tific

of

associated

childbearing

been

?McGouron,

post

the immediate

post parturn

in

period

I” suicide. infanticide

and i”stiturlonallzatlo”.

At that time.

parium

sion. “w4c phrenia

d&b.

ante among a number of possibilities. This

article reviews and new,

relevant

past

research on the

syndromes.

and uhizo nyn~ptoms

Mild or post p&urn

de.

which “ccurs 1.7 days after b chamrtertzed

by tearfulness,

birth is one of the interacting causal

fall

agents.

after deltvew, or an imbalance of the tw” hom&s-. The dfmi”!&zd mental activiy and co”haion “b

.includi”g

classifiable

such as schizophrenia. sis,

depression,

and

transient

illness

psychonew”.

organic

psychosis,

situational

ertm~e”

and

~ogestemne

disorders

sewed by Pitt was not suppotted

more co”trolkd 3NBati”“~. Yakmi~ study identtfted additionzd feelings of

urn disturbance does not constitute a

“ormal

I”

limits, i.e.

the ‘host parturn bl3er” While there is general agreement that post part.

in speclflc relationship

to pregnancy

divreet nos”lcgical estity-‘. is confusion over pswholwk.4

and the post

periods.

physiological prodicpbsition~

The

of matemtty

of mania, depres-

and manifesting

of the&‘. pressa

n

blues””

anxkty. depmssio”. restkzsnes and irritability atht$uted to the pwctptt”,,s

Ztlb”“~

parturn

cover

found to af-

psychological disorder in which child-

unprecipitatad by childbirth’. It was not until the 1920’s, however, that Idea that those disturbances occurred

bluoP,

psychiatric illness

birth

immedte

t” catsgodes of the “xaf,x

specific type of pod par&

regarded as within

challenged the

the period

range from “matantty

deneported incidence, and the difhculties associated with diagnosing a

such disturbance was viewed as basitally different from mental illness

successfully

of

parturn

feet as many as so408

“post parturn syndrome.” thu is ‘hny

lurid

stressresponse.

‘Tstutbanxs

or “pat

!.N.

literature

s&n.

&servaio”s

and recount

stodas of behavIoral disturbances which resulted

D

patient@“,

OWNi.XU

T

by

2) a” orgrmkally based rerponse 3) an holfstk

he

prafpftated

chlidbwfng

in a

loneliness, low s&f Odean. estra”geme”t and increased vulnerabilihl or

there and and the

with fears of ln&acity master a “ew event

to control or Both studies at.

popular view UJ~ t!w” replaced with the intight that physical prrrbkms or

nature of the interaction of the etiologtc factors. Vlewed in a” h”listic

events are not determfnants.

manner. post parturn disturbance has many characteristics of a stress re.

tempted to corelate contributing fat tars with smcttcnd upset. but only worn aal. f”u”d any relatian&ps

sponsa

to be signifkint:

clpttattng zqents

but pre-

In psychological

ill-

ness’. Intsestlngly.

the

argument

has

continued about the unique nature of

inasmuch

conditions stimulus

as environmental

of childbearmg for

create a

an acceleration in the

post

p&m

the occurwncz

blues

ks+s fear of l&or.

c”rr&ted

of wtth

. _ infee.

low o&v.

rate and an increase in the anwunt of

tlonss,long43 interval since last prq-

urns. fts etfology, and charactedstics. Dif:icultks of study tn the area have

anxiety.

nancy and yo,,“ger age at menarche.

been identifted by man?” who note the problems in establishing a link

general will be viewed on a continu-

Both studies r,oted that post p&urn blues were sel’ limiting, and recovery

um horn brief. transient disturbawes t” psychos@ thz writer will highlight

was spo”ta”e”us i”tWIe”t,““.

salient

The f”waIg syndmnr! ewlws most closety fmm -normai” b&w

Illness

assodated

with the puerperi.

between neuro.endoaf”e ic change, the probabfllty

and psychof a” u”.

Whtls

past parturn disturbances in

characteristics

and psychoneurotic Ms. McGoran

of depression disturbance.

A”

fs cwrendy (I doctoral condfdate “t New York Uniuerslty. She ha wvrd 01 the Mental Health Conwltwd with Parent-Child Nmmg at Herbed H. Lehman College in

dmmes and recent research Identifying potential stressors in these dtsturbances. suppat meantngful analy sls of total oga”lsmtc response to a

New York.

life event. Three cunently

JOURNAL

OF NURSE-IIIDWIFERY:

increased

incidence

Vol. XXII, No. ‘2, Summa,

of

187,

such

syn-

held view

ices observed

without

in

the

psychkIm

puqertum.

While puemeraf depression mimts the tearfulness, rwtlewnesx and de pressed feeltngs of the “blues” the dkturbance in thought procases

klenttly a distinct psychopathology”. D!arban..zs in ihe level of eewrtty of poerpud deprenlon. mania, xhimphrenii~ and d&turn oo:w with an inddencf of approximately 12 casa ~BI 1ooD births*=“and of these. depro&on constitutes eppmximately 2.96’0 ‘Nhtle post partum reactlona are conmon*the more severe rexE!hns, psychoses,are not. Addhiond obwwtions by Bra, Karacan, and Madden indicate I dlagnostie trend in the direction of lea psychosesand more psychoneurosis.In 1911. 4:b of post pxtum illness was diagnosed in this later category ‘13compared to 20% tn 19SX. Maddtn athtbutesthls increaseto a recog~Uion of diag nosttc subtleties, but also acknowl edgemcnt of the difficulties and dyn. amics of role adjustment in mothorhood w ,.rectpitatingstressfactors”. Slnt e trends in diagnrrsisvary with tnneasi.Iy scientifici--asligation and social a mlyais over time, the ceusative facIors of less severe reJp”“~!s cre unclear. Psychodynamics of depresion and schizophrenic response~ are also subject to curreni trer.ds in psyrbiatrk thought. but .orne Iwic similarities occur in all psych”,+ re6ch”ns. Repdion of thr ,nfant is classir.#y seen ,n psychotk ‘esponses regardless of diagnosis ~&stile fantasies to the patient’? mo!her and about death or damage :a ihe infant. antagonism 1” the marital partner and re,ecU”n of the ~nirm. and ambivalence about sexual Xentity additionally chnractnim the psychic constellations oi the client and me the same as thos! of illness unrelated to childbearing,“,“,“. De peesion mu’; be pqchotk or neur”?. k.. but themes of loss. gu:lt and dependency predomirmte and low self esteem with a senseof por+>nd inadequac)‘. occur conshtently”. Low self esteem and vulnerzbllity accompany both mild post pwttun depression and anxiety states.coostitutlngrecur. rent themes on the continwrn of seuerity. The nature of the onset of psych”. 11sversus neurotic depression tends to suppat the lmpo~tanceof cumula. 2m

li’ve stress factors. sgs of psychotic 1 neurotic or borderllne oattentsdurlns dlshxbance occor early in the leg. ” ancy according to Madden, Indkat. lone have identifkzdk?ssp”sNve and h19 a person&y predtsp”rltl”R alnore spedftc charecterktks of em”. dlough overt depresaton or other +xml and cogottive states of prsgwwy and early puorpedum. Tod t!,pes do not usually occul until the knmediate post perturn palod8aJ’. vated that most pregnart women Cl&on“ observed a conttnuum described anxiety within resolvable tllmugh pregnancy of early anxiety, wxameters and Bfsldnd relates anti. 1,> elation. to demo&on In the ouer~tytnp~~ancyt”thefoUo~“~ 1) fear of phy&l pain, disability or Perium,b’otherknangs are not .&. ated bv o:hers”. Additionellv. obP death ervaU”& of early personatlh;‘dys 2) severe taboos about sex organs u-&on in the schizophrenically andfuncuons orderline individual vlyv widelv and 3) ambivalent feelings about pregppear dependent up& sub&tlve nancy Beament versus conbvl!.ed study. 4) emotional Immaturity and on. Uhile argumenta very on the ttme wtllingne3sto accept rep”“slMlny .nd natlue of onret, it is genemuy 5) fecbngsof inadequacy #greedthat other psychoses appear 6) rejection of femlntntty nosl dramatkally and suddenly in 7) unatteinable goals or attempt to he immediate post parturn period. live beyond one’s eraotlonal capacity uvhile depression occurs more insidi. While the above appear to contra. uslvb. A complicating factor In asses. did the serenity described by Beire I&data is the difference b time dek, note that she de&es the bbeled the “post parturn” I xiads healthy, fully matore woman who wriod’“. demonmated ego lnteqratton in the face of the regresswe&vects of pregiU”l”glC nancy - an Ideal of health versusthe norm. Atwisty heightens to &mu. efore re~lewtng core differwith fears of bnpending disaster, at ences In etlologlc Ideas among labor and delivery according to the three viewpoints mental ill. several authod’,h’.‘O. and the state was precipitated by childbirth, organ. of parttuitIon Is normally describedas tally pn;ipttated dydoncti?n. tind “mobllizina the bask anxtetu of the I”li5ttCstressresponse.some “b+!rvfemale”“.-Fer of labor is ;“i”ersal ktions on normal psychologic states and Robin says that the paturftlon ,f childbearing are relevant. The expelonce Is subjectto amnesia, dts. mrmally clot corresponience of torted perceptkm, hypnsenswitity xldlly IHe and psychic pmcesx!. in and an assodeted mental etate of he woman ere noted by Bardtick as suggestibility. Kane’s dinkal pqrchl. nom intense than In the man. The atrk survey” of 0bsIetlical patbnts :“nmmitant physiologic mantfate. on the ihld post parhun day, >f anxiety earlier noted by Cannor~ is focused on feelings during preg. ~eitaated by Basowih dal.” and nancy and the early post partom :he newokqkal influences of nancy are detalled by Benedek. She period. Asked about subjective tiatrs that hormone induced moc& awareness of increasedtenslon. aox& kanriently invade the ago ato dw ety. Initabillty. sexual activity and ing pregnanc.y, and psychcdynamk desire. menstrual hbtory and reproawes can be undewood as or IP”“se to nlenses, SkePiness or intenstftcationof the menstrual cycle momlng skknessIn the firsi trimester, She describesan improved emotion and !&lHy of mood dulng the post al state of vegetattw calmness,pka wtum wriod, only 36% of the 137 surable thoughts about mothaln( patients desatbed themselveses feel. and litddinour feebngr ‘luring preg ing as usoat or b&w. &htv_seven nancy. Whtle several a>thoa not‘ peramt showed sub@ctlveevidence Improved functioning of normal of ilnxlety and/or dcproprlon end

B

Variations

t

‘preg.

JOURNALOFNUHSE-MIDWIFERY

l

Vol. XXII, No. 2,S,,mnm,O,,

I

cognltivs dysfunction. The studv has

some limiiations. Racial factors-were

not controlled for I” the sublective evaluation thallgh wide educational discrepancies were noted between white and bkck patients. Also, no attempt was made to differentiate patients suffering “maternity blues” or the mild depression desaibzd by Pin’ and Yalom. In c”ncluri”n. cettein pnychological and cognitive characteristicshave been observed in “normal” pregnant and newly delivered women. The quantitative and universal nature of psychological change needs further investigallon. Also. cognitive characteristics of the post perturn period must also be separated from affective changes prior to labelling a baseline of factorsas “normal.”

natnnal imagi,

ego

Those who view mental illness during the pump&urn as prodpi. rated bv childbirth sod charactcdzed by certain psychic constellationspresent primarily psychoenalydc view. The interactions of the physiology oi pregnanc$ with psychological pm oases is acknowledged but the events are “nlv veouelv correlated. Markham end &he?; note the reacti. vat,“” of earlier conflkts”~‘~” and describe D constellation of psycho. dynamics of the woman with severe p&t parturn distorbances.She cites 1) a distorted relationohio to the mate& Rgure based on intense dependency needs of a symblotk quality, 2) me&w, hostility to the mate& f&ore contrastingsharply to positive patLent.mother fedings in the normal partorient described by Robin, 3) severe inner conld around phallk wishes and .the hope of pawring a penis through bearing a male child Adminktering projective tests to a small sample (11) and controk. Markham differentiated between ‘well’ and 92” mothers according to the occurrence of post parturn psy choelr. ill mothers perceived their children as a Qein “$1their emotIonal resowca ee rivals for “oml” supplies. C”ntro!4 wew able to use chiklren to solidify their defensive structwe and further thdr emotional growth. Ill JOURNAL OF NURSE-MIDWIFERY

mothers were swbioticallv tied to a I wrium. In 1942. Blumberg“ wed and ““able to derogestin and desskated -pih!itw golop a self identity. Women in the lend in attempts to decree psyisjrontrol (poop had achieved a well hoticsymptoms.andnotedatth& differe~tlated identity. were more me, cydk “rgank symptoms assodted with prewoti tendon. mature, wed greater sublimation and motor dischargein coping. tdarkham, Pregnancy inrolves interglaoduku like Deutsch. Benedek and Barddjushnentsof the endoaine system. wick=, views post parturn disturb he thyroid and prhritary gknds enante ZISa disturbancein function. uge and inaeaee the> secrefions; Brew agrees, noting that psychorogesterone cod estragen are prcphysiologic stress may weaken the .uced in increased amolmts, and ego to the point where energy of ariaions have been noted in the conflicts earlier repressed can no ind and aoxwot of 17 hydroxylonger be subdued and make thek terokk and 17 ket”Cief”al9. Spatpresence felt. Regardlessof the diag ation es to whether sudden reverwk notis, the etiology postulated is thar d these endoab~olc@c chaws are of ego decomoensation.“rrcidtated ausative “I merely contribotcey to by events of-pregnant; and childmerperal disturbawe is reseicted by birth. The approach desaibes a psyw” factors:4 limited and nooewcifchologk response versus an “rganc human research”.” and b) l& of ismic one. let&d. soecif? ohvsiolook data on mmmrr~ bakncid-&tog &na~cy.

l

rhe ,y~ii,?~ euser?i tha metaboli= represents LI deuelopmenlnl milestone

for tFle

man and the peak

of

psychosexucil maturity for the woman 99 The organic view stated by Kar. nosh and Hope” and maintained currently in varying degrees’~‘“.‘”suf fers from a paucity of research on humans to correlated hormone levek and behavioral change. Animal studier lndlcat!ng disturbance in endcaine equilibrium following pla cent.4 separation and the influence of stresson progesterone production and behaviom have susoested oossible distind behaviorei-respon&s to hormom levels. Y&m and Hamburg’s stodier indicating early monmche, quality o menstroa! wdoda as related to DOS pertom b&es may also lend s&m support. Dalton“ noted that wome, with difficulties adjusting to hnrmsm levels in the pre-menstruum .ISI tended to have greater difficulty ad justtog to hormone levels in the pwr

subsequent sexual

Vol. XXII, No. 2. Bummer 1011

:hange%in p.egwncy and the puerprium are pbysaqii s&sson ill a total process. and a number of :.Ivestiiators SUMbe to thisview. SelyezLdescribedstressas the rum of all non specificchangescaused by functiw, or damage, iodudlng re. establishmentof norm.4 resting state. after the descent of treatment or during continwxs exposure (adeptation). His outline OT relationshii of psychic experience and phyxioio@z c”“c”mi!anis in the general syyndrome, have become b&c to undnsrandina Me events oerceived as stresrfil, and end&in”l”gical chaws. Thomm and Gordon ideonfy d-&e sets d circumstances that could account for the ectivation of stressresponse in mental disorder: a) se*s of impacts from an idetuifled stressor b) equal impact from stress of multiple natures c) accumulatkm of sinzssesthat are of little signifrcencein themselvesand yet are of such degree that a sing!e added stresswill tip the scde. ldeot& fied stieswrs and the presence of anxiety in later pregnancy and the pwrperium have been previoosfy cited in “umerous studies.

First

meIF. mique Benedt:k.

Madden.

ham. Norman.

Brew.

and BiSklnd

Mark-

,9 identi-

fy &siMestwsorsresulting

from

any

set of observations.

Free

must be considered

in re-

one

awiety”

‘ion which

and as a restxmse

it eve& which vary in significance among individuals. As an indtvidualized factor it contributes :o stressors akeadv deftned in nature. For exam

pie,brood

loss

during

delivery

be-

comes a more potent stressor for the woman who is already a,;xious. Stressor cf the puert:eral period can be ;!;c;iticd as: al ph~iologtc

or physic al

presents

has only

recently

tent&.

:hild

yemind us that birth of a represents

r&stone >f

a

developmental

somen.

The

woman’s

maturity has

value to tndtvlduals

factors.

of

or death which

Numerous

hauma.

to otherr

enP”.

Fears

of

conflict attributed

rhsgee. lacerations, an abnormal obstet%,al or nedical history. infections.

uncin~iou* responsibility.

drug effects”.

ine I&.

stresses

irre cultural.

chosexual and emotional.

psy.

Bardwick

or

to

cultural expwtations rejection iaeoting

may exist.

bodv

the social “predictor

decate-

of wife’s histow

previbus mmiage. statusof

her

tory: emotional

of husband’s his and fam-

problems

ily’s statlls. of the marriage:

d) physical complkatlons.el comdicatioinntith chlldbeartnq.

to

fjrecehenvironmental

Those

versus

change.-

subjects. involved in the ew

perimental group received antenatal teaching. Gordca denies, however. that such intewent!on affected the

of maternal and feminIPSychic StreSS

may evolt e from poor marital adjust-

significant

ment ~ee*ua!identity ambivalence. il. legitimate pregnancy. and expecta-

j&s with high numbers of stre~~ors indicated in the Social hlstoy and

tions of Se!f that do not conform

emotional

to

realistic aspocrs of the child bearing sitaatlon’s~a~z’

dilemma).

and the chanws

to the

family hlstoly

American

culture

family

hinth related responsibility’n.

Environmental

Stressor

This

include

financial p&lems. limited 1ivir.g Spwe. problematic relatIonships with the family of origin. tragic death o* surcide of family

members, unstable

or marriage and extu

the

apart and there are problems of iden-

al. The incidence of seve:e reactloo!

tification awciated

is low when considering

experience

post Othns

regarding

~;artum. asked a the intlu

ewe of psychosoctal factors during pre9nancy and at its outcome. Kai) etat. Interviewed 108 Swedish rubfeds and dgnlficantly

Among 9roup.

correlated neg

the

asp&

“emotionally

the simultaneous

of asphrxia

appaalr

by negative potenti thi

difficulties

question

Sub.

livery with physiologic complications.

It is eaS1

with child care*? mothers and dcughters often live !ong diS:ances

chiidhirth

between

ative attitudes of pregnancy and de.

to speculate on the cumulative ef fects of mulriple Stressors For some ouerdetermmed

correlation

Is qwitionable.

similar

Me. Extended families are no longer available for suppoti and guidance

with role change.

are not

role oroblems or intermarriaae.

ma;

notes that the best we can hope for is an “ambivalent” Iversus negative) anitude on wornenS parts toward sex and reproduction given the cultural atmosphere. Yslom and othars cite the role change required for R young woman with a career (mothexareer regmdhg

&bed),

c) complications

the expresSed desire to have a child to fulfill

Status

and controls

b) iomplications

intrapsychic

bq Menninger

are lim-

(they used

socioec.onomic

family. emotional problems.

prer-

distortion

studies

application

middle

al comollcations

has oc-

assault

physical

data. Al-

subjects,

age.

congenital

Unconvzious

the Gordon

studies. prediction

pories” are worth desctiing

The

is frequently

tained in the cited works Physiologic stressors include the meiaboltc read. justment uf glaatdai !u.:c!ion. &c ImlWe imb&nce. protein metobol. irm change’. pain. physical exhaw tton and sleep deprivation, homor-

&chic

thouqh

ited in their only

Stress may consist of con-

:uned

tension, anxiety about

of Social history

-achi&

deformities

exist”~“.

the

various

claims Succasful

but is oenerallv

or uncon~iow

lmagr

of

with

Gordon

differing

a psychosexual

Pnlchb

the

affkmetioo

femininity

see? as men, ‘3.

for

of

disturb.

appear to vary in im-

by we

for the man and the peak

psychosexual

Othen

portance

as well as Deutsch and

Nomnnd 3&wick

or car.

relates to the development

ante.

bwareneSs

the outcome of labor, and a sudden droe in hornone level~.‘~~‘~’

identdted as preditiors

mild or sovew post parturn

tw*

c) environmental con-

or per

A

soon.Sllty, or decreased coping abili-

icicus

are

number of variables have been

been

increased integration

bl psychic

examples

a

recosoized a~ a “crisis” with dual PO-

sponse to stress, ~4s integral to total ego orwmiration

pregnancy

Stress and a major life transi-

and uterine

stressed” occwre”ce inertia was

57%. nils limited Study bar impat. ant implications Lr further work. A Sym~:om

related

post partu n disorder

prediction

of

was suggested

Moues from urban centers to subur-

Host-envhonment

ban towns are streasor~~‘. Young husbands are frequently involved to develooins ;a,eers and are rarelv availab& ti help or to work out thei rote adjustment. Upward mobtltty and e~ooorotc S~UXJT,require adjust-

stressfu or~ty one

Symptoms during pregnancy did not precede orurrence of psychic prob-

Tbo outcome of negotiating Such stwssful Situation will be determine<

lems in the pumpertom, significant relationships occurred between the

22

\oteraction

marked with numaous events. .childbirtb beiw

by constitutional

and acquired

t’

i

trait’

number

2nd othnP.

OF NURSE-MIDWIFERY

l

While sxne

of symptoms post parturn

and delayed involution,

of (be host JOURNAL

by Nllsxn;

change of

Vol. XXII, No. 2. Summer1977

of mensmml

duration

cvde, genital

puemerium

with

disturbance.

Pains and sexual disturbance. l-he

mature woman

w

expertence to resolve

of ihe questionnaire

tcxd end

the retrospecthe

this study, limit Paffenbwger loting

as the onlv n&w

its predktive

df

0thersz~‘~“4~’

attiibute

long standing

maladjustment,

Preg.

Preperetton

factors as pwdic.

nancy and childbkth being only ano-

shorter gestation.

ther one of many stressful ltfe events

lower

for

which prerent

birthweight

baby, higher

identtfted

older age of mother,

difftcult to wcertein emotional

tra-

who will experience Post Parian et.&

attempts to identify

logical

signpasts.

15.80%

endoaino-

unbrtunataly,

blues occurs

ofnew

tha came

where paems

prychdic.

os sib-

but the small here&-

tary or familtal predisposition

tu any

dice

maj-x diagnostic cate-

issue of parity

ha -hen

ex-

development of post partmn disturb ante. The

and Its application to a

ego to me&r

Whether

or not

one to Post

pattern awl level of ad-

debatable.

justment’ have been noted as deter-

thwretiiy

age predisposes

Partum

disturbance

Paffenberger

states

is

that

the older woman is more subject to

to ti,s

difficulty

stress of childbirth’.‘. As a predicator of the other types of mental iflness. it

concept of a new expel6

ence and asscxiated attempts b, the

-9

total population.

of one’s adiustment

found

amined in attempts to link it with the

cation and replication of the studies is

mlnint

beattng a,d

Brew

percentage raises doubt the

The

mothers

all

necessary to increase the objectivity

Personality

to chit

of his study populatkm

than for otha Qolies.

are begtnnlng stages of traits identifi-

of the d&a

of diiub-

the findings

normals.

greater for post part!ml

in anywherefrom

dif-

ficulties. They are similar to Yalonis

pmximaes

lings we

“Mdernity

attempts

of the Roman

of

patients,

ante unrelated

from families

Para ormuhipara. All the studies represent

early

Sea&s

11 had a lam& h&toy of psycho&, 2 of the6 bag port Patal. HlnveveI, MS Sgt.

12 post pmt”rn

14%

of the elderly Primi-

to develop a profile

in

cttes

of abnormal ckents and

stmlla

cr-

it is

or

for the pre-

disoosed individual

if the above ere

predispositions

ditional p&ems

difficulty

disturbance

Hamikon

iheh family histcdes of pqrehoi+

to

tive: lower fertility,

pertnatal rate. However, since he also

parturn

xxnptin

position.

dlfficulttes

1 1x1*

~udte+‘.

old conflicts

and strengthen the feminine

value.

et.d.l’ ldenttfted the fol-

a

uses the pateaton

support

and

‘Thomas’

comments

this on the grounds that I:fe

a new life support

the primtpaous

event could

the occlnence

of more pod p&m

diiubanw

woman”.

gmryl made the point

for

Yafom’s

that even p,e

natal teaching and guidawe canny prepare a woman for the intense im-

has been relevant to the occurrence

sttcc~ is’eddltive: since mental illness is a stress, one mrght as~,m,e that the

pact of physical sensationr of d&very. peaonal senfatkms of creeam,

of tllnsss, but not its paticular

typolo-

older wane,,

would

and the ma,.x physical md emo~on-

which

susceptibility.

It 15 Pointed

gy. personality

constellatior;s

have a higher out

that

al changes required rote. t&pite

in the mother

this theoretic&y

round

predispose e womon to post parturn

years of maximum

dlsturbancos

delimit the age group of wmen af flicked with such reactions”. Yalom’:

aumption. Tad pamus muthers

group found no correlatkm

petturn upset than multiparous.

but rawly

have been postulated

vaIldated by study. Bard.

wick notes that because reproduction 1s so crktcally linked tith the v,c-

fmility,

15 to 45

betweer

stvdy of 700

found that prim& dewlop len pod

pregnanc&.

In hi

he found

man’s self esteem, the psychosomattc

post parturn disturbance and age. Early studies. including Small

changes associated with

the repro.

den’s’, suggested race as a predispo

that post parturn disturbance u)w more frequently r&ted to the third

system may serve as a psy

skion. Later studies did not bear thi!

And later pregnancies and attributed

out but Kane etal. found

this to cwwlative

dwtive chol~cal

defense.

a teehntque

keeping the person&y

of

intact. Cer.

their

IntenJe unfuffilled

wishes

whkh

make

them to moth&“. or i&ntifkatlon

self. In evaluating

dependency it dtfftcult

the puerperium

for

mi~iveness

Intense iealowy

lngs

wtth the infant may

They

populate

an

Immature

OF NURSE.YIDWlFERY

probab+!

ditional sire*6

as a predl:;p&ng

Vol. XXII, No. 2, Summer

III77

fwtor

i,

of greate? blaod Lorr.

greater fears of f&x,

edww.

but no

observed bid those

women had &so sxpertenced the ad-

The study lacks a sufftciont identiica of contributing social factors Y

supwded l

al.’ supported this. Y&m more aying in pimipaa

hat&an ~ntiily

was suggested

stress of chddbear

ing and rearing. A study by Katj e%.

remesent character defenses second my adaptation to their scdal role

Heredity

woman responds to the skel$ of the JOURNAL

in self rat

Blacks

that the depresstve quality if associ eted withracetsnotdetectable.

adjustment”~‘~”

that

they found that sub

and passivity

Southern

tion

that meturtty Is the key dltingul$hing factor between hedthy and u”. puolperal

of

mood changes o

to

b&-a intmpsychk conflict and asswtated illness. Sawal authors note

heakhy

that thei,

study data was changed by raze re lated attitudes and perceptions D

taln women may be psychologically unsuited to motherhood because of

Of the

so that the ex-

factca mt& b-z considered. they were II h~hly sbea. women

Fondeu

stud&d

who were depressed after chiibkth. 51%

had been dewased

with

the

birth of the fkst child M campawn ,mn*Mdci,pq)cJpf s1

tQ 49% of muliiparas. Reviews other literatuw of pettty

end post

parturn

ante etmem inmncluslve’ wh?&

~&tdbute

Fen&e,

of

regarding oxrelations

for

to difficulties, bed

that

Ieers

for

themselw

ad

symptoms

of twitablltty -then multi-

paar.

The

question

fxtor.

Tad

found

anxiety was a s;gnifkant

ecwence of the same syndwme?

In by

question

naiadjustment obutingto

or

IS anwexed

of predisyosltions

of the client 05 corn

such distress, the expecta-

ton may be e positive

rather than parity is the deter.

minng

or the

- If en Investigetor Identified chronic

again emerges

increased anxiety

a

rart, thls

w, understanding

the baby and fewer

as to whether she>

post parturn dtrtwbence

end

found

more

ilfness provide

of the Oecwence of

pdktor

on factors

example,

primigravldae

Qes ~evioos

diiturb-

leur points

that high

om9.

Foon.

out that while post pat-

emdtsturbnnce is not a unique entity

facror whlk

is unuwel

because it can happen in

perky was not. A number .of other variables have

in otherwise healthy subje.3 who ,“I!, reacts ebnonnelly to mother.

Ir,ived

lood. He. a5 do othes’~‘q~‘n tends to

sxxne ittention

to have

proved

but hew not

discrimineting

sex of the child. r&km mother.

previous

lecgth of host&d mend found

‘me&l

power

upport the idea that reiponreto

of the

hersful

health.

lands to petterns of life adjustment.

slay6 a.‘. While Nor-

ihet tmun:3

event

of chiklbirth

l’he tentativeness

did not ep

ion

the

corres-

of such e qualdico.

is reinforced

by the

fact that

childbirth

but he notes a recunence

rate of 158.35%’

for women

who

have had (I reagonse to chlldbeering. Paffenbwger’r

recurrent rate after en

eightem year siudy wes 50% but this is onusually high”. One cennot dtxount

the applica-

tton of rates of recovery to claaifiable diagnoses -

if a schlzophrenlc

reac

tton, like those described by Ztlboorg and Smallden,

occurs in the immedi.

ate post parturn period, It Is essential to identify previoss

responses of the

same type to life stress temptins

~rognQ&.

don,d&g

before at-

Similarly

depres-

the puerp&mbc&s

varying degrees in normals

I” imetem

ity blues). Prognods in post parturn disturbance diagnosis.

depends The

on

definitive

literature

rence and prognosis

on

recw

for specifically

,revious post parturn disturbance is lot significantly identified as a predis

diagnosed illness

rrothers cried mere when they had experienced physical birth trauma or

,ositton to post pertum disturbance uith ad&tonal pregnancies”. This

when their infant was distressed or ill

group alx,

Two aspects of management in post pMum disturbance will be di+ cussed: a) treatmen: and b) preven-

shonly

hrence between the general fife risk :Qr mental or emotionel disturbance

pear related to posi parturn ance. Yalom’r

group

after birth. Salk”

patterns

ot holding

disturb-

observed thet

found

that

varied between

inothers who had been sepamted from their premature infants from tirth and mothers of normal babies. and

felt

that

the

st;muhs

of the

baby’s presence is essentid

to &it.

found

no stgnificant

dif.

and risk for post patum disturbance. Pugh and hts group” supported this finding. however, they noted some predisposition to some illness during

versus

“post part-

urn disturbance” is spew.

tton. Treatment post

pertum

deoendent

in the acute phase of disturbance

won

bar been

the sumotomatol-

ogy and the &verity of-that disturb. ewe. Pitt and Y&m found post parturn

metemny

Mues

relatively

the puerperium.

Baker. in his experi-

benign and self limittng. More severe

ing the respor.se of maternal behw

ment

65

psychotic

ior. This sepaaetion “trauma” may predispus the women to disturb

whom had suffered a depressive re. action. the recovery rate was 90%

awe in should h

for e corn&e recovery end 10% for social adjustment le\,el of recovery.

A final

thowht or feeling, Investigated further. issue for

consideration

previous

p.lst

This

be dixussed

will

and

patinm

is

disturbance. in regard to

prognosis. The value of studying to= tars which-occur !wquent!y in the syndrome deyrends on ine appiicabil“y of such factors to .=.general pop”&ion. here

A number cl fictors

reviewed

appeared to have imd

relanonship tn the ocarrenc<

some of pa*

parturn disturbance but none demonstrated w .inconclusiw.

is

involving

Fondeur

wornen,

cites similarly

recovery r&es for a nixed grow

13

Of

optimlstlc diagnosis

who experienced post parturn

disturbances

including

whtophrenic

reactions

intitutioneliration

have

required

and with

the ad-

vent of the major trai~quilizers, chlor. promazine’~“. Recelcihant cases of depression have favorably respond. ed to ECT‘ end monemineaidese inhibitors have also been utilized. Minor

tranquilizers

mpodde

such a.s Chuxia.

have been administered

reactions, depreeslon. psychonew rods and manic depession. He notes that diagnosis is not ir variable in ad.

the psychoneuroses’O.

justment after illness although the prognoas seemed better when the ill-

reactions, end no particular therapy hasbeen utlltzed.

“es

was releted to childbearing

ar

in

Genorallv.

ovmpt~matic treatment has pa&l. ed usual claulfication of post pmtum

Several authon

somatic

support the we of

short term suppotilve psychothem. py”.“.‘. Aimed et symptomettc relief through ventilation and BQO suppat.

vary in the experiences of each sub-

ommsed to unrelnted childbearino. supports favorebl@ pmgnosis, cii. ing the statishcs thet M)% of thlr sampl; of 100 had tocovered end were at home, 25% had improved and only 10% had not Impraved. No?

ject. They ere hdplul es areas in need of further ea>essment.

maad reiterates that the prognods b approximately the same es thd fo!

wer-Foner

or

causally related becauiz of a) prob. lems of conMl!er! reszuch Qr b) aif. ferentietion of stress factors which

32

G

JOURNAL

OF NURSE-MIDWIFERY

such en approach strews the crisis oriented, temporally oriented, trans. lent nature of the disturbence4~‘. Sar. in hb andysis

ful treetmed

of symptoms

of success. of vulnpr.

9 Vol. XXII, No. 2, Sumnw

1S71

a*j”nme”t to me me.lcmal

c&m, all noied

r&urently in post p&urn reactiow found good to excellent effectivenesswith psycho. analysis, psychoanalytically oriented psychotherapy and supportive psy &therapy

pre-

.

Ultimately, research results should dkect scientific progressin treatment end preventIon. Some key ideas of prevention were implied by several studies. The wcwrent question of personality predisposition by virtue of previorrs illness or psychological constkutkm indicates a need to mnside the use of elements of the psychiatric history in the prenatal setting to identify emotional and organic factors, as suggestedby Kaij et.al. Gordon and Gordon, ustngsocial history data es the predktor of emotional reactions support the psycho-sodal of prenatal assessment.A.A. Robin woposes that this knowledge of previous personality determines behavior durirlg pregnancy and the pat patum period, but the accuracy of psychologkal eseessment of the prepregnant personality is decreesed once pregnancy has corn. menced”~“. Perhaps Caplan’s princiDle of entkioatow widence is best e&+led dy th; &unseling sugsated bv B!&nd and the combinatkm of teeching and modified psy chotherapy used by the Gordons. Bisklnd proposer acknowiedging the ambivalent nature of pregnancy end the frequent poestbllitythat ‘psycholcgtc wishes to not necessarily c* indde with biologic drives.” By assbtlng the client in overcoming anxieties awadated umh pregnancy, educating client and husbend on the facts of pregrancy, explaining the importance of cathantr and interpreting the meenlng of the dent’s feelings, the health wofesslond can leseen the skessful eepeds of .the experience and enhhance the client’s coping potenttal. Technkel orobkms influence the value of int&ention ured and prowsed by the Gordans”. Thek ob&ved &~~Ietlon wee small, homogeneour end reldively similar in the types of needs they had regarding JOURNAL OF NURSE-MIDWIFERY

role.

wtal educetion classesand su~po,tEvepsychotherapy centered a&d: a) assistingclient in obtaining help and guidance of people experienced In child care. b) suwmxt of husband and assistance to both spouses in sexual adjustment, c) diwussion of plans and provistons for assistance with child and household management, d) establishment and adherence to a leisure time whedule, e) competent medical attention, and f) suppolt of ventilation of fears, anxietks Gordon and ht gmou~claimed high successfor both social history and positive tesponsf! to teaching and support.

l

hi topic is

Summary end Condu.sions of particular interest because it exemplifies the need for a new assessmentof a common. but recently little studied syndrome behavior exhibited by women followtng childbirth and basic to maternal-child adjustment. An et. tempt has been made to view the event holiMcally as a multidetermined occurrence in life adjustment, involvins Dhvslolodc as well as DW chologi: ‘pheno&na. Altho&h odalnallv viewed In the 1920’s as I d&a brgank entity, with grow& sophistication in saciologic and psychodynamic methods of assess ment. the behavioral syndrome it now understood In broader and more relevant conten. The skesset undergone during pregnancy ant the post parturn period. a) endocrine changes. b) activation of psychologic connicis pertaining to pregnancy enc c) the roclel and intrapsychic reorga nkation of becoming a mo’her. arc complicated by unique responseso individual women. .4ttempts to ident ify a high risk population seem mos bask In terms of endocrinologic dif ferenws“ because mens3nal hii tories are skeightfonvard and ho, mane levels are measurable. Vai abler discussedin the literature suet as parity, psycholqic corstitutior etc., are modified ic their saiience a! predktors by psychos&al factors it life events.

T

Generalizing from t:te prerenta Vol. XXII, No. 2, SummwlW7

ata one might starethe lol!+wiog bout wst paturn dishrrbance.The lccllrrence-of scvc?e post partum iisturbmce of thought n affezt ie are. epproximetely I-2 cases per howand, while emotkmd leg or natemity blue* Dccurs in anywhere mm 1%30% of new m&he@. The ypes of post patum diibence folova c!z&ffable psychiatricdiiosez md correspond to the psycho!cqiczd nakeup of a paticular woman. A women with long standing life edj&nent problems will develop e differmt type of di5turbaxce from a wxnan only recently exposed to Went skeaore. A women with ambivalent feelings about feminini(y DI mothertng a Roman who ts exceedkgly dependent or peoccupted with meeting her own dependency needs, or whose se”53 of ident@ ts not clearly differenttied, will expaience difficulties adjjng w matema: respon&lities and may manifest tbii response physic& and physielogkally in the form of e pod p&urn disturbance. Numerous physiolo@c skessors may inereare endarinokx$c 5uzceptibility - a Woman who is n-are emotionally sensftive to hormonal fluctuations may be more inclined to exhibit a total skess r-we. The anxiety 2 skess rektionsht, implies a higher risk for women who are chronically anxious. the prognosis for recovery from post patum disturbance is generally favar&e but certainly dependent upon enwon. mental and interpersonel supports during an approtimate six week period after delivay. !&m&ii and therapeutic intervention is important end generelly effective in suppating abilities of women to withstand long term effectsof this skessfd iifeewnt. E%entlally, post pawm distutbawe is defined by its assodatm with the childb4aina event rather than its existence as a-iisti”ct dinkd entlty. Traits manifested are those of M hdlstic skcss -we in clblcgy and imptketionr for client fundton. Its analysis es a skes rssponse o&as the broadest range for intewentkm on both educative end psychothere. peutic levek. 3s

JOURNAL

OF NIIRSE~MID’VIFERY.

WI. XXII, No. Z.SummerlB77