Complications during pregnancy and postpartum

1. PSYCOLOGICAL COMPLICATIONS
Anusha G
MMC, Mdu-20

2. INtroduction
• A mother's joy begins when new
life is stirring inside...
when a tiny heartbeat is heard for
the very first time
and a playful kick reminds her
that she is never alone

4. Conception
• Formation of a viable zygote by the
union of the male sperm and female
ovum by the process fertilization

5. Pregnancy
• The period from conception to birth.
After the egg is fertilized by a sperm
and then implanted in the lining of the
uterus, it develops into the placenta
and embryo, and later into a fetus.
Pregnancy usually lasts 40 weeks,
beginning from the first day of the
woman's last menstrual period, and is
divided into three trimesters, each
lasting three months

6. Puerperium
• Puerperium is defined as the time
from the delivery of the placenta
through the first few weeks after
the delivery. This period is usually
considered to be 6 weeks in
duration. By 6 weeks after delivery,
most of the changes of pregnancy,
labor, and delivery have resolved and
the body has reverted to the
nonpregnant state.

7. Normal reactions to
conception
• Before the pregnancy symptoms
occur, it is normal for a woman to
experience a few conception
symptoms like
• Spotting
• Missing of cycle
• Raise in body temperature
• Cramps
• Frequent urination

8. In planned pregnancy
• Acceptance
• Excitement
• Enthusiasm
• Expecting the baby

9. In unplanned pregnancy
• Shock to the news of conception
• Rejection
• Developing negative feelings

10. Normal reaction in Pregnancy
• First trimester
• Un certainity
• Ambivalence
• The self as primary focus

11. Uncertainity
• Woman is unsure if she is pregnant
or not
• Observes her body carefully for
changes indicating pregnancy
• Often uses an over the counter
pregnancy test kit for validation
• Eager to find the confirming signs
• Seeks information from the health
personnel

12. Ambivalence
• Once the pregnancy is confirmed,
most women have conflicting
feelings about being pregnant
• May feel that it is not the right
time , even if the pregnancy is
wanted and planned
• Women who have planned may often
say they thought it would take
longer for the pregnancy to occur
and they feel unprepared for it

13. Cont..
• Women may wish they had
completed some specific plan or
goal before becoming pregnant
• In first pregnancy women may worry
about the added responsibility
• A multipara may be apprehensive
about how this pregnancy will affect
her relationship with her other
children and her partner

14. The self as primary focus
• The woman’s primary focus is on herself
,not the fetus
• As she has not gained weight to confirm a
growing, developing fetus, she probably
thinks more about being pregnant than
about the coming baby
• Physical changes and increased hormonal
levels may cause emotional stability

15. Cont....
• Her mood can quickly changes from
contentment to irritation
• She may change from optimistic
planning to an overwhelming
sleepiness
• These changes may be confusing to
her partner and her family who are
accustomed to more stability

16. Second trimester
• Experiencing the physical changes of
pregnancy
• The fetus as primary focus
• Narcissism and introversion
• Changes in body image
• Changes in sexuality

17. Physical evidence of
pregnancy
• The physical changes occur in the
mother make the fetus ‘real’
• Uterus grows rapidly, weight
increases, and breast changes are
obvious.
• Ultrasound examination , allows the
mother to see the fetus

18. Cont....
• Quickening, the feeling of the fetal
movement occurs during this time
• This is important because it
confirms the presence of the fetus
with each movement
• She no longer feels fetus to be
simply a part of her body but
perceives it as separate although
entirely dependent on her

19. The fetus As primary focus
• The fetus becomes the major focus
during the second trimester
• She is now concerned about
producing a healthy infant
• She is often interested in
information about diet and fetal
development
• A feeling of creative energy and
satisfaction is common

20. Narcissism and
introversion
• Many women become increasingly
concerned about their ability to
protect and provide for the fetus
• This concern is often manifested as
narcissism and introversion
• In first pregnancy the women
wonders about the infant, looks baby
pictures and likes to hear stories of
her infancy

21. Cont...
• Multiparas were concerned with
child’s acceptance by the siblings
• Women often spends time in day
dreaming with the baby born
• She may call it by the name chosen
and talk about the personality of the
fetus
• This intense introspection may be
confusing to her partner and to the
family

22. Body image
• Rapid and profound changes takes
place in the body image during the
secondtrimester
• Changes may be welcomed because it
gives the woman and her partner a
feeling of pride
• For some women the changes in the
body shape and the
hyperpigmentation of the skin may
contribute to the negative image

23. Changes in sexuality
• The sexual interest and activity of
the pregnant women and their
partners are unpredictable
• It may increase, decline or remain
unchanged
• The woman’s physical comfort and
the sense of wellbeing are closely
linked to her interest in the sexual
activity
• The couple’s culture is also very

24. Third trimester
• Feeling of vulnerability
• Increasing dependence
• Preparation for birth
•

25. Vulnerability
• Increase in the feeling of
vulnerability occurs in the third
trimester
• Often feels that the precious baby
may be lost or harmed if not
protected always
• Many expectant mothers have
fantasies and nightmares about
having a deformed baby or harm
coming to the infant

26. Cont...
• Avoid crowds because they feel
unable to protect the infant from
infectious diseases or potential
physical dangers
• They need assurance that dreams
and fears are not unusual in
pregnancy

27. Increasing dependence
• The expectant mother often
becomes increasingly dependent on
her partner during the last weeks of
pregnancy
• She may insist that he should be
easy to reach at all times
• Her need for love and attention
from her partner is even more
pronopunced in late pregnancy

28. Cont...
• She expects her partner to
understand the feeling and becomes
angry if he is not sympathetic
• Irritability may increase because of
the fatigue at this time

29. Preparation for birth
• Longs to see the baby and become
acquinted with the child
• Concerned with their ability to
determine when they are in labour
• They review the signs of labour and
may question the friends and the
family members

30. Cont....
• Anxious about getting into the birth
facility during the time of childbirth
• Increasingly concerned about the
due date and the experience of
labour
• May develop fear towards the labour
• Seek help for their fear by seeking
information

31. Normal reaction in
puerperium
• Accepting parenthood
• Perceiving physical changes

32. Accepting parenthood
• Becoming parent may create a sense
of instability
• Effective role transition is essential
for the acceptance of the parent
role
• Acceptation and love towards the
child leads to better parent child
attachment

33. Perceiving the physical
changes
• The perceives the physiological
changes like
• Change in the abdominal size
• Presence of lochia
• Pain and swelling in the perenium
• Reversion to the non pregnant stage

34. Psychiatric disorders in
pregnancy
• Stress
• Anxiety
• Depression
• Panic disorder
• Eating disorder
• Mood disorder

35. Stress
• The physiological changes within the
woman may lead to increased stress
and may find difficulty with coping
to the changes happened
• It's very normal to experience
stress during pregnancy, and for
many women these feelings will come
and go. However, for around 15% of
women, it can be more serious and
potentially harmful

36. causes of stress
• some common causes are:
• Nausea, constipation, being tired or
having a backache.
• Hormonal changes.
• Worry about what to expect during
labor and birth or how to take care
of the baby.
• Job responsibilities
• Unexpected life events.

37. Symptoms
• Difficulty sleeping
• Loss of appetite
• Headaches
• An upset stomach
• Low mood and low self esteem
• Irritability
• Smoking or drinking more
• Racing thoughts and difficulty
concentrating

38. anxiety
• The changes during pregnancy can be
anxiety-provoking
• Reasons for anxiety during pregnancy
could include:
• Worries about what type of parent a
woman will be
• Concerns about interruptions to
career
• Concerns about financial stability
• Fears about how to cope with
childbirth

39. symptoms
Constant worry
• Feeling that something bad is going
to happen
• Racing thoughts
• Disturbances of sleep and appetite
• Inability to sit still
• Physical symptoms like dizziness,
hot flashes, and nausea

40. Depression
• Inpregnancy, symptoms of
depression such as changes in sleep,
appetite, and energy are often
difficult to distinguish from the
normal experiences of pregnancy
• The prevalence of women who meet
the diagnostic criteria for
depression has been shown to be
between 13.6% at 32 weeks
gestation and 17% at 35 to 36 weeks
gestation

41. C0nt........
• In a recent study, more women
became depressed between 18 and
32 weeks gestation and 8 weeks
postpartum.

42. risk factors include
• previous history of depression
• discontinuation of medication(s)
• previous history of postpartum depression,
• family history of depression.
• negative attitude toward the pregnancy
• lack of social support
• maternal stress associated with negative
life events
• partner or family member who is unhappy
about the pregnancy

43. Symptoms of depression
• Being in a depressed mood most of the time
for at least two weeks
• Decreased interest in the world around
• Guilt
• A sense of worthlessness
• Low energy
• Poor concentration
• Appetite changes
• Feeling hopeless
• Thoughts of suicide
• Getting too much sleep, or not enough sleep

44. Panic disorder
• women may experience first-onset
panic disorder during pregnancy.
• One study showed a correlation
between increased anxiety and
increased resistance in uterine artery
blood flow
• Other Cause are hormonal changes
during pregnancy.
• stress and worries of pregnancy.
• Previous panic attacks may become
worse during pregnancy.

45. symptoms
• Rapid heartbeat.
• Lightheadedness or feeling feint.
• Chest pains.
• Leg and muscle weakness or tingling.
• Trouble thinking.
• Shortness of breath.
• Dizziness

46. Eating disorders in
pregnancy
• The prevalence of eating disorders in
pregnant women is approximately 4.9%
• One recent study reported that
pregnant women with active eating
disorders appear to be at greater risk
for delivery by cesarean section and
for postpartum depression
• In addition, eating disorders during
pregnancy have been linked with higher
rates of miscarriage and lower infant
birth weights

47. Bipolar mood disorder
• some women with bipolar disorder may
experience a relief from symptoms
during pregnancy, but that the risk for
relapse in the postpartum period is
high.
• In a study, pregnancy appeared to
have a protective effect against an
increase in symptoms in women with
lithium-responsive bipolar I disorder
who had discontinued their lithium
during pregnancy; however, there was a
14% rate of relapse in the last 5 weeks
of pregnancy

48. Problems related puerperium
• Physical weakness
• Pain
• Ineffective maternal role transition
• Unacceptance of the child
• Bereavement in case of stillbirth

49. Physical weakness
• In the postpartum phase, fluctuating
hormone levels combined with
additional physical changes as a
result of delivery may also result in
musculoskeletal problems such as
excessive joint mobility, weakness
of the core stabilizers, and altered
spinal mobility and function.

50. Cont....
• This can be manifested by
• Back, sacral, hip, pelvic, rib pain
• Pain in the neck or upper back
• Headaches
• Decreased ability to do normal daily
activities
• Weak or tight muscle
• Urinary incontinence

51. pain
• Most women experience some degree
of pain or discomfort after childbirth
• The perineum may be bruised, &may
have had some stitches to repair a tear
or episiotomy.
• In a Cesarean birth, may have pain at
incision site and it is uncomfortable to
move, cough, and even laugh
• Afterpains (cramping) are the
contractions of the uterus occurring in
the days following childbirth

52. Ineffective maternal role
transition
• Effective role transition is essential
for the acceptance of the parent
role as she develops a relationship
with the unborn child
• Ineffective role transaction makes
her to find difficulty in establishing
her relationship to the child

53. Unacceptance of the child
• Acceptation and love towards the
child leads to better parent child
attachment
• Incase of postpartum psychiatric
disorders and some other factors
related to the pregnancy this love
and affection towards the child will
be absent
• They will manifest as rejection
towards the child

54. Bereavement in case of
stillbirth
• The term stillbirth refers to babies
that are born dead after 24 or more
weeks. It is not always possible to
prevent stillbirth and in many cases
the cause will remain unknown
• the death of your child can cause
utter despair, and that the woman may
become overwhelmed by the grief.
• may feel anger, hate and possibly guilt
and these feelings can have a severe
strain on the psychological and physical
health of not only on the mother but
the whole family.

55. Psychiatric disorders in
puerperium
• Postpartum Blues
• Postpartum depression
• Postpartum psychosis
• Birth Related post traumatic stress
disorder

56. Postpartum Blues
Postpartum blues are very common,
occurring in up to 80 percent of new
mothers
• Occurs within 2 to 3 days of delivery
,Symptoms peak on the fifth day
postpartum and usually resolve within 2
weeks
• characterized by irritability, anxiety,
decreased concentration, insomnia,
tearfulness, and mild, often rapid,
mood swings from elation to sadness

57. postpartum depression
• postpartum depression (PPD) occurs
within 4 weeks of childbirth.
• most reports on PPD suggest that it
can develop at any point during the
first year postpartum, with a peak of
incidence within the first 4 months
postpartum.
• controlled studies show that between
10% and 28% of women experience a
major depressive episode in the
postpartum period

58. symptoms
1. Depressed mood.
2. Loss of interest or pleasure.
3. Significant increases or decreases in
appetite.
4. Insomnia or hypersomnia.
5. Psychomotor agitation or
retardation.
6. Fatigue or loss of energy.
7. Feelings of worthlessness or guilt.
8. Diminished concentration.
9. Recurrent thoughts of suicide or
death

59. Postpartum psychosis
• The prevalence of postpartum
psychosis has consistently been
reported as approximately 1 to 2 per
1000 live births.
• This condition has a rapid onset,
usually manifesting itself within the
first 2 weeks after childbirth or, at
most, within 3 months postpartum,
• should be considered a medical and
obstetrical emergency.

60. Cont..
• May present with delusions or
hallucinations that are frightening
to them.
• Many patients also have additional
symptoms that resemble a delirium
and involve distractability, labile
mood, and transient confusion

61. PREDISPOSING FACTORS:
• Past history of psychosis.
• Past history of puerperal psychosis:
20 percent risk of recurrence in
subsequent pregnancies.
• Family history of psychosis.
• Primiparity.
• Single parenthood.
• Lack of social support.

62. SYMPTOMS OF POSTPARTUM
PSYCHOSIS
• Delusions
• Insomnia
• Lack of pleasure or interest in activities that
once gave pleasure
• Loss of energy
• Agitation or anxiety
• Crying
• Thoughts of death or suicide
• Refusing to eat
• Suicidal or homicidal thoughts
• Feelings of terror and shame about the
disturbing thoughts and visions they're having

63. treatment
• Psychotherapy for the woman and her family can
be very helpful in enhancing coping skills,
educating them on caring for a newborn, and
providing support.
• Electro convulsive therapy
• Treatment of moderate to severe postpartum
depression includes antidepressants, lithium,
electroconvulsive therapy (ECT), or
antipsychotics, depending on the nature of the
symptoms and diagnosis.

64. NURSING DIAGNOSIS:
• Impaired social interaction related
to overvalued ideas
• Ineffective coping related to
grandiose thoughts and ideas
• Imbalanced nutrition related to loss
of appetite
• Disturbed sleep pattern related to
occasional paranoid ideas and lack of
time

65. • Ineffective family coping related to
patients suspicious and grandiose ideas
• Impaired communication verbal related to
grandiose ideas as mental status
• Risk for violence, self directed or other
directed related to manic excitement
• Risk for injury related to hostility as
evidenced by potentially injurious
movements.
• Risk for injury to fetus related to
hostility
• Social isolation related to episode of
depression

66. Nursing management
• The woman must be kept under
constant observation until
appropriate psychiatric help is
obtained.
• Family support also needs
consideration.
• The midwife needs to offer advice
and support to women during
subsequent pregnancies and to alert
the physician regarding psychiatric
care

67. post traumatic stress
disorder
• After childbirth, women may also
experience post traumatic stress
disorder (PTSD). PTSD includes two
key elements:
• (1) experiencing or witnessing an
event involving actual or threatened
danger to the self or others, and
• (2) responding with intense fear,
helplessness or horror.

68. symptoms
• Obsessive thoughts about the birth
• Feelings of panic when near the site
where the birth occurred
• Feelings of numbness and detachment
• Disturbing memories of the birth
experience
• Nightmares
• Flashbacks
• Sadness, fearfulness, anxiety or
irritability

69. Management of Problems
• Effective maternal role transition
• Paternal adaptation
• Appropriate parenting information
• Adaptation of grandparents
• Adaptation of siblings

70. Effective maternal role
transition
• The transition into mothering begins
during pregnancy and increases with
the gestational age
• The woman must accept the pregnancy
and the changes that will result
• She develops a relationship with the
unborn child
• Near the end she must prepare herself
for the birth and for parenting the
newbaby

71. Paternal adaptation
• The responses of expectant father
are dynamic,progressing through
phases that are subject to
individual variation
• Jordan(1990) describes the three
developmental process that an
expectant father should address
• 1.Grappling with the reality of the
pregnancy and the new child

72. Cont..
• 2. struggling for recognition as a
parent from his family and social
network
• 3. making an effort to be seen as
relevant to child bearing

73. Contd…
• Becoming a father
Reaping
rewards
Creating
role of
involved
father
Confront
ing
reality
Emotional
binding

74. Appropriate parenting
information
• Expectant parents need information
about infantcatre and parenting

75. Adaptation of grandparents
• A first grandchild may be a exiting
event that creates great joy
• Many grandparents see their
relationship with their grandchildren
second to parent-child relationship
• They want to be involved in the
pregnancy and often engage in
rituals suchas shopping and
giftgiving that confirm their role as
important participants

76. cont,....
• On the otherhand some contemperory
grandparents plan little participation in
pregnancy or childcare
• They may say “I have raised my
children and i don’t plan to do it again
• Letting grandparents know that the
parents want them to share in the joy
the child brings without other
expectations may ease the situation
• ‘

77. Adaptation of siblings
• Toddlers
• Until children feel secure in the
affection of their parents
,expecting two year old children to
welcome a new stranger is not
realistic
• Frequent reassurance of parental
love and affection is very important

78. Cont....
• They should accept the feelings a
toddler may express and to continue
to reinforce the child’s feeling of
being loved

79. Older children
• They may be aware of the changes in
the mother’s body and may realise that
a baby is going to be born
• Younger children may expect the
infant to be a full pledged playmate
and may be shocked and disappointed
when the infant is small and helpless
• Parents should reassure the children
about their continuous importance to
prevent the events becoming
overwhelming

80. Maternal role transition in
pregnancy
• Rubin (1984) observed specific steps
that provide a framework for
understanding the process of
maternal roletaking

81. Steps in maternal role
taking(rubin 1984)
• Mimicry
• Role play
• Fantasy
• The search for a rolefit (or)
introjection, projection, rejection
• Griefwork

82. mimicry
• Observing and copying the behaviour
of other mothers
• It is an attempt to discover the
characteristics of a role
• It begins in the first trimester

83. Role play
• Role play consists of acting out some
aspects of what mothers actually do
• Searches for opportunities to hold are
give care for the infants in the
presence of others
• Roleplaying gives an opportunity to
‘practice’ the expected role and
receive validation from an observer
that she performed well
• She is particularly sensitive to the
responses of her partner and her own
mother

84. Fantasy
• Fantasies allow the woman to
consider & ‘try on’ a variety of
behaviours
• Fantasies often revolve around the
characteristics of the infant
• The woman may daydream about
taking her child to the park or
holding or reading for the child
• She may also have dreams at night

85. The search for a rolefit
• The search for a rolefit occurs when
the woman has established a set of
role expectations for herself and
internalised a view of the behaviour
of a ‘good’ mother .
• She observes the behaviour of
various mothers and compares them
with her own expectations of
herself

86. Cont....
• She imagines herself acting in the
same way and either rejects or
accepts the behaviours , depending
on how well they fit her idea of
what is right

87. griefwork
• Women often experience a sense of
sadness when they realise that they
must giveup certain aspects of their
previous selves and can never go back.
• A mother will never again be a
carefree woman who has not had a
child
• Even simple things such as going
shopping or to the movies will require
planning to include the infant or to find
a alternative care

88. Factors influencing
psychosocial adadtation
• Age
• Multiparity
• Social support
• Family support
• Abnormal situations
• Socio-economic status

89. age
• Birth statistics over the past 20
years show that all around the world
women are delaying having a baby
until their 30s or beyond
• . This is mostly because women are
pursuing higher education and
getting married later. More women
are also choosing to settle in their
careers before planning for a baby

90. Cont.....
• Older women run a greater risk of
having a Down's syndrome baby
• Miscarriage and ectopic pregnancy
are sadly more common in older
women (Franz and Husslein 2010,
RCOG 2011), as are pregnancy
complications such as gestational
diabetes, placenta praevia, pre-
eclampsia and premature birth
(RCOG 2011, )

91. Cont...
• Pregnancy presents a challenge for
the teenagers who must cope with
the conflicting developmental tasks
of pregnancy and adolesence at the
same time

92. multiparity
• The assumption that the multipara
needs less help than a first time
mother is inaccurate
• She may have worries about her
other children accepting the infant
and about finding time and energy
for other responsibilities
• Developing attachment for the
coming baby is hampered by feelings
of loss between herself and the
firstchild

93. Social support
• Social support includes that from the
woman’s partner, family, friends, and
co-workers
• Support from the woman’s partner and
her mother is important
• Women with higher social support are
more likely to say they indented to
become pregnant and that they are
happy with the pregnancy than those
with low social support (sabil et al
2007)

94. Social support
• Social support includes that from the
woman’s partner, family, friends, and
co-workers
• Support from the woman’s partner and
her mother is important
• Women with higher social support are
more likely to say they indented to
become pregnant and that they are
happy with the pregnancy than those
with low social support (sabil et al
2007)

95. Family support
• Women who receive strong social
support from their families during
pregnancy appear to be protected
from sharp increases in a particular
stress hormone, making them less
likely to experience depression
after giving birth, a new study by
UCLA life scientists indicates

96. Cont.....
• "Mothers with support from fathers
may be more likely to practice
healthy behaviors, which has been
shown to contribute both to
healthier babies and lower
postpartum disturbance,“
• low or absent support is a significant
risk factor for postpartum
depression and that strong support
is a protective factor

97. Absence of a partner
• These woman may experience more
stress about telling their family and
friends about the pregnancy
• Legal issue such as whom to list as
the father on birth records will be a
concern for the woman
• Single woman without partners are
mostly below the poverty line and
this will make them to delay prenatal
care which end up in complications

98. Abnormal situations
• The abnormal situations which
affects the pregnancy includes
• Intimate partner violence
• Unexpected incidents in life

99. Socioeconomic status
• One of the greatest influences on
childbearing practices is the
socioeconomic status of the family
• Socioeconomic status can be divided
into
• The affluent
• The middle class
• The working poor and unemployed

100. The affluent
• Has financial reserves to protect
from economic fluctuations
• Has health insurance or can able to
pay for healthcare
• Values the preventive care
• Seek early antepartum care and
comply with recommendations of the
healthcare providers

101. The middle class
• Has fewer reserves
• Mostly rely on insurance obtained as
part of their salaries, to shield
themselves from exorbitant
healthcare costs
• They prepare for the birth and
make plans to provide for their
children’s security

102. The working poor and
unemployed
• They work for low wages
• They live below the poverty level and
have barely enough to survive
• They place more emphasis on
meeting present needs than on
attaining future goals
• They place less value on preventive
care and this often postpone
prenatal care until the second or
even the third trimester

103. Cultural influences on
childbearing
• Each culture has its own health and
healing belief system for pregnancy
and childbirth. The success of
healthcare depends on how well it
fits with the beliefs of those being
served