After the birth of her son, pediatrician Tricia Pil struggled with post-traumatic stress disorder (PTSD). The delivery had been complicated by hemorrhaging, large blood clots, invasive emergency medical care, and fear that she and/or her infant might be dying.

“In the months after my son’s delivery,” she recalled, “it was as if a curtain had descended over my life. In addition to a terrible feeling of numbness, I was haunted by flashbacks and nightmares . . . . Billboards for the hospital where I’d delivered, people dressed in scrubs, pregnant women, . . . and worst of all, my own baby—the sight of any of these could trigger flashbacks and bouts of heart-stopping, sweat-drenched panic.”

Though we typically associate the birth of an infant with relief, joy, and adjustments to a new family member, in some cases the picture is complicated by postnatal PTSD (also referred to as postpartum or birth-related PTSD).

Some women are at higher risk for postpartum PTSD.

Photo by Alexander Grey on Unsplash

Research by Slade and Murphy found that “one-third of women experience giving birth as traumatic, and consequently 3-6% of all women giving birth develop postpartum post-traumatic stress disorder,” adding that many more are likely to have undiagnosed PTSD or it’s symptoms. Discussing their development of a scale to measure postpartum PTSD, Ayers, Wright, and Thornton cite research estimating that postnatal PTSD “affects 15 to 19% of women in high-risk situations such as those who have pregnancy complications or preterm birth and up to 39% of women whose babies die.”

Identifying patients at risk for childbirth trauma.

Risk factors for postnatal PTSD include:

  • preterm birth
  • stillbirth
  • preeclampsia
  • miscarriage
  • traumatic birth involving a perceived life-threatening event for the infant or mother

For a variety of reasons, Black women may have an “increased risk of living with undiagnosed and untreated postpartum mental illness and birth-related PTSD.”

Other risk factors include: antenatal factors like depression in pregnancy, fear of childbirth, and a history of mental illness, trauma, or sexual abuse; perinatal factors like negative subjective birth experience, operative birth, obstetrical complications, or lack of support; and postpartum factors such as postpartum depression, stress, or poor coping.

Identifying those at risk of traumatization after childbirth and offering psychological education and effective support can reduce the risk of developing PTSD. As such, nurses working in neo- and postnatal care settings should be familiar with and prepared to screen for its symptoms.

Common signs and symptoms of postpartum PTSD include:

  • Re-experiencing aspects of the trauma, such as having flashbacks, nightmares, intrusive thoughts and images, and/or intense distress or physiological reactions (e.g., nausea, racing heartbeat) that are consciously or unconsciously related to the trauma.
  • Hyperarousal such as hypervigilance, hyperreactivity, panic, insomnia, or loss of concentration.
  • Avoidance of stimuli associated with a traumatic event such as distressing memories or reminders like people, places, or situations that arouse distress or painful thoughts or memories.
  • Negative cognitions and/or mood such as an inability to remember important aspects of the trauma (dissociative amnesia); negative beliefs about oneself, others, or the world; negative emotional states; or distorted cognitions about the causes or consequences of the traumatic event.

Post-childbirth emotional struggles.

Mothers with postnatal PTSD may feel on edge, have trouble sleeping, become easily upset, or experience persistent distressing emotions like fear or anger. They may feel numb, avoid or have a hard time feeling emotions and/or difficultly expressing affection including for one’s infant. They may have difficulty trusting others and feeling safe or may blame themselves for adverse events or negative beliefs associated with birth.

Bonding challenges.

PTSD can also make it more difficult to bond with an infant and/or cause relational strain with others. Anger may be directed at nurses and other medical professionals perceived as insensitive, or who may be blamed for complications during or after a delivery. It can also cause worry or catastrophizing about future pregnancy and fear of recurrent trauma.

Shame about postnatal PTSD symptoms.

Some new mothers may attempt to conceal symptoms of PTSD because they fear psychiatric labeling or or feel guilt that they are not feeling connected with or happy about their infant in the way they or others had anticipated.

Distinguishing PTSD and postpartum depression.

Postnatal PTSD may be misdiagnosed by medical professionals as postpartum depression. This is understandable, given they share some common signs and symptoms. Writing about postnatal PTSD, Ilana Strauss notes that “[m]others with postpartum depression generally don’t suffer from the intrusive memories and flashbacks that plague PTSD sufferers.” At the same time, they may experience symptoms that are also seen in postpartum PTSD, like “sadness, trouble concentrating, difficulty finding joy in activities they once enjoyed, and difficulty bonding with their infants.” This underscores the need for medical professionals able to differentiate between the two.

What can nurses do?

It’s important to be aware that postnatal PTSD affects spouses and partners as well. Nurses are in an important position to recognize when a new mother or her partner is struggling with PTSD or its symptoms and to reduce the likelihood of long-term traumatization by providing early support and facilitating access to effective psychological care. Those in settings with established protocols for screening patients for PTSD will be able to initiate those protocols.

For those in settings with no such protocols, there are basic screening questions that can help assess for possible PTSD. The Primary Care PTSD Screen for DSM-5, for example, is a 5-item screen designed to identify individuals with probable PTSD in health care settings. It can be useful whether formally administered or as a guide for the kinds of questions that might be helpful to ask.

For mothers who have been assessed as having an elevated risk for postnatal PTSD, nurses can play important roles in providing emotional support and basic education, as well as arranging access to appropriate psychological care.

The author of this post, Scott Janssen, MA, MSW, LCSW, is a clinical social worker specializing in end-of-life issues, grief, and PTSD. A former member of the National Hospice and Palliative Care Organization’s Trauma-Informed Care Workgroup, his writing has appeared in numerous professional and literary publications as well as the Washington Post, Reader’s Digest, and HuffPost. His last post for AJN Off the Charts was “Death by PTSD: When Patients Are Afraid of Health Care.“