During the initial assessment of an infant in our pediatric clinic, the mother mentioned that she was having flashbacks and nightmares about the birth. Are these signs of posttraumatic stress disorder (PTSD)?-B.F., MINN.

Roxanne Ferguson, EdD, MSN, RN, responds: Your patient's flashbacks and nightmares indicate she may be experiencing a condition known as postpartum posttraumatic stress disorder (P-PTSD). It's more likely to affect those who've experienced a traumatic birth.1 Women who've experienced a higher level of intervention during their labor process or fear that their baby may be harmed are also predisposed to develop P-PTSD.2

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), PTSD is caused by an "exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury."3 Patients experiencing PTSD have recurring nightmares about the traumatic event, flashbacks, negative cognition relating to mood behaviors such as a persistent and distorted sense of blame of self or others, and an inability to remember key aspects of the event. Some become aggressive, reckless, self-destructive, or hypervigilant.4

Certain events during the birth, such as extraordinary interventions, may trigger development of the symptoms of P-PTSD. Many patients find it difficult to understand what happened during the process of delivery and have an altered perception of the delivery process.5 After delivery, some of these women exhibit signs and symptoms of P-PTSD, such as flashbacks. (See Signs and symptoms of P-PTSD.)

Nurses caring for patients in the postpartum setting need to be aware that early identification of P-PTSD is critical to the emotional well-being of the mother and baby. All patients should be treated with respect, dignity, and a nonjudgmental attitude. Letting them verbalize their feelings, using open-ended questions, builds trust and allows for further dialogue to clarify any misunderstanding. It can also defuse some of the patient's tension.5

During the postpartum assessment of patients who experienced multiple interventions or an unusual outcome, certain questions and statements could help the nurse to screen those predisposed to develop P-PTSD.

* "Tell me about your birth experience."

* "It sounds as if things didn't go as anticipated. How did this experience compare to what you had expected?"

* "What was the best (or worst) part of this experience?"5*

Nurses should assess patients for P-PTSD in the outpatient setting when they bring their newborns in for well-baby checkups. Reviewing the mother's history of the delivery and evaluating her for some of the risk factors associated with P-PTSD would further help to identify this disorder.

Patients who are experiencing symptoms of P-PTSD should be referred to a mental health professional for evaluation. Additionally, mothers experiencing thoughts of harm to themselves or their infant should be evaluated immediately.

Signs and symptoms of P-PTSD

These may appear after a traumatic childbirth:

* emotional numbing-taking the feeling out of emotional memories

* reduced awareness of one's environment

* intrusive thoughts

* insomnia

* impaired concentration

* avoidance behaviors

* irritability

* autonomic arousal, such as palpitations, hyperventilation, and/or nausea

* nightmares

* flashbacks.

Source: Stone HL. Post-traumatic stress disorder in postpartum patients: what nurses can do. Nurs Womens Health. 2009;13(4):283-291. Reprinted with permission from Heidi L. Stone, MS, RNC-OB, CNE.

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