Sleep Deprivation: Why the postnatal period should not be an endurance test. 


I was involved in a discussion on Twitter the other day, reminiscing about the old days when babies were taken into the nursery at night and cared for by the staff on the maternity unit whilst mum was able to take advantage of the opportunity to catch up on some much needed sleep. Within seconds I was questioned (rather accusingly) as to whether I supported the concept of ‘separating mums and babies’! 

Actually nothing could be further from the truth. I think the mother-baby dyad should be supported and nurtured whenever possible when that is what the mother wants but establishing a secure attachment goes much deeper than just rooming in and promoting skin to skin.

Sleep deprivation is known to exacerbate mental health issues, occasionally with very severe consequences. Fit, healthy males have been known to suffer from hallucinations whilst undertaking the Royal Marine Commando Course whilst undergoing enforced periods of sleep deprivation to test endurance, and many fail. The very fact that we would treat something which is just generally expected of new mothers as an endurance test should speak volumes yet this is rarely acknowledged by health care professionals.

The subject of sleep needs to be discussed with women antenatally, especially those who may have pre-existing mental health conditions or identified as being at high risk of developing PND. Sleep is not a dirty word. It is a fundamental human need and is essential to promote mental well being.

Dads or birth partners should be a welcome addition to the postnatal ward. There is no golden rule that states all parenting duties should fall to the mother. Allowing partners to remain on the postnatal ward overnight ensures a mother is able to rest properly whilst her baby is cared for in the same environment, dads can enjoy skin to skin too!

Women should be encouraged to think about how they will protect their sleep, especially during the early days when establishing breast feeding (or not) or simply adjusting to new motherhood. It would be incredibly unrealistic to expect to be able to sleep through the night, but a plan to enable the new mother to have a few hours uninterrupted sleep during a 24 hour period can literally be a life saver. Friends and/or relatives can be instrumental in achieving this.

Midwives and health visitors are notoriously good at knocking on the door to perform a postnatal visit just after a mother has finally fallen asleep after a wakeful night then reminding her to ‘sleep whilst the baby sleeps’ as we leave. Co-ordinating these visits with a mother and her support network can ensure that precious ‘sleep time’ can be protected and she is able to sleep whilst friends or family take over with baby for a few hours.

24 hours of sleep deprivation can lead to symptoms of psychosis in healthy adults, similar to those observed in schizophrenia. Sleep deprivation also triggers a key biomarker in psychosis important in the research of anti-psychotic drugs and has been proven to lead to a re-wiring of the brains emotional circuitry. Is it any wonder women can begin to experience a significant deterioration in their mental well being when this goes on for much lengthier periods of time?

As health care professionals we must not be afraid to address the fact that, for some women, sleep must be prioritised. We are not interfering in the parent-infant bond by suggesting a woman think about a sleep plan in the same way we would encourage her to make a birth plan. Psychiatric disorders are a leading cause of maternal death according to the most recent MBRRACE-UK report (2014) and sleep deprivation has been identified as a contributory factor in many of these cases. Sleep should be considered equally as important as any other intervention necessary to maintain good physical or emotional health. If we want to be truly baby friendly we need to first achieve ‘mum friendly’.


Engaging Fathers – Keeping Dad in Mind

Recently I attended a meeting with our local CCG to review our parent infant mental health pathway and looking at means of improving outcomes for families in our area. The discussion around the table very quickly identified the importance of engaging and including dads during the perinatal period.

Historically pregnancy has primarily focused on the needs of the woman and unborn baby. Dads have been sub-consciously sidelined and considered more as an interested onlooker than an expectant father with the same anxieties and needs as a soon to be mother. There are colleagues I work with now who still remember the days when it was unheard of for the father of the baby to even be in the room for the birth.

Fortunately times have changed in as much as there is an expectation that dad will be present for the birth to “offer support” to his partner but who offers support to him?

Male post natal depression and birth related PTSD is on the increase. Health professionals are very vocal about keeping women informed, making them feel supported and respected during the birth experience but what about dad? Men are often left feeling overwhelmed, scared and apprehensive watching their partner give birth, with the expectation of showing strength and control weighing very heavily on their minds, this can soon turn to abject terror and confusion if things don’t go to plan.

I was at a conference recently and heard a father describe how he felt when his wife needed an emergency Caesarean section. As she was wheeled through to the operating theatre he was told to ‘say goodbye to your wife’. He was left, alone, thinking he might never see his wife again before a member of staff appeared after a lengthy period of time to inform him that all was well.

Post natal de-briefing is offered to parents if requested following a traumatic birth but this is often focussed on an affected mother. How often is this service offered to a father who may be deeply affected by something he has witnessed during the birth which he is struggling to make sense of? Do we ever even ask dad about his experience?

Engaging fathers isn’t difficult. Appointment letters for example can be addressed to both parents. There will be occasions where this may not be appropriate but a discussion at the primary booking appointment can identify where this is not required. Sending a letter to both parents may seem like a small gesture but it says ‘we acknowledge you’re in this together, that this is happening to both of you and we consider you equally important’.

Welcome dads onto the postnatal ward after the birth. Why, when a couple have been through childbirth together and welcomed this precious baby into their lives, do we send dad home whilst encouraging mum to ‘bond’? Dads need to bond too and how wonderful to be given the opportunity for the parents to spend those first, irreplaceable few hours alone with this new life before going home to face the onslaught of visiting well-wishers. 

The importance of secure attachment with fathers is often underestimated. Disengaged and remote father-child interactions as early as the third month of life have been found to predict behaviour problems in children when they are older (Ramchandani et al., 2013). This attachment can also have a positive influence on the relationship between mother and baby, and is linked with lower stress and depression in mothers (Fisher et al., 2006).
The term ‘midwife’ means ‘with woman’ but I feel we have moved on from this. Our role has always been to support women through pregnancy, birth and the postnatal period but we should be ‘with family’, walking alongside both parents, supporting, nurturing and encouraging. 

One in Seven

Today brings the latest report and recommendations  from the second MBRRACE -UK confidential enquiry into maternal deaths. The fact that a quarter of all late maternal deaths (between 6 weeks and a year following pregnancy) for the 2011-2013 period were down to mental health related causes shouldn’t come as a shock to those of us who have insight into perinatal mental health, because we know how prevalent it is. It comes as a shock because despite these figures there is still a shameful lack of provision for women who have a history or diagnosis of a mental health issue during pregnancy.

According to MBRRACE-UK one in seven women died by suicide and if those women who died were to become ill today, 40% of them would be unable to access any specialist perinatal mental health care and only 25% would be able to get the highest standard of care.

Women with a history or diagnosis of mental ill-health need to have access to specialist staff to ensure their care is planned effectively in partnership with them and their families because they are the experts in their condition. This will not be achievable unless women are asked the right questions early on in pregnancy. It astounds me how many women I hear from on social media who were not asked about their mental health at their initial booking appointment because it is every bit as important as recording a full medical history. It is ridiculous to think that recording a tonsillectomy at the age of seven would be somehow more important than the anxiety and depression the woman has suffered since age sixteen. Health care professionals also need to be asking the same questions to partners, and support should not be limited to the pregnant woman as mental ill health for either party will require increased support from professionals during the perinatal period and beyond.

Women and their partners need to be able to access information on mental health issues which may affect them during pregnancy or the postnatal period. The reason why so many parents do not even realise there is an issue until they have become very unwell can be down to a lack of insight and an inability to recognise when things “don’t feel right”. The fear of the unknown is also a huge factor and a perception that by admitting there is a problem their ability to parent may be called into question. A universal approach to providing information is a starting point and should include signposting to further information and support. Health care professionals have a responsibility to open a dialogue which can be ongoing throughout the perinatal period. What better health promotion than to begin to educate about perinatal mental health to the people who are most likely to benefit?

Women and their partners who have a history of mental ill health need a care plan, the intensity of which depends entirely on the individual needs of the person but at the very least should include a discussion around medication and expectations in regard to infant feeding. Most anti-depressant medication is completely safe during pregnancy and breastfeeding although some drugs are recommended over others. Psychotropic medication may be contra-indicated in some cases and this requires more of a discussion and the involvement of a perinatal psychiatrist. Women need to be able to chose the best option for them but need to be given the correct information to make an informed choice. In the inquest into the tragic death of Charlotte Bevan and her newborn baby last year, stopping her medication due to her desire to breastfeed and the lack of a care plan meaning she was not given the correct support and monitoring which may have kept them both safe were highlighted as two major contributory factors in her suicide. 

Health care professionals can not work effectively in isolation. If other professionals, such as mental health services, are involved it is imperative they are included in planning care. Support is most effective when it is co-ordinated and each professional will have their own expertise to contribute to ensure the care is of the highest standard. Postnatally this is especially important as women need to feel supported but not overwhelmed with professionals one day with feelings of abandonment the next. A discharge planning meeting prior to going home can be invaluable in identifying need and offering a co-ordinated response and should include the parents, family members who will be offering support too when possible, as well as key professionals such as Health Visitors, Mental Health Services and Midwives. 

This is of course not a complete insight into supporting parents where there may be a mental health issue, for some there may be many more complex factors to consider but is a baseline of the very least that should be offered. Not hugely difficult to achieve and not expensive, so why are so many areas getting it wrong? 

Why I stay in the job I love…

I read an article recently, actually I’ve seen it several times, popping up on my social media feed as friends and colleagues have shared it with their followers etc. 

The article is by a midwife with 8 years of experience who has been forced to resign because of what she feels is a culture of stress and bullying and has begun a new career in risk management. 

I wish her well but I’d like to share a few thoughts with you now, on why I choose to stay in this profession. 

I qualified in 2000 having been a haematology nurse before that. I hadn’t had children when I started my midwifery career, believe me becoming a mother changes your perspective on pregnancy, childbirth and (especially) breastfeeding. I felt so safe as a student midwife in Norwich. Part of a team, surrounded by wonderful midwives who’s practice I wanted to emulate and who really wanted to teach me how to become an expert in normal birth. I’ve stayed in touch with many of them over the years and hope they feel that I’ve lived up to their high standards and professionalism as well as compassion and caring. 

The role is not always easy, shifts can be horrendously busy, there are times when it seems like there will never be enough staff. It’s tiring, challenging, emotionally draining and very demanding but here’s the thing.

I work with an INCREDIBLE group of women. 

Wives, mothers, daughters, sisters, all here for a common goal. To support women, mostly strangers before they encounter them on this journey, as they embark on motherhood. 

They care, boy do they care. 

They want that woman to achieve the birth she hopes for, they will fight anyone who enters the room in order to protect the birth environment if they need to and they will watch over her whilst she drifts in and out of sleep in between contractions thinking of their own experiences of childbirth in the spirit of sisterhood.

These women supported me as I gave birth to my own three children, they watched me transition into motherhood in front of their eyes and I would still trust each and every one of them with my life and that of my children.  I love the fact that I have the pleasure of seeing the women who brought my children into the world every day and they see my children growing up. 

Don’t get me wrong, we’ve had some dreadful shifts. Times when all we want to do is just put our coats on and go home because our shift has ended and so what if it’s short staffed?? But we don’t, we stay and make sure everyone is safe because that’s what you do when you care. 

I’ve seen midwives break down and cry after delivering the “born asleep” baby of the woman who they stayed after their shift to care for because they’d made a connection. I can tell you that we still hold our breath, in the faint hope that there may be some mistake, that this beautiful, precious child will take a breath and cry at birth because if wishing could make it happen it surely would. 

I’ve watched the expressions on the faces of my colleagues as we’ve heard women in the second stage of labour, the sounds turning to that first cry of a newborn baby, smiling to themselves in secret relief that another baby has safely made their way into the world but always ready to rush to the side of the midwife who has requested help. Calmly co-ordinating themselves without the need for instruction to ensure everything and everyone that is needed is on hand. 

And the women, and partners, who I truly feel honoured to be able to support during the most life changing event they will ever encounter. The wonderful conversations we have during the course of our meeting. Some of the women I meet have overcome the most horrendous personal circumstances to get where they are, some have been gifted with the most amazing lives but each of them have a story and they fascinate me. There can surely be few people on earth who are lucky enough to witness a couple become a family in front of their eyes. That beautiful moment when a mother first sets eyes on the child that has emerged from her body and the look that is exchanged between her and her partner. Those who have seen it will know exactly what I mean. 

I’m not trying to paint the picture that everything is perfect. There are many reasons why midwives are leaving the profession in droves, but, for me, there are many more reasons to stay. 

When Medical Opinions Differ (The Huffington Post)

This really highlights the importance of training regarding anti-depressant/ant-psychotic medication. Specialist review is imperative to ensure women receive the best advice and care.

Among the numerous healthcare professionals I saw during my pregnancy I saw not one, but two psychiatrists.

The first psychiatrist I saw was attached to the local Mother and Baby Unit (MBU) and I was petrified about seeing her. Up until then I’d never been referred to a psychiatrist before and to me seeing one meant that not only was I ill but that things were rapidly getting out of hand.

But scared as I was I still went to see her, determined that I would talk to anyone who could possibly help me with my unstable mental state, no matter how difficult and scary taking to people and admitting that I had problems was.

I saw this psychiatrist at the MBU twice more before I had Squidge and each time I left I felt as confident as I could that, by continuing to take the maximum dose of my…

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Erin Sutherland: Falling Through The Cracks

The news over the last couple of days has been filled with reports of the tragic death of 10 month old Chloe Sutherland who was killed by her mother Erin back in February. 

Erin had been treated for postnatal depression before but was unable to access the help she asked for because Chloe was more than 6 months old and, The High Court in Edinburgh heard, postnatal depression is not considered a factor after 6 months.

Erin was previously diagnosed with postnatal depression following the birth of her older daughter back in 2006. Her symptoms worsened when the child was 8 months old and this led to an admission for treatment as an in-patient.

Recognising the symptoms, Erin sought help from her GP in December last year who rightfully contacted the perinatal mental health team only to be told there was no support they could offer her due to the fact her baby was older than 6 months.

It seems no consideration was given to Erin’s risk factors when making this decision. Her last episode had been when her older child was 8 months old yet she had managed to receive support. The fact that she had required an admission for treatment would indicate a significant risk during a subsequent pregnancy and a need for an increased level of support and monitoring following this. 

Postnatal depression is often not apparent until around 6 months but it is very dangerous to assume that women can not be affected by the condition later than this. There is much evidence from women who have begun to experience the symptoms up to 12 months after giving birth. Erin was concerned about her mental health and asked for help, which she was refused because she didn’t fit into the box assigned for women who have just had a baby.

If it was identified that Erin didn’t meet the criteria for the perinatal mental health team why was she not referred on to general adult outpatient services? Why was the door just closed in her face?  The mother and baby unit in Livingston can provide inpatient psychiatric care up until the baby is 12 months old, why was no referral made for assessment? There is also a Lothian Perinatal Mental Health Community Team who could have advised.

We practice a “no blame” culture in the NHS but are we in danger of failing to take responsibility for our actions, or inactions, because of this? 

Professionals caring for parents during pregnancy, childbirth and beyond need to be aware of the support available in their area, which can, admittedly be a lottery as there is a distinct shortage of beds in mother and baby units in the UK.  Research shows that women can be affected by PND up to a year after giving birth but depression is by no means limited to childbirth. It takes many forms but the common denominator is that it will not go away spontaneously. People who present with mental ill health need support, understanding and, in a lot of cases, treatment. 

We are taught to ask women how they feel, assess mood etc, but do we know what to do beyond that? How many of you reading this are fully aware of what services are on offer in your area?

Erin asked for help but none was given. She was alone and vulnerable dealing with a mental illness which ultimately cost the life of her daughter. Ironically Erin is now being detained in hospital under a treatment order, hopefully receiving the support she needed several months ago but what now?

A system which denies help to a woman because she doesn’t meet a criteria which is flawed anyway will continue to fail the most vulnerable and put their lives as well as those of their children at risk unless it is changed. If women are only beginning to describe symptoms of postnatal depression at 6 months then they need access to specialist support at that point and beyond. There is a distinct lack of provision for women with mental ill health, in particular beds on mother and baby units, which could well have contributed to the decision to limit access to the perinatal mental health team to women who’s babies are less than 6 months old but where does that leave women such as Erin? 

Only 3% of Clinical Commissioning Groups (CCG’s) have a perinatal mental health strategy. Of the 97% with no strategy 60% have no plans to put one in place. There are whole areas where GP’s, midwives and health visitors have no training or time to dedicate to this service which means women are not getting the help and support they need. This has a devastating impact on the well-being of the child and family and in the most extreme circumstances will result in tragedy and loss of life. 

The resources for these services need to be provided urgently, our government needs to stop paying lip service to perinatal mental health and actually make good on these promises of investment instead of making cuts to an already depleted service. 

How many more women, children and babies need to lose their lives before things change? “Lessons learned” are all well and good but I for one am tired of reading about them. 

Mums with PND – Let’s walk from the shadows together.

So much respect for Rosey and how hard she works to reach out to other women suffering with #pnd

PND and Me

Dear Mums.

If you have or have had Postnatal Depression keep reading.. If not then please read on regardless.

I was there 6 years ago, covered by the shadow of this hidden illness, the all consuming blackness, tiredness, the tears and anger, the questions ‘Why me?’ ‘This is all I ever wanted why can’t I be happy’ ‘Everyone else is coping so why aren’t I?’, the guilt, the resentment, intrusive thoughts, so many horrible emotions, all caused by Postnatal Depression.

PND takes so much from us, it steals those memories that should be remembered with a smile – not tears. It ruins relationships, friendships, steals what should be one of the happiest times of our lives, makes us feel so isolated but will I let you in on a secret? You are not alone. There are so many women out there who have been where you are, women feeling the same emotions you are right now. There are people…

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