Benefits of Postnatal Debriefing

Benefits of postpartum De drawinging215133POSTNATAL debrief STILL VALUED BY WOMENIntroductionProviding query for women in the postpartum period is believed by many midwives to uphold women to adjust to their child redeem experiences, and to help tighten postnatal psychological morbidity. The consequence base is equivocal in resemblance to the efficacy of these affables of treatments, which argon typically delivered by midwives in clinical practice.This essay pass on review several pieces of seek relating to postnatal debrief associated with the psychological di centering and strength post impairmenttic stress incommode associated with childbirth. It will look at the quality of evidence available and discourse any(prenominal) of the parameters of the arguments surrounding the provision of postnatal question, listening and advise services. It will alike make recommendations for practice in relation to this kind of provision, and in relation to coming(prenominal) rese arch.DiscussionLavender and Walkinshaw (1998) carried let on a randomized trial of a postnatal debrief service provided by midwives, to collide with what effect it had on psychological morbidity later childbirth. The writes comprise unriva conduct midwife and one obstetrician, and the midwife has a postgraduate degree, suggestive that they progress to the skills to carry turn out and report on such a register. exploitation a randomised trial design is aimed at filling an obvious gap in the research at the time of the take, in relation to this area of practice (Lavender and Walkinshaw, 1998). This contain was carried forth in a regional teaching infirmary in northwest England, and used a exemplar of one hundred and twenty postnatal primigravidas, who were allocated by sealed envelopes to gull the query intervention (n 4 56) or non (n 4 58). (Lavender and Walkinshaw, 1998 p 215). The bailiwick involved the collection of baseline intrapartum and demographic infor mation in order to assess a wide variety of variables in the study (Lavender and Walkinshaw, 1998).The intervention is draw as follows Women randomised to the intervention participated in an interactional wonder in which they spent as much time as necessary discussing their labour, asking questions, and exploring their feelings. One research midwife, who had received no testicle training in counselling, conducted the interviews, which lasted between 30 and 120 minutes, the duration universe guided by the needs of the respondent. Hospital nones were available through with(predicate)out the interview so that direct questions could be answered. No interview schedule was defined, since the interviews were respondent led. (Lavender and Walkinshaw, 1998)This approach raises several layers. To being with, it is positive that in that respect is such transparentness in explaining the intervention, even if the intervention is brief, because it concedes the reader to understand the constitution, it aids replication, and it demonstrates the escape of specialist knowledge claimd to perform the intervention. Secondly, it immortalizes that a research midwife, who was non a counsellor, was carrying out the intervention. And thirdly, it demonstrates a woman- centreed, obstetrics-oriented approach, in that the interviews were respondent led and the aloofness was not throttle. Such an approach reflects midwifery philosophies which makes the article useful for midwifery practice.Lavender and Walkinshaw (1998) used an completed data collection instrument,the Hospital apprehension and Depression (HAD) scale, which was administered by postalquestionnaire 3 weeks afterward delivery. Using an launch data collection instrument adds strength to the study, simply at that place is a small amount of unreliability intimately postal questionnaires, because there is never any guarantee that they are filled out by the psyche they are sent to. Using the pre-tested sca le allowed the authors to compare the proportion of women in each congregation with anxiety and picture scores of more than 10 points, using betting odds ratios and 95% confidence legal separations, both of which are unimpeachable statistical applications for these data. The 95% response rate ensured a good precedent size (Lavender and Walkinsahw, 1998), although the study would have had even more statistical moment if it could have been carried out across more than one site. The benefits of this intervention were established by the study, but the authors raise just about concerns, including concern at the high up levels of morbidity detected, and question whether using the chosen scale was appropriate for amount psychological morbidity after childbirth (normal or abnormal) (Lavender and Walkinshaw, 1998). This study is limited now by its age, and by being superceded by more fresh studies.Kershaw et al (2005) carried out a prospective randomised controlled trail with card inal arms, which compared debriefing methods after birth which were aimed at cut awe of future childbirth. As can be seen, this studied a more precise intervention, in relation to a very specific outcome, rather than measuring psychological morbidity per se. This would make it more applicable to specific aspects of practice. This study was similarly carried out in one site, and the authors provide details of the hospital site, which this author would question due to the issue of confidentiality. Kershaw et al (2005) focused on m others whose first birth was an in effect(predicate) delivery, and gained ethical approval. More details well-nighwhat the ethics of this study would have enhanced its quality. Kershaw et al (2005) provide their comprehension and exclusion criteria, but do not discuss controlling for other variables. They also use a pre-established measurement tool to assess the fear of childbirth undergo by the study participants (Kershaw et al, 2005). They do sub sequently insert demographic information, and they use a range of suitable statistical tests, explaining the implication of these, which makes it easier for the novice reader to begin to assess the quality of the data analysis. This once more was a debriefing intervention carried out by midwives in the postnatal period (Kershaw et al, 2005).However, unlike the old study, this one differed because the debriefing was held on 2 separate occasions, and seances were held at home (Kershaw et al, 2005). Another significant element of this study was that the midwives involved received training in critical incident stress debriefing (Kershaw et al, 2005). The authors justify their study as follows In this study fear of childbirth and post-traumatic stress were measured rather than maternal slump and ordinary health. It was decided not to measure maternal depression as research hassuggested this is frequently associated with chemical elements not related to childbirth. Women were all owed sufficient time to debrief, sessions lasted up to an min and a half. (Kershaw et al, 1508).This shows some strengths, including a focus on specific psychological features, rather than on general health and depression, which can be serious to assess. Although the authors state women were allowed sufficient time for the session, this study does not reflect the kind of midwifery philosophy that the Lavender and Walkinshaw (1998) study did. The ruleings from this study do not musical accompaniment the use of this particular intervention in this particular population.The findings of this study demonstrated in the short term no significant end in the WDEQ fear of childbirth scores and IES activated distress scores. These findings show community-led debriefing is not proven to be of any value in reducing womens fear of childbirth spare-time activity an operativedelivery. (Kershaw et al, 2005 p 1508).However, this study whitethorn not be the last word on this kind of interventio n, and there are limitations, including the focus only on women who had operative deliveries, focusing on one site, and in the intervention itself. Maybe the constitution of the intervention, and the training provided for midwives, was limited. The authors agree that a longer-term evaluation might show assorted impressions (Kershaw et al, 2005). It might be that the data collection tool was inappropriate, as with the previous study. However, this study, as with the previous one, does establish the usefulness and facility of midwives providing postnatal support of this kind. Kershaw et al (2005) show that midwives identify those women who would be needing debriefing, but this author would compete that midwives are not experts in mental health, and limiting debriefing to those identified by midwives as at higher risk might suffer important cases. Reading between the lines of this study seems to imply that this intervention is determine by midwives and by patients, despite the fi ndings of the statistical analysis. smooth et al (2000) carried out a randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth, again, focusing on women who are viewed as potentially at higher risk of mental health morbidity postnatally. This study was carried out in a large maternity teaching hospital in Melbourne, Australia, unlike the previous two studies, which were carried out in the UK. littler et al (2000) had a sample of 1041 women who had given birth by either caesarean section (n = 624) , by assisted vaginal delivery using forceps (n = 353) or vacuum extraction (n = 64), and these women were randomised to the intervention group or the control group (Small et al, 2000). The sample size was statistically calculated for significance, which is a strength of the study. The methodology is clear and the randomisation butt described. The intervention provided women with an opportunity to discuss their labour, birth, and post delivery events and experiences (Small et al, 2000 p 1044). Although there is a woman-centred focus in this study, only 1 hour utmost was allowed for the discussion, which this author would suggest is a severe limitation of this intervention in relation to woman-centred debriefing. The midwives were not trained but described as experienced and skilled. The main outcome measures were maternal depression (score 13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF36 subscales) measured by postal questionnaire at sixsome months postpartum (Small et al, 2000 p 1044). Again, established scales are being used to lend strength to the study.Small et al (2000) show that more women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum precaution (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio = 1.24, 95% confidence interval 0.87 to 1.77) and they were also more likely to report that depression had been a conundrum for them since the birth, but the difference was not significant (123 (28%) v 94 (22%) odds ratio = 1.37, 1.00 to 1.86). (p 1043). According to this study, the authors demonstrated that midwife led debriefing sideline operative births was not only not effective in reducing maternal morbidity (in particular, psychological morbidity), at the six month point after delivery, but that it may have been a impart factor to emotional health issues for certain women (Small et al, 2000). This author would suggest that it might be the personality of the intervention that is the issue here, because it was provided in hospital, soon after birth, and may not have been particularly woman-centred. Cultural differences between Australian women and UK women cannot be ruled out neither can cultural differences in models of care and practice.Priest et al (2003) carried out a randomised single-blind controlled trial, stratified for co mparison and delivery mode, to test whether critical incident stress debriefing after childbirth reduces the incidence of postnatal psychological unsoundnesss, also in Australia, in two maternity hospitals. They had a large enough sample size, consisting of 1745 women who delivered profound term infants between a specificed time period, with 75 allocated to the intervention group and 870 to control group (Priest et al, 2003). Again, the study design is transparent, and the randomisation process clear. As with the previous study by Small et al (2000), the intervention was carried out soon after delivery, but this intervention consisted of an individual, standardised debriefing session ground on the principles of critical incident stress debriefing. The intervention is described briefly, and it is stated that the midwives were trained in the intervention (Priest et al, 2003). However, the intervention itself and the training is not really described in great detail, which affects re plication of the study. The intervention is based on theories which are not specifically developed for childbirth trauma, but that have been adapted, and this may be a weakness. As with the other studies, accepted outcome measures are used.Priest et al (2003) found that there were no significant differences between control and intervention groups in scores on Impact of Events or Edinburgh Postnatal Depression Scales at 2, 6 or 12 months postpartum, or in proportions of women who met diagnostic criteria for a stress complaint (intervention, 0.6% v control, 0.8% P = 0.58) or major or minor depression (intervention, 17.8% v control, 18.2% relative risk 95% CI, 0.99 0.871.11) during the postpartum year. Nor were there differences in median(prenominal) time to onset of depression (intervention, 6 interquartile range, 49 weeks v control, 4 38 weeks P = 0.84), or duration of depression (intervention, 24 1246 weeks v control, 22 1052 weeks P=0.98). (p 544).This leads to the conclusion th at this single session of midwife led, specific debriefing was ineffective as a means of cake of postnatal psychological diseases (Priest et al, 2003). While the authors conclude that the intervention had no ill effects (Priest et al, 2003), this author finds these findings significant in their lack of support for the intervention, and would suggest, again, that it may be the nature of the intervention that is leading to these kinds of results. assay et al (2005) carried out a randomised controlled trial to assess the effectiveness of a counselling intervention after a traumatic childbirth, based on a midwife-led brief counselling intervention for women deemed at risk of developing symptoms of psychological symptoms postnatally. This was a small study group, with only 50 in the intervention group and 53 in the control group, and the intervention was also provided as scene to face counselling within 72 hours of birth, as with the previous study, but also had a telephone counselli ng session at between iv and six weeks postnatally (Gamble et al, 2005). The allocation/randomisation process is described, but the midwife was not blind to the randomisation, which may represent a potential source of bias. completed data collection scales were used as with all the previous studies Edinburgh Postnatal Depression Scale (EPDS) , Depression Anxiety and Stress Scale-21 (DASS-21) , and Maternity loving Support Scale (MSSS) (Gamble et al, 2005 p 13). Gamble et al (2005) measured the following outcome measures posttraumatic stress symptoms, depression, self-blame, and confidence about a future pregnancy. Gamble et al (2005) provide great detail about the underpinnings of the therapeutic intervention, and there is a midwifery/woman-centred focus to the intervention (and, by association, to the study). Gamble et al (2005) found their intervention to be effective in reducing symptoms of trauma, depression, stress, and feelings of self-blame. tout ensemble of these studies fall within the scope of good standards of evidence for practice, but find marked differences between studies in relation to efficacy and non-efficacy of interventions. There may be a number of reasons for this. Only one study suggests potential disallow effects of this kind of intervention, but this was not conclusive and warranted come along investigation. However, the literature around this subject does seem to predominantly suggest that such interventions are useful for women following birth. Axe (2000) suggests that women can use such support to help them cope with the difference between their expectations and experiences of birth. Robinson (1999) argues for the increasing position of post traumatic stress disorder following traumatic childbirth, and suggests that this is under-diagnosed and represents a significant maternal morbidity which needs addressing, a suggestion also found by Ayers and Pickering (2001). Creedy et al (2000) state that posttraumatic stress disorder af ter childbirth is a poorly recognized phenomenon, and that women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate (p 104).Therefore, the focus on debriefing may not be the only bureau forward to improve psychological morbidity there may be a need for research to explore ways of reducing the trauma that occurs in the first place. Czarnocka and Slade (2000) suggest that there may be opportunities for keep onion of post traumatic stress and psychological morbidity after birth, through providing care in labour that enhances perceptions of control and support. One study demonstrates that negative experiences of interactions with maternity staff can contribute to psychological morbidity (Wijma et al, 1997).Kenardy (2000) suggests that it is the nature of the debriefing tha t may be ineffective in those studies that have found such results. Gamble et al (2002) also suggest that the kind and measure of the debriefing warrants further investigation. Hagan et al (1996) did not find any drop-off in psychological morbidity following this kind of intervention. black lovage (1999) suggests that some of the problems may be linked to the lack of clarity and understanding that exists about these processes, which are neither necessarily formal psychological counselling nor a simple sharing session.Yet there does seem to be some indication that these kinds of supportive therapies are found to be useful by women and by midwives. Westley (1997) describes providing women with the opportunity to tittle-tattle about their birth experiences, and have their questions answered, as useful, a finding supported by Smith et al (1996), Phillips (2003), Inglis (2002), Dennett (2003), Charles (1994), Charles and Curtis (1994), Baxter et al (2003), and Allott (1996). Certainl y, a range of literature established post-traumatic stress disorder as a potential and/or real psychological morbidity for women having had a baby (Ayers and Pickering, 2001 Creedy et al, 2000 Laing, 2001 syndicate, 1996 Robinson, 1999 Ballard et al, 1995 Crompton, 1996). psychological debriefing interventions may be effective in preventing or managing post traumatic stress disorder in a range of situations (Rose et al, 2004), but there would seem to be some dangers native in some of the interventions found in the literature (Kenardy, 2000 Madden, 2002).ConclusionIt would appear from the randomised controlled trials analysed here that while some evidence supports postnatal debriefing as a means of reducing psychological morbidity, significant evidence shows no correlation between postnatal interventions of this kind and improved emotional health outcomes. However, anecdotal evidence and other literature suggests that midwives and women find some benefit from opportunities to talk about their childbirth experiences. Some of these simply allow women an opportunity to talk and to ask questions about what happened to them. This leads to the conclusion that such interventions require much more research, preferably research which includes detailed, qualitative evaluations of interventions, and interventions which are specifically designed for this client group. However, this author would also recommend that such interventions be provided, as they are not proven to do harm in the majority of studies, and represent a woman-centred approach to good midwifery care.ReferencesAlexander J (1998) Confusing debriefing and defusing postnatally the need for clarity of terms, pattern and value. tocology 14 122-124.Allott H (1996) Picking up the pieces the post-delivery stress clinic. 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