Single-session visuospatial task procedure to prevent childbirth-related posttraumatic stress disorder: a multicentre double-blind randomised controlled trial.

Preventive evidence-based interventions for childbirth-related posttraumatic stress disorder (CB-PTSD) are lacking. Yet, 18.5% of women develop CB-PTSD symptoms following an unplanned caesarean section (UCS). This two-arm, multicentre, double-blind superiority trial tested the efficacy of an early single-session intervention including a visuospatial task on the prevention of maternal CB-PTSD symptoms. The intervention was delivered by trained maternity clinicians. Shortly after UCS, women were included if they gave birth to a live baby, provided consent, and perceived their childbirth as traumatic. Participants were randomly assigned to the intervention or attention-placebo group (allocation ratio 1:1). Assessments were done at birth, six weeks, and six months postpartum. Group differences in maternal CB-PTSD symptoms at six weeks (primary outcomes) and six months postpartum (secondary outcomes) were assessed with the self-report PTSD Checklist for DSM-5 (PCL-5) and by blinded research assessors with the Clinician-administered PTSD scale for DSM-5 (CAPS-5). Analysis was by intention-to-treat. The trial was prospectively registered (ClinicalTrials.gov, NCT03576586). Of the 2068 women assessed for eligibility, 166 were eligible and 146 were randomly assigned to the intervention (n = 74) or attention-placebo control group (n = 72). For the PCL-5, at six weeks, a marginally significant intervention effect was found on the total PCL-5 PTSD symptom count (ß = -0.43, S.E. = 0.23, z = -1.88, p < 0.06), and on the intrusions (ß = -0.73, S.E. = 0.38, z = -1.94, p < 0.0525) and arousal (ß = -0.55, S.E. = 0.29, z = -1.92, p < 0.0552) clusters. At six months, a significant intervention effect on the total PCL-5 PTSD symptom count (ß = -0.65, S.E. = 0.32, z = -2.04, p = 0.041, 95%CI[-1.27, -0.03]), on alterations in cognition and mood (ß = -0.85, S.E. = 0.27, z = -3.15, p = 0.0016) and arousal (ß = -0.56, S.E. = 0.26, z = -2.19, p < 0.0289, 95%CI[-1.07, -0.06]) clusters appeared. No group differences on the CAPS-5 emerged. Results provide evidence that this brief, single-session intervention carried out by trained clinicians can prevent the development of CB-PTSD symptoms up to six months postpartum.

Maternal childbirth-related posttraumatic stress symptoms, bonding, and infant development: a prospective study.

BACKGROUND: Childbirth-related posttraumatic stress symptoms (CB-PTSS) including general symptoms (GS, i.e., mainly negative cognitions and mood and hyperarousal symptoms) and birth-related symptoms (BRS, i.e., mostly re-experiencing and avoidance symptoms) may disrupt mother-infant bonding and infant development. This study investigated prospective and cross-sectional associations between maternal CB-PTSS and mother-infant bonding or infant development (language, motor, and cognitive). METHOD: We analysed secondary data of the control group of a randomised control trial (NCT03576586) with full-term French-speaking mother-infant dyads (n = 55). Maternal CB-PTSS and mother-infant bonding were assessed via questionnaires at six weeks (T1) and six months (T2) postpartum: PTSD Checklist for DSM-5 (PCL-5) and Mother-Infant Bonding Scale (MIBS). Infant development was assessed with the Bayley Scales of Infant Development at T2. Sociodemographic and medical data were collected from questionnaires and medical records. Bivariate and multivariate regression were used. RESULTS: Maternal total CB-PTSS score at T1 was associated with poorer bonding at T2 in the unadjusted model (B = 0.064, p = 0.043). In the adjusted model, cross-sectional associations were found at T1 between a higher total CB-PTSS score and poorer bonding (B = 0.134, p = 0.017) and between higher GS and poorer bonding (B = 0.306, p = 0.002). Higher BRS at T1 was associated with better infant cognitive development at T2 in the unadjusted model (B = 0.748, p = 0.026). CONCLUSIONS: Results suggest that CB-PTSS were associated with mother-infant bonding difficulties, while CB-PTSS were not significantly associated with infant development. Additional studies are needed to increase our understanding of the intergenerational consequences of perinatal trauma.

Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals: a rapid review.

BACKGROUND: Epidemics or pandemics, such as the current Coronavirus Disease 2019 (COVID-19) crisis, pose unique challenges to healthcare professionals (HCPs). Caring for patients during an epidemic/pandemic may impact negatively on the mental health of HCPs. There is a lack of evidence-based advice on what would be effective in mitigating this impact. OBJECTIVES: This rapid review synthesizes the evidence on the psychological impact of pandemics/epidemics on the mental health of HCPs, what factors predict this impact, and the evidence of prevention/intervention strategies to reduce this impact. METHOD: According to rapid review guidelines, systematic searches were carried out in Embase.com , PubMed, APA PsycINFO-Ovid SP, and Web of Science (core collection). Searches were restricted to the years 2003 or later to ensure inclusion of the most recent epidemic/pandemics, such as Severe Acute Respiratory Syndrome (SARS). Papers written in French or English, published in peer-reviewed journals, and of quantitative design using validated measures of mental health outcomes were included. Of 1308 papers found, 50 were included. The full protocol for this rapid review was registered with Prospero (reg.no. CRD42020175985). RESULTS: Results show that exposed HCPs working with patients during an epidemic/pandemic are at heightened risk of mental health problems in the short and longer term, particularly: psychological distress, insomnia, alcohol/drug misuse, and symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, burnout, anger, and higher perceived stress. These mental health problems are predicted by organizational, social, personal, and psychological factors and may interfere with the quality of patient care. Few evidence-based early interventions exist so far. DISCUSSION: HCPs need to be provided with psychosocial support to protect their mental wellbeing if they are to continue to provide high quality patient care. Several recommendations relevant during and after an epidemic/pandemic, such as COVID-19, and in preparation for a future outbreak, are proposed.

A two-item screening of maternal or infant perceived life threat during childbirth prospectively associated with childbirth-related posttraumatic stress symptoms up to six months postpartum: two observational longitudinal studies.

Objective: This study investigated prospective relationships between the perception of threat to one's own life or to that of one's infant during childbirth and maternal childbirth-related posttraumatic stress symptoms (CB-PTSS) and probable childbirth-related posttraumatic stress disorder (CB-PTSD) in a community and a community and an emergency cesarean section (ECS) sample. Methods: Study samples included 72 mothers from a community sample and 75 mothers after emergency cesarean section. Perceived maternal and infant life threat were assessed at ≤1 week postpartum. Maternal CB-PTSS and probable CB-PTSD were assessed with validated questionnaires up to 6 months postpartum. Covariates were extracted from hospital records. Secondary data analysis with logistic and linear regressions was performed. Results: Globally, mothers were significantly more likely to perceive their infant's life to be threatened, rather than their own. Both types of perceived threat were prospectively but differentially associated with maternal CB-PTSS and probable CB-PTSD at 4-6 weeks and 6 months postpartum. Statistical significance was set at p<0.05. Conclusion: The type of perceived threat differently influences maternal CB-PTSS and probable CB-PTSD up to 6 months postpartum. These results may be the basis for the development of a short screening instrument after traumatic childbirth in clinical settings. Future studies need to assess the psychometric properties and acceptability of such a brief screening tool.

Early mother-infant interactions within the context of childbirth-related posttraumatic stress symptoms.

BACKGROUND: Childbirth may lead to perinatal mental health issues, such as childbirth-related posttraumatic stress symptoms (CB-PTSS), depression, and anxiety. Despite well explored mother-infant interactions in the context of maternal depression and anxiety, only limited studies investigated mother-infant interactions in the context of CB-PTSS, which is the aim of the present study. METHODS: One-hundred mother-infant dyads in the French speaking part of Switzerland were classified into three groups: birth-related symptoms (BRS, i.e., symptoms of re-experiencing and avoidance) (n = 20), general symptoms (GS, i.e., symptoms of negative cognition and mood and hyperarousal) (n = 46), and non-symptomatic (NS) (n = 34) based on maternal report on PTSD Checklist for DSM-5 (PCL-5). At six months postpartum, mother-infant interactions were video-recorded and their quality was assessed using the Global Rating Scale. Data was analyzed using ordinal logistic and negative binomial regressions. RESULTS: In the adjusted model, mothers in BRS group engaged in more frequent coercions compared to the NS group (B = -1.46, p = 0.01, 95%CI = -2.63, -0.36) and showed lower reciprocity in their interactions with their infants compared to the GS group (B = 1.21, p = 0.03, 95%CI = 0.05, 2.37). LIMITATIONS: The use of a cross-sectional design limited the exploration of how consistent these findings are regarding mother-infant interactions between groups over time. CONCLUSIONS: Mothers with higher BRS may need support to improve interactions with their infants. Future studies should consider longitudinal design to observe mother-infant interaction changes between CB-PTSS groups over time.

Tackling childbirth-related intrusive memories with a single-session behavioural intervention involving a visuospatial task: protocol for a single-blind, waitlist-controlled randomised trial.

INTRODUCTION: Approximately 12.3% of mothers experience childbirth-related post-traumatic stress symptoms (CB-PTSS). However, evidence-based interventions to treat CB-PTSS are lacking. Intrusive memories (IM), a key CB-PTSS, are distressing and can trigger other PTSS by reliving the traumatic event. Emerging evidence shows that a behavioural intervention involving a visuospatial task (BI-VT) can reduce the number of IM and PTSS, supposedly by interfering with the reconsolidation of the trauma memory. This study aims to test the efficacy of a single-session BI-VT targeting IM to reduce the number of childbirth-related (CB-)IM and PTSS, in comparison to a waitlist control group (WCG). METHODS AND ANALYSIS: In this multicentre, single-blind, randomised controlled trial being undertaken at one regional and one university hospital in Switzerland, 60 participants will be allocated to the Immediate Intervention Group (IIG), receiving the immediate intervention on day 15, and 60 participants to the WCG receiving the delayed intervention on day 30. All participants will report their CB-IM during the 2 weeks preimmediate and postimmediate intervention in diaries. The IIG will additionally report their CB-IM over weeks 5 and 6 postimmediate intervention. Self-report questionnaires will assess CB-PTSS at 2 weeks preimmediate and postimmediate intervention in both groups, and at 6 weeks postimmediate intervention in the IIG. A feedback questionnaire will evaluate the intervention acceptability. The primary outcome will be group differences in the number of CB-IM between the 2 weeks preimmediate and postimmediate intervention. Secondary outcomes will be CB-PTSS at 2 and 6 weeks postimmediate intervention, the number of CB-IM at weeks 5 and 6 postimmediate intervention, and intervention acceptability. ETHICS AND DISSEMINATION: Ethical approval was granted by the Human Research Ethics Committee of the Canton of Vaud (study number 202200652). Participants will provide an informed consent before study participation. Results will be presented in peer-reviewed journals and at conferences. TRIAL REGISTRATION NUMBER: NCT05381155.

Reducing childbirth-related intrusive memories and PTSD symptoms via a single-session behavioural intervention including a visuospatial task: A proof-of-principle study.

BACKGROUND: Intrusive memories (IMs) of traumatic events are a key symptom of posttraumatic stress disorder (PTSD), and contribute to its maintenance. This translational proof-of-principle study tested whether a single-session behavioural intervention reduced the number of childbirth-related IMs (CB-IMs) and childbirth-related PTSD (CB-PTSD) symptoms, in women traumatised by childbirth. The intervention was assumed to disrupt trauma memory reconsolidation. METHODS: In this pre-post study, 18 participants, whose traumatic childbirth had occurred between seven months and 6.9 years before, received an intervention combining childbirth-related reminder cues (including the return to maternity unit) with a visuospatial task. They recorded their daily CB-IMs in the two weeks pre-intervention (diary 1), the two weeks post-intervention (diary 2; primary outcome), and in week 5 and 6 post-intervention (diary 3). CB-PTSD symptom severity was assessed five days pre-intervention and one month post-intervention. RESULTS: Compared to diary 1, 15/18 participants had ≥ 50% fewer CB-IMs in diary 2. The median (IQR) reduction of the number of CB-IMs was 81.89% (39.58%) in diary 2, and persisted in diary 3 (n = 17). At one month post-intervention, CB-PTSD symptom severity was reduced by ≥ 50% in 10/18 participants. Of the 8 participants with a CB-PTSD diagnosis pre-intervention, none met diagnostic criteria post-intervention. The intervention was rated as highly acceptable. LIMITATIONS: The design limits the causal interpretation of observed improvements. CONCLUSION: This is the first time such a single-session behavioural intervention was tested for old and real-life single-event trauma. The promising results justify a randomized controlled trial, and may be a first step toward an innovative CB-PTSD treatment.

Prenatal insomnia and childbirth-related PTSD symptoms: A prospective population-based cohort study.

BACKGROUND: Certain populations are at high risk of experiencing a traumatic event and developing post-traumatic stress disorder (PTSD). Yet, primary preventive interventions against PTSD are lacking. It is therefore crucial to identify pre-traumatic risk factors, which could be targeted with such interventions. Insomnia may be a good candidate, but studies on civilians are sparse. Furthermore, the mechanisms at stake in the relationship between pre-traumatic insomnia and PTSD symptoms are unclear. METHODS: This prospective population-based cohort study (n = 1,610) examined the relationship between insomnia symptoms at 32 weeks of pregnancy and childbirth-related PTSD (CB-PTSD) symptoms at eight weeks postpartum. Postnatal insomnia symptoms, prenatal psychological symptoms (depression, anxiety, PTSD, fear of childbirth), subjective birth experience (SBE) and birth medical severity were included as covariates in the analyses, which were based on a Piecewise Structural Equation Modelling approach. RESULTS: The relationship between prenatal insomnia and CB-PTSD symptoms was mediated by negative SBE and postnatal insomnia symptoms. All relationships involving insomnia symptoms had small or very small effect sizes. LIMITATIONS: This study used self-report questionnaires. Postnatal insomnia and CB-PTSD symptoms were concurrently measured. CONCLUSION: Prenatal insomnia symptoms may impair the ability to cope with a difficult birth experience and contribute to postnatal insomnia, a risk factor for CB-PTSD. Thus, prenatal insomnia symptoms may be a promising target for CB-PTSD primary preventive interventions, although other prenatal psychological symptoms could also be considered. Even beyond the perinatal context, future studies on pre-traumatic insomnia and PTSD should include post-traumatic insomnia as a covariate.

The Lausanne Infant Crying Stress Paradigm: Validation of an Early Postpartum Stress Paradigm with Women at Low vs. High Risk of Childbirth-Related Posttraumatic Stress Disorder.

Stress reactivity is typically investigated in laboratory settings, which is inadequate for mothers in maternity settings. This study aimed at validating the Lausanne Infant Crying Stress Paradigm (LICSP) as a new psychosocial stress paradigm eliciting psychophysiological stress reactivity in early postpartum mothers (n = 52) and to compare stress reactivity in women at low (n = 28) vs. high risk (n = 24) of childbirth-related posttraumatic stress disorder (CB-PTSD). Stress reactivity was assessed at pre-, peri-, and post-stress levels through salivary cortisol, heart rate variability (high-frequency (HF) power, low-frequency (LF) power, and LF/HF ratio), and perceived stress via a visual analog scale. Significant time effects were observed for all stress reactivity outcomes in the total sample (all p < 0.01). When adjusting for perceived life threat for the infant during childbirth, high-risk mothers reported higher perceived stress (p < 0.001, d = 0.91) and had lower salivary cortisol release (p = 0.023, d = 0.53), lower LF/HF ratio (p < 0.001, d = 0.93), and marginally higher HF power (p = 0.07, d = 0.53) than low-risk women. In conclusion, the LICSP induces subjective stress and autonomic nervous system (ANS) reactivity in maternity settings. High-risk mothers showed higher perceived stress and altered ANS and hypothalamic-pituitary-adrenal reactivity when adjusting for infant life threat. Ultimately, the LICSP could stimulate (CB-)PTSD research.

The relationship between early administration of morphine or nitrous oxide gas and PTSD symptom development.

BACKGROUND: Posttraumatic Stress Disorder (PTSD) is a debilitating mental health disorder. Certain drugs, such as morphine and nitrous oxide gas (N2O), are administered to individuals who just experienced a traumatic event (e.g., soldiers, injured civilians). It is therefore crucial to understand if they incidentally affect PTSD symptom development. Furthermore, such observations could pave the way for the development of pharmacological prevention strategies of PTSD. METHODS: In this prospective population-based cohort study (n = 2,070), we examined the relationship between morphine or N2O administration during childbirth, and subsequent childbirth-related PTSD symptoms at eight weeks postpartum. Pain during labour, prior PTSD symptoms, and birth medical severity were included as covariates in the analyses. RESULTS: In women who developed PTSD symptoms, N2O administration during childbirth predicted reduced PTSD symptom severity (p < .001, small to medium effect size). A similar tendency was observed for morphine, but was not significant (p < .065, null to small effect size). Both drugs predicted increased PTSD symptoms when combined with severe pain during labour. LIMITATIONS: This study was observational, thus drug administration was not randomised. Additionally, PTSD symptoms were self-reported. CONCLUSIONS: Peritraumatic N2O administration may reduce subsequent PTSD symptom severity and thus be a potential avenue for PTSD secondary prevention. This might also be the case for morphine. However, the role of severe peritraumatic pain in context of drug administration deserves further investigation.

Improving mental health and physiological stress responses in mothers following traumatic childbirth and in their infants: study protocol for the Swiss TrAumatic biRth Trial (START).

INTRODUCTION: Emergency caesarean section (ECS) qualifies as a psychological trauma, which may result in postnatal post-traumatic stress disorder (PTSD). Maternal PTSD may not only have a significant negative impact on mother-infant interactions, but also on long-term infant development. The partner's mental health may also affect infant development. Evidence-based early interventions to prevent the development of postpartum PTSD in mothers are lacking. Immediately after a traumatic event, memory formation is vulnerable to interference. There is accumulating evidence that a brief behavioural intervention including a visuospatial task may result in a reduction in intrusive memories of the trauma. METHODS AND ANALYSIS: This study protocol describes a double-blind multicentre randomised controlled phase III trial testing an early brief maternal intervention including the computer game 'Tetris' on intrusive memories of the ECS trauma (≤1 week) and PTSD symptoms (6 weeks, primary outcome) of 144 women following an ECS. The intervention group will carry out a brief behavioural procedure including playing Tetris. The attention-placebo control group will complete a brief written activity log. Both simple cognitive tasks will be completed within the first 6 hours following traumatic childbirth. The intervention is delivered by midwives/nurses in the maternity unit.The primary outcome will be differences in the presence and severity of maternal PTSD symptoms between the intervention and the attention-placebo control group at 6 weeks post partum. Secondary outcomes will be physiological stress and psychological vulnerability, mother-infant interaction and infant developmental outcomes. Other outcomes will be psychological vulnerability and physiological regulation of the partner and their bonding with the infant, as well as the number of intrusive memories of the event. ETHICS AND DISSEMINATION: Ethical approval was granted by the Human Research Ethics Committee of the Canton de Vaud (study number 2017-02142). Dissemination of results will occur via national and international conferences, in peer-reviewed journals, public conferences and social media. TRIAL REGISTRATION NUMBER: NCT03576586.