Be quiet and man up: a qualitative questionnaire study into fathers who witnessed their Partner's birth trauma.

BACKGROUND: Research focusing on paternal mental health is limited, especially regarding the impact of the experience of poor mental health in the perinatal period. For example, little is known about the experiences of fathers who witness their partner's traumatic birth and the subsequent impact on their mental health. Therefore, the aim of this study was to explore fathers' experiences of witnessing a traumatic birth, how these experiences impacted their wellbeing, and what support they received during and following the traumatic birth. METHODS: Sixty-one fathers were recruited via targeted social media to complete an anonymous online qualitative questionnaire regarding their birth trauma experience. Eligible participants were fathers aged eighteen or over, resided in the UK and had witnessed their partner's traumatic birth (that did not result in loss of life). Thematic analysis was used to analyse the questionnaire data. RESULTS: Three main themes were identified: 'fathers' understanding of the experience' (subthemes: nothing can prepare you for it; merely a passenger; mixed experiences with staff; not about me); 'life after birth trauma' (subthemes: manhood after birth; inability to be happy; impact on relationships); and 'the support fathers received vs what they wanted' (subthemes: prenatal support; birth support; and postnatal support). CONCLUSIONS: Fathers reported that witnessing their partner's traumatic birth had a significant impact on them. They felt this affected their mental health and relationships long into the postnatal period. However, there is no nationally recognised support in place for fathers to use as a result of their experiences. The participants attributed this to being perceived as less important than women in the postnatal period, and maternity services' perceptions of the father more generally. Implications include ensuring support is available for both the mother and father following a traumatic birth, with additional staff training geared towards the father's role.

Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth.

OBJECTIVE: To synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births. DATA SOURCES: PubMed, Scopus, and PsycINFO databases. STUDY SELECTION: Quantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth. DATA EXTRACTION: The final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis. DATA SYNTHESIS: In the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women's Relationships With Their Infants and Partners, Critical Influence ofSupport, and Debriefing. CONCLUSION: When a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.

Obstetric brachial plexus injuries (OBPIs): health-related quality of life in affected adults and parents.

BACKGROUND: Obstetric brachial plexus injuries (OBPIs) are rare but can have significant implications for those affected, their caregivers and the health system. Symptoms can range from restricted movement to complete paralysis of the arm. We investigated health-related quality of life in adults with OBPIs and parents of children with permanent OBPIs, compared these with population norms, and investigated whether certain socio-demographic or clinical factors were associated with the quality of life in these cohorts. METHODS: A cross-sectional study examined 50 affected adults and 78 parents. Participants completed EQ-5D-5 L and characteristics questionnaires. EQ-5D-5 L responses were mapped onto an EQ-5D-3 L value set to generate utility scores. Mean utility scores were compared with English population norms. Univariable and multivariable linear regression models were conducted to assess for associations between participant characteristics and the utility scores. RESULTS: The overall mean utility scores for affected adults and parents were 0.56 (SD 0.28) and 0.80 (SD 0.19) respectively. Affected adults (95% CI (- 0.38, - 0.22), p < 0.001) and parents of children with permanent OBPIs (95% CI (- 0.10, - 0.02), p = 0.007) had lower mean utility scores, and therefore quality of life, compared to English population norms. For affected adults, previous OBPI surgery (95% CI (0.01, 0.25), p = 0.040), employment in non-manual work (95% CI (0.06, 0.30), p = 0.005) and having a partner (95% CI (0.04, 0.25), p = 0.009) appeared to be positively associated with the utility score. Affected adults receiving disability benefits related to OBPIs appeared to have worse utility scores than those not receiving any disability benefits (95% CI (- 0.31, - 0.06), p = 0.005). For parents, employment was associated with better utility scores (95% CI (0.02, 0.20), p = 0.024) but the presence of one or more medical condition appeared to be associated with worse utility scores (95% CI (- 0.16, - 0.04), p = 0.001). CONCLUSIONS: Adults with OBPIs and parents of children with permanent OBPIs reported worse utility scores, and therefore quality of life, compared to the English general population. We also identified certain characteristics as possible factors to consider when dealing with utility scores in these cohorts. The utility scores in this study can be used in future economic evaluations related to OBPIs.

Just another ordinary bad birth? A narrative analysis of first time mothers' traumatic birth experiences.

A difficult birth experience can have long lasting psychological effects on both mother and baby and this study details four in-depth accounts of first time mothers who described their birth experience as traumatizing. Narrative analysis was used to record discrepancies between the ideal and the real and produced narrative accounts that highlighted how these mothers felt invisible and dismissed in a medical culture of engineering obstetrics. Participants also detailed how their birth experience could be improved and this is set in context alongside current recommendations in maternal health care and the complexities of delivering such care in UK health settings.

Psychiatric Injury Claims and Pregnancy: Re (a Minor) and Others v Calderdale & Huddersfield NHS Foundation Trust [2017] EWHC 824.

RE and others concerned a clinical negligence claim against the Defendant NHS Trust by a baby injured during childbirth, as well by her mother and grandmother for psychiatric injury found to have been caused by those events. This commentary focuses on the claim for psychiatric injury by the mother and grandmother, both of which succeeded on the basis that the childbirth was a sufficiently shocking and horrifying event. This commentary urges caution about this development based on how it represents law's view of childbirth and the growth of claims that might result from any expansion of liability in this area.

Long-term Follow-up of Neonatal Brachial Plexopathy: Psychological and Physical Function in Adolescents and Young Adults.

PURPOSE: The prevalence of neonatal brachial plexus palsy (NBPP) has been increasing since the early 1980s. No known studies have examined long-term psychological health and quality of life (QOL) in young adults. The purpose of this study was to investigate the psychosocial and intellectual aspects of NBPP during adolescence into young adulthood. METHODS: A total of 31 patients were enrolled in the adolescent group (16 to 18 y) and 25 in the young adult group (23 to 28 y). Clinical assessment included functional ability, range of motion and strength, weight and body mass index, and education level. Patients were administered measures of psychiatric symptomatology, self-concept, QOL, and cognitive function. RESULTS: Narakas injury level for the adolescent group included 11 level I, 6 level II, 8 level III, and 6 level IV. The young adult group had 10 level I, 2 level II, 9 level III, and 4 level IV. The degree of physical impairment determined by the Modified Mallet Classification showed persistent impairment in both groups. The average DASH scores were higher than the normal range for the adolescent and young adult groups. Forty-five percent of the adolescents and 68% of the young adults were either overweight or obese. All received high school diplomas with 20 of the young adults pursuing higher education.Scores on measures of psychiatric symptomatology and self-concept showed that both groups fell within the normal range. QOL for both groups was also within the normal range. All participants scored average to above average on the cognitive assessment. All measurements were patient reported. CONCLUSIONS: Patients with NBPP can adapt and participate in most activities. This patient sample demonstrated persistent functional limitations and a higher rate of comorbid obesity. However, these patients function psychologically and cognitively within the normal range and many have pursued higher education. LEVEL OF EVIDENCE: Level IV.

Effectiveness of trauma-focused psychological therapies compared to usual postnatal care for treating post-traumatic stress symptoms in women following traumatic birth: a systematic review protocol.

INTRODUCTION: Maternal mental health has been largely neglected in the literature. Women, however, may be vulnerable to developing post-traumatic stress symptoms or post-traumatic stress disorder (PTSD), following traumatic birth. In turn, this may affect their capacity for child rearing and ability to form a secure bond with their baby and impact on the wider family. Trauma-focused psychological therapies (TFPT) are widely regarded as effective and acceptable interventions for PTSD in general and clinical populations. Relatively little is known about the effectiveness of TFPT for women postpartum who have post-traumatic stress symptoms. METHODS AND ANALYSIS: We will conduct a review to assess the effectiveness of TFPT, compared with usual postpartum care, as a treatment for post-traumatic stress symptoms or PTSD for women following traumatic birth. Using a priori search criteria, we will search for randomised controlled trials (RCT) in four databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO and OpenGrey. We will use search terms that relate to the population, TFPT and comparators. Screening of search results and data extraction will be undertaken by two reviewers, independently. Risk of bias will be assessed in RCTs which meet the review criteria. Data will be analysed using the following methods, as appropriate: narrative synthesis; meta-analysis; subgroup analysis and meta-regression. DISSEMINATION AND ETHICS: As this work comprises a synthesis of existing studies, ethical approvals are not required. Results will be disseminated at conferences and in publications.

Paternal mental health following perceived traumatic childbirth.

OBJECTIVE: the objective behind the current study was to explore the experiences and perceptions of fathers after childbirth trauma, an area of minimal research. This is part two of a two-part series conducted in 2014 researching the mental health of fathers after experiencing a perceived traumatic childbirth. DESIGN: qualitative methodology using semi-structured interviews and reporting of qualitative questions administered in part one's online survey (Inglis, 2014). SETTING: interviews conducted face-to-face at an Australian University or on Skype. PARTICIPANTS: sixty-nine responded to the online qualitative questions and of these seven were interviewed. MEASUREMENTS: thematic analysis of verbal and written qualitative responses. FINDINGS: thematic analysis of qualitative survey data and interviews found a global theme 'standing on the sideline' which encompassed two major themes of witnessing trauma: unknown territory, and the aftermath: dealing with it, and respective subthemes. KEY CONCLUSIONS: according to the perceptions and experiences of the fathers, there was a significant lack of communication between birthing teams and fathers, and fathers experienced a sense of marginalisation before, during, and after the traumatic childbirth. The findings of this study suggest that these factors contributed to the perception of trauma in the current sample. Whilst many fathers reported the negative impact of the traumatic birth on themselves and their relationships, some reported post-traumatic growth from the experience and others identified friends and family as a valuable source of support. IMPLICATIONS FOR PRACTICE: improved communication between midwifery staff and fathers before, during and after childbirth may reduce the rates of paternal postpartum mental health difficulties and experiences of trauma.

The impact of pediatric brachial plexus injury on families.

PURPOSE: To determine the impact of brachial plexus injuries on families to best meet their clinical and social needs. METHODS: Our cross-sectional study included families with children between the ages of 1 and 18 years with birth or non-neonatal brachial plexus injuries (BPIs). The consenting parent or guardian completed a demographic questionnaire and the validated Impact on Family Scale during a single assessment. Total scores can range from 0 to 100, with the higher the score indicating a higher impact on the family. Factor analysis and item-total correlations were used to examine structure, individual items, and dimensions of family impact. RESULTS: A total of 102 caregivers participated. Overall, families perceived various dimensions of impact on having a child with a BPI. Total family impact was 43. The 2 individual items correlating most strongly with the overall total score were from the financial dimension of the Impact on Family Scale. The strongest demographic relationship was traveling nationally for care and treatment of the BPI. Severity of injury was marginally correlated with impact on the family. Parent-child agreement about the severity of the illness was relatively high. CONCLUSIONS: Caretakers of children with a BPI perceived impact on their families in the form of personal strain, family/social factors, financial stress, and mastery. A multidisciplinary clinical care team should address the various realms of impact on family throughout the course of treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Risk and resistance factors associated with paternal adjustment to obstetrical brachial plexus injuries.

This study aimed to identify risk and resistance factors associated with the psychological adjustment of fathers of children with obstetrical brachial plexus injuries (OBPI). Participants were 34 fathers of children with OBPI recruited from an Australian OBPI clinic. Measures completed were OBPI severity, disability related stress, family functioning and social support. Together the risk and resistance factors of severity and family functioning accounted for 28% of the total variance in paternal psychological adjustment. Family functioning explained 12% of the variance in psychological adjustment in addition to that explained by severity. These findings highlight the importance of considering paternal perceptions of OBPI severity and family functioning when providing health care to families of children with OBPI.

Maternal experiences of vaginal breech delivery.

BACKGROUND: The optimal mode of breech birth remains controversial. In Finland, a trial of vaginal delivery is possible if strict selection criteria are met. As clinical practice in managing vaginal breech birth differs from that in normal delivery, the birth experience may also be different. This cohort study compares the childbirth experience between term breech and vertex deliveries. METHODS: Intended vaginal term breech births from 2008 to October 2012 were included, and for every breech delivery, a vertex control was selected. The proportions of deliveries ending in a cesarean section and of mothers who had given birth vaginally before were equal in both groups. Three hundred eight mothers were sent the childbirth experience questionnaire and 170 returned it. RESULTS: The birth experience does not differ between breech and vertex births, except for aspects with respect to the choice of birthing position. Indications of an even more positive experience were observed in the breech group, with the exception of the choice of analgesia, but these were not statistically significant. Primiparity, emergency cesarean section, infant birth trauma and prolonged hospital stay were identified as risk factors for a negative birth experience. CONCLUSION: The birth experience of vaginal breech birth seems to be at least as positive as the vaginal vertex birth experience.

Psychometric properties of outcome measures for children and adolescents with brachial plexus birth palsy: a systematic review.

AIM: The aim of this review was to evaluate the psychometric properties of outcome measures used to quantify upper limb function in children and adolescents with brachial plexus birth palsy (BPBP). METHOD: Eleven electronic databases were searched to identify studies on the effects of conservative management to improve upper limb function in young people with BPBP. Outcome measures used in these studies were extracted and used in a subsequent search to identify studies that evaluated the psychometric properties of these measures. The methodological quality of these studies was rated using a standardized critical appraisal tool. RESULTS: Thirty-three outcome measures and 12 psychometric studies were identified. Nine outcome measures had some psychometric evidence, which was variable in quality. The outcome measures which seem to have the most robust psychometric properties include the Active Movement Scale, Assisting Hand Assessment, Pediatric Evaluation of Disability Index, and the Pediatric Outcomes Data Collection Instrument. INTERPRETATION: Further research is required to determine the psychometric properties of outcome measures used for children and adolescents with BPBP. Caution is required when interpreting the results of commonly used outcome measures in this population owing to their relatively unknown psychometric properties.

Medical decision-making among adolescents with neonatal brachial plexus palsy and their families: a qualitative study.

BACKGROUND: Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with neonatal brachial plexus palsy and their families when faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process. METHODS: Eighteen adolescents with residual neonatal brachial plexus palsy deficits between 10 and 17 years and their parents were included. Qualitative research design was used involving separate, 1-hour, in person, semistructured interviews, which were audio recorded and transcribed. Grounded theory was applied by two members of the research team to identify recurrent themes and create a codebook that was applied to the data. RESULTS: Medical decision-making among adolescents with neonatal brachial plexus palsy and their families is multifaceted and individualized, composed of both patient- and system-dependent factors. Four codes were identified: (1) knowledge acquisition, (2) multidisciplinary care, (3) adolescent autonomy, and (4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system-dependent factors, whereas adolescents largely based their decisions on individual treatment desires to improve function and/or aesthetics. CONCLUSIONS: There are many areas for improving the delivery of information and health care organization among adolescents with neonatal brachial plexus palsy and their families. The authors recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. The authors believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The obstetric nightmare of shoulder dystocia: a tale from two perspectives.

PURPOSE: Shoulder dystocia is one of the most terrifying of obstetric emergencies. In this secondary analysis of two qualitative studies, the experiences of shoulder dystocia are compared and contrasted from two perspectives: the mothers and the labor and delivery nurses. METHOD: In the first study mothers' experiences of shoulder dystocia and caring for their children with obstetric brachial plexus injuries were explored. The second study explored secondary traumatic stress in labor and delivery nurses due to exposure to traumatic births. Krippendorff's content analysis technique of clustering was used to identify data that could be grouped together into themes. RESULTS: It was striking how similar the perspectives of mothers and their nurses were regarding a shoulder dystocia birth. Four themes emerged from the content analysis of these two data sets: (1) in the midst of the obstetric nightmare; (2) reeling from the trauma that just transpired; (3) enduring heartbreak: the heavy toll on mothers; and (4) haunted by memories: the heavy toll on nurses. CLINICAL IMPLICATIONS: Providing emotional support to the mother during shoulder dystocia births and afterward in the postpartum period has been acknowledged. What now needs to be added to best practices for shoulder dystocia are interventions for the nurses themselves. Support for labor and delivery nurses who are involved in this obstetric nightmare is critical.

Psychological adjustment, maternal distress, and family functioning in children with obstetrical brachial plexus palsy.

PURPOSE: To examine emotional and behavioral characteristics of children with obstetrical brachial plexus palsy (OBPP), psychological distress of their mothers and their family functioning, and compare them with healthy peers. METHODS: Participants included 42 children with OBPP (22 boys, 20 girls; age range, 4-16 y; mean, 7 y 0 mo; SD, 3 y 3 mo) and 43 healthy controls (24 boys, 19 girls; age range, 4-15 y; mean, 8 y 0 m; SD, 3 y 0 mo). Childhood Behavior Checklist, Symptom Checklist 90, and Family Assessment Device were filled in by the mothers. RESULTS: Participants with OBPP displayed higher problem scores than the comparison children in most of the domains, including internalizing and externalizing problems. Maternal distress was higher in the OBPP group, and few differences in family functioning were noted. Maternal distress and having the diagnosis of OBPP were the strongest predictors of children's total problem scores and explained 26% of the variance when the effect of age, sex, and family functioning were controlled. CONCLUSIONS: Children with OBPP and their mothers are at increased risk for a variety of psychological problems. Professionals should be aware of these children's and their caregivers' psychological adjustment and refer them for further psychological support when needed. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Understanding quality of life and patient expectations among adolescents with neonatal brachial plexus palsy: a qualitative and quantitative pilot study.

PURPOSE: To explore the quality of life (QOL) and patient expectations among adolescents with neonatal brachial plexus palsy (NBPP)and their parents using qualitative and quantitative approaches. METHODS: A total of 18 adolescents (10-17 y) with residual NBPP impairment and their parents under went separate 1-hour tape-recorded semistructured interviews. We also collected quantitative physical examination measures and patient-rated outcome scores, specifically the Pediatric Outcomes Data Collection Instrument and the Child Health Questionnaire, to quantify the severity of each adolescent's functional deficit and increase our understanding of QOL and patient expectations. RESULTS: Through qualitative analysis, we identified several patient- and system-dependent factors contributing to QOL, such as social impact and peer acceptance, emotional adjustment,aesthetic concerns and body image, functional limitations, physical and occupational therapy, finances, pain, and family dynamics. Despite residual impairment, most adolescents and their parents reported a good overall QOL according to quantitative outcome measures. Our study results showed that functional and aesthetic factors were responsible for most observed differences in QOL among NBPP adolescents. We also found that the Pediatric Outcomes Data Collection Instrument might be more sensitive than the Child Health Questionnaire in assessing patient expectations and QOL among this patient population. CONCLUSIONS: Understanding patient expectations and QOL in NBPP adolescents is essential for medical decision making and advancing care. Physical examination measurements alone may not be sufficient for measuring outcome, and knowledge regarding environmental factors and family dynamics is important for clinicians to consider when counseling families of children with NBPP and improving overall outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Burnout, depression and anxiety levels in mothers of infants with brachial plexus injury and the effects of recovery on mothers' mental health.

OBJECTIVE: To evaluate depression, anxiety and burnout in mothers of infants with brachial plexus injury and assess the effects of the severity of injury on the mothers' mental health, as the literature provides no information on this topic. STUDY DESIGN: The study was based on eighteen mothers without psychiatric antecedents who had infants with perinatal brachial plexus paralysis (PBPP). The severity of the brachial plexus injury was classified according to the Narakas classification system. The recovery rate following conservative treatment was classified according to the Modified Mallet Classification System. The Maslach burnout inventory, Beck depression inventory, and Beck anxiety inventory were administered to the mothers. RESULTS: The mothers whose infants were in the third Narakas group were mildly depressed and the depression scores of the mothers in Narakas groups II and III were regularly increased. Mothers in the first and second groups reported a minimal level of anxiety scores. There was no statistically significant difference between the depression, anxiety, emotional exhaustion, depersonalization, and personal accomplishment scores of the mothers in relation to the severity of the injury in the child (p=0.218, p=0.078, p=0.149, p=0.138, and p=0.246). In addition, the depression and anxiety levels of the mothers whose infants recovered fully or partially showed a statistically significant decrease when compared to the mothers of infants with no recovery (p=0.003, p=0.015). There was, however, no statistically significant difference between the emotional exhaustion, depersonalization, and personal accomplishment scores of the mothers of infants with full recovery, partial recovery and no recovery (p=0.591, p=0591, p=0.062). CONCLUSION: Infants' disability may cause psychological distress in their mothers. When brachial plexus injury is predicted in infants, more mothers may become depressed.

Diseased, maimed, mutilated: categorizations of disability and an ugly law in late nineteenth-century Chicago.

The article places Chicago's "ugly" law­an 1881 municipal ordinance that fined "any person who is diseased, maimed, mutilated or in any way deformed so as to be an unsightly or disgusting object" for appearing in public­within the context of late nineteenth-century imaginings of disability. Drawing on the framework of disability studies, this paper demonstrates that nineteenth-century understandings of disability had little to do with the impairments of individuals but instead were tied to the status of the person with the disability. Examining the role of disabled people as workers, as bodies and as charity recipients reveals the hierarchies of disability in late nineteenth-century Chicago and demonstrates who the ugly law intended to restrict and, just as importantly, who it did not. While the law appears to be a blanket indictment of all physically disabled people, multiple sources indicate that the public expected disabled veterans, workers, and freak show performers to occupy the public realm; they therefore cannot be the intended objects of the ordinance. Instead, Chicago's ugly law was one of many pieces of legislation enacted in the wake of the panic of 1873 that attempted to eradicate street begging in general by specifically targeting beggars with disabilities.