Postpartum post-traumatic stress disorder (PTSD) stems from the parturiant's personal experience of childbirth as a stressed, traumatic, frightening and even life-threatening event. The lately mandatory continuous use of personal protective equipment (PPE) in COVID-19 times by both the patient and caregivers interferes with the caregiver-patient relationship. As shown by Gluska et al, in a study published this week in the European Psychiatry journal, the use of PPE kits correlates with risk of developing PTSD in post-partum period.
As the use of PPE is crucial in this era of COVID-19 pandemic in order to protect both parturients and caregivers, creative measures should be taken in order to overcome the communication gap it poses.
Face-to-face psychological support, sufficient eye contact, touch, and tone of speech are critical elements of care during any caregiver-patient encounter, all of which are interrupted by PPE regulations. Prior to COVID-19 era there was limited use of PPE by staff during labor: rubber gloves were commonly used, but other elements like goggles were not essential in the setting of labor until the final time of fetal delivery.
The authors aimed to investigate the perceived impact of PPE on parturients and to evaluate its association with the development of postpartum post-traumatic stress symptoms (PTSS) and postpartum depressive (PPD) symptoms.
In this multicenter, retrospective cohort study concerning women who delivered during the COVID-19 pandemic first lockdown period in Israel were enrolled. Postpartum women were approached and asked to complete a comprehensive online questionnaire. Impact of PPE was graded on a scale of 1-5, and Impact of PPE ≥4 was considered high. PPD and PTSS were assessed using the EPDS and City BiTS questionnaires.
Of 421 parturients, 36(9%) reported high Impact of PPE. Parturients with high Impact of PPE had significantly higher PPD and PTSS scores. Following adjustment for socio-demographic and delivery confounders and fear of COVID-19 (using Fear of COVID19 scale), the impact of PPE remained positively correlated with PPD symptoms (but not PTSD symptoms).
The main finding of the study was that women who reported healthcare providers' use of PPE as difficult, i.e. women with higher impact of PPE, experienced higher levels of PPD and postpartum PTSD, compared to their counterparts.
During any medical encounter, patient-caregiver communication is composed of at least 55% non-verbal communication, including facial expressions, eye contact and manner of speech. This is especially important in the setting of childbirth, which is a unique, emotional and intimate event, in which there is great value to the caregiver-parturient relationship. The use of facemasks by healthcare providers has been found to negatively influence the level of empathy, thus interfering with caregiver-patient relationship.
The study gives following messages to health-care providers:
1. Creative measures are needed in order to overcome the gaps of caregiver-patient relationship, following the use of PPE in delivery suites.
2. Parturients should be given information prior to their deliveries, on the PPE that is going to be used by the team, ways to increase communication with the team in this situation, and encouragement to processes their feelings about this unique birth experience.
Source: European Psychiatry: Gluska, H., Mayer, Y., Shiffman, N., Daher, R., Elyasyan, L., Elia, N et al. The use of Personal Protective Equipment as an independent factor for developing depressive and post-traumatic stress symptoms in the postpartum period. European Psychiatry, 1-29. doi:10.1192/j.eurpsy.2021.29