Psychological Challenges in Obstetrics and Gynecology : The Clinical Management

The discipline of obstetrics and gynecology is changing rapidly. It is changing in respect of science and technology (IVF, minimally invasive surgery) and of ethics (termination, genetics, and reproductive technology). The training for the young specialist adapts to these changes. Sadly, however, the old fashioned division of mind from body continues. Words like "holistic" and "psychosomatic" are dismissed, and those responsible for training in the UK persist in refusing to accommodate psychological modules in the training process. This book attempts to address and redress this imbalance. Failure to understand the psychological aspects of a patients presentation leave the doctor feeling vulnerable and inadequate, searching for the right thing to say, avoiding that patient in future with subsequent poor care. This book, by providing the background knowledge, empowers the obstetrician/gynecologist to be in the key coordinating role, and to communicate effectively with all parties and other health workers who may need to be involved in psychological care. This book meets the needs of doctors that are not covered by their training (e.g. a chapter on "Communication Skills. What you can do in 15 minutes", chapter on "Coping and Adjustment in Pregnancy": Giving Babies a Better Start, and chapter on "Communicating with Cancer Patients") Chapters are written by experts in widely differing areas, and show how to use the consultation to maximum benefit for the patient and doctor. Easy-to-read with stand-alone chapters, this book covers key aspects of obstetrics and gynecology, and addresses areas that are not covered in other texts. The book is relevant to all stages of obstetric and gynecological practice - from trainees to consultants (and some lay interest). Cover Page......Page 1 Title Page......Page 3 ISBN 184628807X......Page 4 Foreword......Page 5 Preface......Page 7 Contents (with page links)......Page 10 List of Contributors......Page 13 Part One Background for the Study of Psychosomatic Obstetrics and Gyneocology......Page 17 1.1. The Essentials of Psychosomatic OB/GYN......Page 19 1.2.1. Contents......Page 20 1.3.1. Contents......Page 22 1.3.2. Educational Methods......Page 23 1.4.1. The Psychosomatic Diagnostic Process......Page 24 1.4.2. Psychosomatic Therapeutic Interventions......Page 26 1.5. Summary......Page 29 References......Page 30 2.2. Communication......Page 31 GMC Guidance, December 2001......Page 32 2.5. Competence to Give Consent......Page 33 Vaginal Examination......Page 34 2.6.1. How Do You Feel, Doctor?......Page 35 2.6.3. How Are You Behaving, Doctor?......Page 36 Things to Think About......Page 37 2.8. Potential for Abuse......Page 38 2.10. Avoided Examination......Page 39 2.12.1. Vaginismus......Page 40 Vaginismus: Definition......Page 41 2.13. How Do You Feel Now, Doctor?......Page 42 Suggested Reading......Page 43 3.1. Communication Skills......Page 45 3.2. Breaking Bad News......Page 47 Reference......Page 48 4.1. Transference......Page 49 BOX 1 Managing Negative Transference......Page 50 4.1.3. What to Do Instead......Page 51 4.2. Countertransference and How to Use It......Page 52 4.3.1. How to Address Somatized Distress BOX 2......Page 53 4.4. Defenses......Page 54 4.4.2. Primitive Defenses......Page 55 4.5. Trauma and Psychological Space......Page 56 4.5.1. How to Help Prevent Trauma......Page 57 References......Page 58 5 Sexuality......Page 59 5.2. Classification and Diagnosis......Page 62 5.4. Treatment Options......Page 63 References......Page 66 6.1. Normality and Difference......Page 67 6.2. Disability as a Human Rights Issue......Page 69 6.3. Disability and Sexuality......Page 71 6.4. Disabled Parents......Page 72 6.5. Disability and Screening......Page 73 References......Page 74 Web sites......Page 75 7 Cross-Cultural Issues in Gynecology and Obstetrics......Page 77 7.2. What the Stars Foretell......Page 79 7.3. The Dowry (Dahej) System......Page 80 7.5. Infant Mortality......Page 81 References......Page 85 8.1. Introduction......Page 87 8.2. What and Who Is a Family?......Page 88 8.3. The Impact of Developments in Medicine on Family and Kinship......Page 89 8.4. Some Implications for Professionals......Page 92 References......Page 94 9.1. Introduction: The best of Both Worlds......Page 97 9.2. One World Standard......Page 98 9.3. BenchMarking: The Methodological Approach......Page 99 9.4.2. Dualism......Page 100 9.4.3. Toward a Humanistic Monism......Page 101 9.5. Ten Postulates......Page 102 References......Page 103 Part Two Obstetrics......Page 105 10 Coping and Adjustment in Pregnancy: Giving Babies a Better Start......Page 107 10.1. Defining Coping......Page 108 10.2. What Can Go Wrong to Create Difficulties in Coping?......Page 112 10.4. Shifting People into More Helpful Ways of Coping......Page 116 10.5. Important Personal Considerations for Clinicians......Page 120 10.6. When to Refer to......Page 121 For an Alternative Perspective......Page 122 11.1. Introduction......Page 123 11.2.2. Stress and Anxiety......Page 124 11.2.3. CVS and Amniocentesis, the Choice......Page 125 11.2.4. Women Who Have a Fetal Abnormality Detected......Page 126 What to Say and How to Say It......Page 127 11.2.6. Aftercare......Page 130 11.2.7. Antenatal Care......Page 131 11.2.8. Preparing for Birth......Page 132 Key Points—Continuing a Pregnancy......Page 133 References......Page 135 12.2. Management......Page 137 12.4. Debriefing After Emergency Delivery......Page 138 Current Useful UK-Based Web Sites......Page 139 12.5.1. Extreme Prematurity......Page 140 12.6. Psychological Impact of Premature Parenthood......Page 141 12.8. Caring for Fathers......Page 142 12.9. Neonatal Death 12.9.1. Parental Fears and Reality......Page 143 12.11. Caring in the Next Pregnancy......Page 144 References......Page 145 13.1. What is PTSD?......Page 147 Sarah (13.1)......Page 148 Juliet (13.2)......Page 150 13.2. What Causes PTSD in O&G?......Page 151 13.3. What Are the Clinical Implications of PTSD?......Page 153 13.4. What Is the Best Way to Treat PTSD in O&G?......Page 154 13.5. Summary and Conclusion......Page 155 Review of PTSD after Medical Illnesses......Page 156 14 Antenatal and Postnatal Depression......Page 157 14.1.2. Impact On the Child(ren)......Page 158 14.1.3. Clinical Management......Page 160 14.2.1. Booking Already Being Treated for Depression......Page 162 14.3.1. Factors Placing a Woman at Risk of Postnatal Depression......Page 164 14.3.2. Postnatal Screening: Measurement of Risk......Page 165 14.3.3. The Effect of Antidepressants on Neonatal Outcome......Page 166 14.4.1. General Principles of Prescribing in the Breastfeeding Mother......Page 167 14.4.2. Advice for Postnatal Support and Health for the Family......Page 169 References......Page 170 15 Maternal Suicide......Page 173 15.3. Methods......Page 174 15.5. Problems in Identification and Risk Assessment......Page 175 15.6.2. Screening Questions......Page 176 15.6.3. Liaison......Page 177 15.6.5. Psychological Autopsy......Page 178 Sharing of Information......Page 179 Further Reading......Page 180 16.2.1. Tokophobia: An Anxiety Disorder......Page 181 16.3. Treatment Studies for Fear of Childbirth......Page 182 16.4.1. Tokophobia Secondary to Childbirth......Page 183 16.5. The Obstetric Consultation......Page 184 16.6.2. The Pregnant Woman with Tokophobia Requesting a Termination of Pregnancy......Page 185 16.6.5. The Woman with Secondary Tokophobia......Page 186 16.7. Managing the Consultation......Page 187 General Reading......Page 188 17.1. Introduction......Page 189 17.2.1. Stages of Grief......Page 190 17.3. Cultural Differences......Page 191 17.6. Stillbirth......Page 192 17.7. Breaking the Diagnosis of Death......Page 193 17.9. Delivery......Page 195 17.11. Postdelivery......Page 197 17.12. Postmortems......Page 198 17.13. Communication......Page 200 17.14.2. Emotional Support for the Next Stage......Page 201 17.16. Preparation for the Poststillbirth Appointment......Page 202 17.17. Conduct of the Appointment......Page 203 17.17.1. Giving the Results......Page 204 17.18. Implications for Future Pregnancy......Page 205 Bibliography......Page 206 18.1. What Are the Physical Problems of Pregnancy After Stillbirth?......Page 209 18.2. Complication for the Baby In Pregnancy After Stillbirth......Page 210 18.5. Risk Factors for Psychological Problems......Page 211 18.7. The Baby’s Psychological Development......Page 212 18.9. Women’s Coping Strategies in Pregnancies After Stillbirth......Page 213 18.10. General Principles of Care......Page 214 18.12.2. Establish a Clear Outline Plan for the Pregnancy......Page 215 18.14. Previous Mid-Trimester Loss and Cervical Cerclage......Page 216 18.18. Maternal Behavior Toward the Unborn Baby......Page 217 18.20.1. Feelings About Having a Baby After a Stillbirth......Page 218 18.20.3. Timing of Delivery......Page 219 18.22. Postnatal......Page 220 18.23. Postnatal Adjustment Problems/Differences in Women in Next Delivery After Loss......Page 221 References......Page 222 Part Three Gynecology......Page 225 19 Health Care and Young People: A Challenge......Page 227 19.1. Considerations of Adolescence......Page 229 19.2. Sexual Assault......Page 231 19.3. Pitfalls of Adolescent Medicine......Page 232 19.5. The Consultation......Page 236 19.5.1. Probity......Page 238 19.7. Child Protection......Page 239 19.8. Young Age and Pregnancy......Page 240 19.9. Examining Young People......Page 243 19.10. Body Image......Page 245 19.11. Vaginal Problems......Page 246 19.13. Eating Problems......Page 248 19.14. Conclusion......Page 250 Reference......Page 251 The Abortion Act 1967......Page 253 20.2.1. Public Opinion......Page 254 20.2.2. Medical Opinion......Page 255 20.3. Unplanned, Unscheduled, or Unwanted Pregnancy?......Page 256 20.3.2. Psychological Impact of Abortion......Page 257 20.4. Identifying Those at Risk of Psychological Sequelae......Page 258 20.5. Understanding Those Presenting for Repeat Abortion......Page 259 20.6. The Unplanned Pregnancy Consultation......Page 260 20.7. Summary......Page 261 References......Page 262 21.1. Reacting to Loss......Page 263 21.2. Language and Vocabulary......Page 264 21.4. Miscarriage and the Family......Page 266 21.6. The Formal/Legal Framework for Miscarriage......Page 267 21.7. Abnormal Grief......Page 268 21.10. Summary......Page 269 Bibliography......Page 270 22.1. Prevalence, Definitions, and Diagnosis of Premenstrual Problems......Page 271 22.2.2. Psychological Theories and Treatments......Page 273 22.3. A Biopsychosocial Approach to Assessment and Treatment of Premenstrual Symptoms......Page 275 Box 1 Goals of assessment......Page 276 22.4. Summary......Page 277 References......Page 278 Box 1 Effect of psyche on infertility......Page 279 Box 2 Motivation to conceive......Page 281 Box 3 Effect of infertility on psyche......Page 282 23.4. More General Effects......Page 283 Box 4 Treatment......Page 284 23.5.1. The Couple......Page 285 23.5.2. The Doctor......Page 286 23.7. Intractable Infertility in the Couple......Page 288 23.7.1. Acceptance......Page 289 Suggested Further Reading......Page 290 Useful Addresses......Page 291 24.2. Rates of Sexual Assault......Page 293 24.3.1. Response of the Clinician to Direct Disclosure......Page 294 24.3.2. Nondisclosure but Abuse Is a Possibility......Page 295 24.4. Therapeutic Needs of Rape Victim......Page 296 24.5.1. Injuries......Page 297 24.5.2. Forensic Sampling......Page 299 24.6.1. Rape Trauma Syndrome......Page 300 24.7. Contact Details, Useful Web sites, and so on......Page 302 Appendix: Diagnostic Criteria from Diagnostic and Statistical Manual for Mental Disorders DSM-IV Posttraumatic Stress Disorder......Page 303 25.1. How Has This Patient Ended Up in My Clinic?......Page 307 25.2. A Conceptual Framework......Page 308 25.3. Assessment in the Clinic......Page 310 25.5.1. Does This Patient Need a Laparoscopy?......Page 311 25.5.3. What Are the Principles of Chronic Pain Management, and Will My Patient Accept Them?......Page 312 References......Page 313 26 Communicating with Cancer Patients......Page 315 26.1. The “Four-Cusp” Approach 26.1.1. Cusp A: Potentially Curable/Cured......Page 317 Case 1......Page 318 Case 2......Page 319 26.1.2. Cusp B: Living with Cancer......Page 320 26.1.3. Cusp C: Preterminal Phase......Page 321 Bibliography......Page 322 27.1. What is the Menopause?......Page 323 27.1.1. Biochemical Changes......Page 324 27.1.3. Cultural Differences in Menopausal Experiences......Page 325 27.2. Depression and the Menopause......Page 328 27.2.1. Treatment of Depression......Page 329 27.2.2. Complementary and Alternative Therapies......Page 330 27.2.3. Sexual Problems......Page 331 27.2.5. Androgens and Effects on Sex......Page 332 27.2.7. Psychosexual Therapy......Page 333 References......Page 334 About the Editors......Page 339 Index (with page links)......Page 341 Background For The Study Of Psychosomatic Obstetrics And Gynecology -- Teaching Psychosomatic Obstetrics And Gynecology -- Vaginal Examination -- Communication Skills, What You Can Do In 15 Minutes -- Psychoanalysis For Emergencies -- Sexuality -- Disability, Normality, And Difference -- Cross-cultural Issues -- The Family -- Research In Psychosomatic Obstetrics And Gynecology -- Obstetrics -- Coping And Adjustment In Pregnancy: Giving Babies A Better Start -- Psychosocial Aspects Of Prenatal Diagnosis -- Premature Labour And The Premature Baby -- Post-traumatic Stress Disorder -- Antenatal And Postnatal Depression -- Maternal Suicide -- Tokophobia : A Profound Dread And Avoidance Of Childbirth (when Pathological Fear Effects [i.e. Affects] The Consultation) -- Psychological Aspects Of Stillbirth -- The Next Pregnancy After Stillbirth -- Gynecology -- Healthcare And Young People -- Unwanted Pregnancy -- Early Pregnancy Loss -- A Biopsychosocial Approach To Premenstrual Problems -- Infertility: A Psychosocial Viewpoint -- Sexual Violence -- Chronic Pelvic Pain -- Communicating With Cancer Patients -- Psychosocial Aspects Of The Menopause. Jayne Cockburn And Michael E. Pawson (eds.). Includes Bibliographical References And Index. By providing the background knowledge, the book empowers the obstetrician/gynecologist to be in the key coordinating role, and to communicate effectively with all parties and health workers involved in psychological care. It meets the needs of doctors not covered by their training (e.g. Communication skills, coping and adjustment in pregnancy, communicating with cancer patients). Chapters show how to use the consultation to maximum benefit for the patient and doctor. Easy-to-read with stand-alone chapters, this book covers key aspects of O and G, and addresses areas not covered in other texts. It is relevant to all stages of O and G practice - from trainees to consultants (and some lay interest). This book offers topics in psychological care to trainees and specialist in O and G, helps them understand the emotional problems their patients face, and shows them how to undertake psychological care.

This book empowers the obstetrician-gynecologist to play a key coordinating role, and to communicate effectively with all parties and health workers involved in psychological care. It provides information not typically covered by their training: communication skills, coping and adjustment in pregnancy, and communicating with cancer patients. Easy-to-read with stand-alone chapters, this book covers key aspects of OB/GYN, and addresses areas not covered elsewhere. The book offers topics in psychological care to trainees and specialists in O & G, helps them understand the emotional problems their patients face, and shows them how to undertake psychological care.