Question: What evidence is there to support a policy of "debriefing following adverse obstetric outcome' such as stillbirth/ Intrauterine deaths/ unexpected admission to SCBU/ Obstetric emergencies etc
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Answer: A Cochrane review of "Psychosocial and psychological interventions for preventing postpartum depression" (Dennis) included pregnant women and new (less than six weeks postpartum) mothers, including those at no known risk and those identified as at-risk to develop postpartum depression. The identified trials evaluating in-hospital psychological debriefing provided good evidence to suggest that this intervention should not be implemented into practice.
(Evidence level 1a)
A review of psychological debriefing for preventing post traumatic stress disorder (Rose), included three studies involved obstetric populations, but excluded studies involving perinatal grief support. This concludes that
"There is no evidence that single session individual psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents."
Various individual RCOG guidelines recommend de-briefing in particular circumstances:
Late intrauterine fetal death and stillbirth:
"What is best practice for use of interventions that might aid psychological recovery?
- Carers should be aware of and responsive to possible variations in individual and cultural approaches to death.
- Counselling should be offered to all women and their partners.
- Other family members, especially existing children and grandparents, should also be considered for counselling.
- Debriefing services must not care for women with symptoms of psychiatric disease in isolation."
Maternal Collapse in Pregnancy and the Puerperium:
"Debriefing is recommended for the woman, her family and the staff involved in the event". (Good practice point)
Operative vaginal delivery:
"There is no evidence to support the use of midwife-led debriefing in reducing maternal depression following operative vaginal delivery."
Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management:
"Postnatal follow-up should include debriefing with an explanation of what happened, why it happened and any implications for future pregnancy or fertility"
Prevention and management of postpartum haemorrhage:
"Major obstetric haemorrhage can be traumatic to the woman, her family and the birth attendants; therefore, debriefing is recommended by a senior member of the team who was involved at the time of events at the earliest opportunity." (Good practice point)
Umbilical cord prolapse:
"Postnatal debriefing should be offered to every woman with cord prolapse" (Grade D recommendation)
Two NICE guidelines also address the issue of debriefing:
The "Antenatal and postnatal mental health" guideline recommends that:
"Single-session formal debriefing focused on the birth should not be routinely offered to women who have experienced a traumatic birth. However, maternity staff and other healthcare professionals should support women who wish to talk about their experience, encourage them to make use of natural support systems available from family and friends, and take into account the effect of the birth on the partner."
The caesarean section (CS) guideline published in 2004 recommends:
"Women who have had a CS should be offered the opportunity to discuss with their health care providers the reasons for the CS and implications for the child or future pregnancies." (Good practice point)
This guideline is currently being reviewed, and an update is due to be published in November 2011 The recommendation in a pre-publication draft of this guideline is:
"While women are in hospital after having a CS, give them the opportunity to discuss with healthcare professionals the reasons for the CS and provide both verbal and printed information about birth options for any future pregnancies. If the woman prefers, provide this at a later date."
(Evidence level IV)
A Cochrane review of "Debriefing for the prevention of psychological trauma in women following childbirth" is currently in preparation. (Bastos)
References:
- Bastos Maria Helena, Bick Debra, Rowan Catherine J, Small Rhonda, McKenzie-McHarg Kirstie. Debriefing for the prevention of psychological trauma in women following childbirth. Cochrane Database of Systematic Reviews: Protocols 2008 Issue 2 John Wiley & Sons, Ltd Chichester, UK DOI: 10.1002/14651858.CD007194 Protocol (Access restricted in some countries). Available to RCOG Fellows, Members and Trainees here
- Dennis Cindy-Lee, Creedy Debra K. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews: Reviews 2004 Issue 4 John Wiley & Sons, Ltd Chichester, UK DOI: 10.1002/14651858.CD001134.pub2 Abstract (and full text restricted in some countries). Full text available to RCOG Fellows, Members and Trainees here
- National Institute for Health and Clinical Excellence (NICE). Antenatal and postnatal mental health, 2007
- National Institute for Health and Clinical Excellence (NICE). Caesarean section, 2004
- National Institute for Health and Clinical Excellence (NICE). Caesarean section (update), 2011
- RCOG. Late intrauterine fetal death and stillbirth. Green-top Guideline 55. London: RCOG, 2010.
- RCOG. Maternal Collapse in Pregnancy and the Puerperium. Green-top guideline 56. London: RCOG, 2011
- RCOG. Operative vaginal delivery. Green-top Guideline 26. London: RCOG, 2011.
- RCOG. Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management. Green-top guideline 27. London: RCOG, 2011.
- RCOG. Prevention and management of postpartum haemorrhage. Green-top guideline 52. London: RCOG, 2009.
- RCOG. Umbilical cord prolapse. Green-top Guideline 50. London: RCOG, 2008
- Rose Suzanna C, Bisson Jonathan, Churchill Rachel, Wessely Simon. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews: Reviews 2002 Issue 2 John Wiley & Sons, Ltd Chichester, UK DOI: 10.1002/14651858.CD000560 Abstract (and full text, restricted in some countries). Full text available to RCOG Fellows, Members and Trainees here
Search date: September 2011
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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