Issues relating to the woman’s altered body image will have taken place during her pregnancy (Price 1993, Baston & Hall 2009) which is linked to self-esteem (Lavender 2007). The type of birth she experienced may have had an effect on the way she feels about herself postnatally. Any physical trauma the woman has endured should not be decried as trivial but treated with extreme sensitivity (Way 1996). She may want to achieve her previous weight or ‘flat’ abdominal muscles. The strength of these desires may influence her behaviour in the postnatal period, and frustration may develop if she is unable to achieve her personal goals. Perceptions may also be influenced by the cultural ‘norm’ for the woman (Boyington et al 2007). Furthermore, her feelings about her body may have an influence on her choice of feeding method, with women who feel more dissatisfaction with their body being less likely to choose breastfeeding (Foster et al 1996). Negative views of breasts as sexual objects or fears about touch may also have an effect on her views about feeding her baby (Hall 1997). In addition, change in libido and her perception of her body may have a positive or a negative effect on her sexual relationship with her partner (Snellen 2006).

A key issue affecting maternal (and partner) mental health is sleep deprivation (Bozoky & Corwin 2002). This may be heightened in the initial postnatal period and be related to an altered pattern in REM sleep, leading to greater fatigue (Lee et al 2000). This may be worsened in women who are recovering from long and exhausting labours that have resulted in traumatic or surgical birth. Busy postnatal wards, which include large numbers of postnatal mothers, are not the most ideal places for women to achieve restful sleep (Sherr 1995).

Midwives need to consider how postnatal hospital care can be adapted to enable a postnatal woman to rest, which includes adapting ‘routine’ care to fit in with opportunity for sleep. This can be a challenge where certain ‘tasks’ are seen to need to be achieved over a shift pattern. However, recognition that sleep and rest are part of healing and restoration and vital to the mental wellbeing of a postnatal woman is important. Taking steps to lower noise levels on wards at all times, especially at night, are essential. This could include the type of shoes midwives choose to wear, and the way conversations are conducted, as well as the levels at which televisions or radios are played. The use of noisy equipment should be kept to a minimum, and reduction of light level is essential at night. Sensitive communication with visitors is important, especially in situations where relatives have travelled long distances. Provision of written information to partners of the need for postnatal rest is valuable, and could be used to pass on to other relatives.

Women will commonly experience emotional feelings following the birth of their babies. Box 8.3 indicates the timing of these experiences after birth. The ‘blues’ is thought to be a transient state of heightened emotional reactivity which is said to affect about 70% of postnatal women. It may last up to 10 days following birth (Ussher 2004). The intensity of the symptoms a woman experiences will be individual to her and may be linked to hormonal imbalances, psychological effects or social phenomena (Miller 2002, Ussher 2004). The signs and symptoms, illustrated in Box 8.4, are varied.

Women who experience the blues are more likely to progress to a postnatal depressive condition (Beck et al 1992, Henshaw et al 2004).

National guidance from NICE (2006) indicates midwives should ask women at each postnatal contact:

The woman and her family should also be:

Further it is advised that:

Though midwives may have handed over care to a community practitioner by this time, it indicates that adequate information about the severity and length of the time should be communicated at handover in order for further assessment to be made.

There has been some debate in recent years as to whether postnatal depressive conditions are pathological illnesses or an ‘understandable response to the difficulties of motherhood’ (Ussher 2004). The conditions most described are non-psychotic postnatal depression or postnatal psychosis (Miller 2002, Brockington 2004). However, women may also present with other conditions such as extreme anxiety, maternal/child relationship disorders, obsessive behaviours, substance misuse, eating disorders or post traumatic stress disorder (PTSD). Awareness of these conditions is important in relation to the wellbeing of the mother (Lewis 2007) and the partner (Goodman 2004) but also to the potential long-term wellbeing of the child (Martins & Gaffan 2000, Hay et al 2003, Murray et al 2003, Luoma et al 2004).