3. What are your plans with regard to work? When do you want to start maternity leave?

68.4. Are you planning to return to work? If so, how much maternity leave will you be ent.i.tled to? How much of this decision do you feel will be made after the arrival of the baby?

5. If you stay at home or work part-time, what will your role be? Both partners should discuss their expectations.

6. What things do you feel you are gaining in becoming a parent and what things do you think will be lost?

4.

Specific psychological difficulties in pregnancy.

The popular image of pregnancy is of the parents-to-be perpetually in 'spring', a time of optimism, new replacing the old, new beginnings, and so on. It's not really like this: most women feel a range of different things through their pregnancy as do fathers-to-be. Chapter 3 has tried to identify themes and issues that are common to many pregnancies, but certainly not all. Reading so far, you may have found certain things that you recognised and others that were not your personal experience. However, for some couples, the entire pregnancy can be very different. A pregnancy can be seen as complicated for very many reasons: the mother may have a history of miscarriage or perinatal death, a previous termination of pregnancy or health problems such as pre-eclampsia.The baby may already be identified as having health problems or disabilities or may have been conceived through a.s.sisted conception. However, this chapter will concentrate on significant emotional problems.These may either pre-date the pregnancy or are generated by the experience of being pregnant.

Most people have heard of 'post-natal depression' and are prepared for the weeks after the birth possibly being difficult, but it still remains something of a 'secret' that depression occurs in pregnancy too. As was stated earlier, we enter pregnancy from a particular place in our lives, which might mean struggling to control alcohol or drug problems, or with a tendency to experience panic attacks or anxiety symptoms in certain situations. Pregnancy can re-ignite old difficulties such as problems with body image and fears about controlling your eating. For women who have experienced childhood s.e.xual abuse, pregnancy may trigger or exacerbate 70 Specific psychological difficulties in pregnancy a range of problems. For both parents-to be, where there were significant difficulties in their childhood, psychological symptoms may begin to surface during pregnancy. We have already talked about the changing nature of relationships in pregnancy and, understandably, in some cases, this leads to relationship problems or breakdown.

But don't we all feel fed-up at some point ?

Research has shown that 15 to 20 per cent of pregnant women could be cla.s.sified as having some form of psychological problem (Report of the General Psychiatry Section Working Party on Postnatal Mental Illness, 1992). But is it useful to separate out certain emotional reactions and call them'problems'? It certainly would be difficult to draw a line and say that the thoughts and feelings of one group of pregnant women are different to the rest. At times all women are terrified by the thought of labour, or feel miserable or unattractive. It is more a question of degree: if you continually feel negative about the pregnancy, intruded upon by the baby, unattractive or that you will make a useless parent, then it is important to recognise that there is a problem and to try to understand the roots of it.

Also it can be very undermining if you are told, 'well, everyone feels like this when pregnant' or 'you'll feel better when the baby is born', if it is clear to you that you are really struggling. Pregnancy can bring problems clearly into focus and it may help to give a sense of urgency to sort out things you have tried to ignore in the past.

Depression has been referred to as the'common cold of psychiatry', that is it is something that most of us will experience at some point in our lives.

However, if depression happens for the first time when pregnant, then this can be particularly puzzling for the mother-to-be and her partner, especially in a planned pregnancy. There is more recognition now that fathers-to-be may get depressed in pregnancy or after the birth of the child and that the emotional situation of one partner may affect the other.

What does it feel like?

We probably all know what it is like to feel really miserable but depression is something much more severe and pervasive. The main aspect of 71.depression is a persistent low mood. Usually an extremely bleak outlook accompanies this: depressed people have a negative view of themselves, the rest of the world and the future. Many people find that their low mood is accompanied by what doctors refer to as 'biological symptoms': their appet.i.te is affected, their sleep is disrupted with waking early being a common complaint, and they may lose interest in s.e.x. Often the depression is much worse in the early part of the day and the person may feel unable to cope at all until the afternoon or evening.

How common is it?

Research has shown that as many as 10 to 16 per cent of women are depressed during pregnancy (k.u.mar and Robson, 1984; Johanson et al., 2000; Evans et al., 2001).There is often debate about whether depression is more common during pregnancy or post-natally, and whether depression at either time is any different than depression that women experience at other points in their lives. Clearly, there are many factors common to depression throughout the life cycle. However, this shouldn't deter researchers from trying to understand which particular aspects of pregnancy and childbirth trigger emotional problems, nor should it deter individuals from understanding which unique aspects of their experience of pregnancy and childbirth have led them to experience emotional difficulties.

Why does it happen?

The reasons that women become depressed in pregnancy are many. Some women may have a history of emotional problems and pregnancy may simply be another 'life event' that reduces that woman's ability to cope.

Research shows there are also'risk factors' specific to pregnancy. Problems may arise where the pregnancy was unplanned and the mother-to-be or father-to-be remain unhappy about becoming a parent. There may be guilt for the woman about a whole range of issues: previous termination of pregnancy or miscarriage, smoking and drinking in pregnancy or just not being good enough to be the'perfect mother'. Poor self-esteem generally puts people at risk for depression but it may be the prospect of becoming a parent that triggers worries about 'doing it right' or feeling inadequate. Often if you are trying to live up to a perfect image of mother-hood, then it is very easy to feel you have 'failed'. For example, if you are trying to give up drinking, then having one drink might confirm the belief 72 Specific psychological difficulties in pregnancy that you are'useless'and, conversely, lead to a drinking binge to cope with the feelings generated.

The physical changes of pregnancy can affect your mood: persistent sickness and lethargy can make it hard to engage in the activities that you find pleasurable or that make your life meaningful. A poor relationship with your own mother when you were a child can underlie depression at any stage in a person's life but clearly becoming a parent yourself is often what triggers anger and sadness about your own lack of mothering.

Pregnancy is a different experience for everyone but most parents-to-be will feel some sense of loss even in a desperately wanted pregnancy. The mother will have to change her work situation, her body will change and probably will never return exactly to the pre-pregnancy state. Both parents will have to give up certain aspects of their life and take on new responsibilities. These factors can contribute to depression. Also for some parents-to-be there may have been a hope that a baby would 'make everything alright' in the relationship and already in pregnancy it may be clear that this is a false hope.

What can I do about it?

Whatever the reasons for depression, the experience can be terrible.

Depression can turn your whole world 'bad', making everything seem hopeless. You may feel completely at odds with the world if everyone around you is telling you how wonderful it is that you are pregnant and you feel desperately unhappy and unsure why you feel like this.

. Understanding the problem: It really is important to try to begin to unravel these feelings and identify what problems underlie them. It may be that there are some things you can do nothing about: a relationship that has broken down or financial problems. Usually there are things that you can change: perhaps in terms of how you view yourself or how you relate to other people. In order to find your way out of depression, it may be necessary to seek professional help to start to identify which things you can change.Trying to look at how your (negative) thinking or underlying false beliefs can affect how you feel is known as 'cognitive' or 'cognitive-behavioural' therapy.Your GP should be able to tell you what types of mental health services are available locally in the NHS.

73.Samantha's story Samantha's relationship had broken down irretrievably and she was to be a single parent which she had always insisted would not happen to her child, as she felt she herself had missed out through the death of her father when she was a toddler. She felt she was clearly a useless person otherwise she wouldn't have ended up pregnant with a man who didn't love her. Samantha needed help to look at what she could achieve as a parent. Although she could not bring her child's father back, she could still provide a warm and loving home for her child with lots of positive aspects. In time too she might help her child to understand something about her father and why he had left. She also became more able to acknowledge that her partner had chosen to leave and had not wanted to take responsibility for his child: that didn't make her a useless person.

. Social support: Another important factor in depression is the lack of a supportive relationship with a confidante and therefore it may be important in pregnancy to rally as much social support as you can so that you have people to call on at times of need.

. Life events: For many women, pregnancy is one life event too many.

This can be particularly acute in an unplanned pregnancy where couples sometimes rush into making a number of other decisions too such as moving house or getting married.

Julie's story Julie came to see me towards the end of her second pregnancy. She told me she was coming to see me now as she was well aware of the risks of post-natal depression and she was worried she might experience it because of all of the stress that she was currently under. She was working very long hours as a GP and the practice was struggling to cope with a rebuilding project that had run into problems. The builders had left a trail of problems behind them and her colleagues expected her to take an equal share in all of the after-hours meetings and paperwork. Julie felt exhausted, she had far too little time for her first child and she felt totally unsupported by her colleagues. Julie was able in time to acknowledge that she was distressed and struggling now. She 74 Specific psychological difficulties in pregnancy had hoped I would agree with her 'post-natal depression' diagnosis because she really didn't feel she had time to be depressed now but hoped to'sort herself out'during her maternity leave.

Anxiety and panic attacks during pregnancy In Chapter 3 much was said about fears and anxieties particularly early on in pregnancy. It is very common to be fearful about labour, about your capacity to be a parent or the health of your baby. However, if you are continually gripped by these fears or experiencing regular panic symptoms, then you may need to look a little deeper into what is going on.

Chapter 8 looks at understanding and dealing with anxiety symptoms.

Below is a brief outline of issues to do with anxiety but Chapter 8 is essential reading for a fuller understanding of the issues.

What are panic attacks?

At some point in their life most people will have a panic attack. You may start to shake or tremble, feel your heart racing, feel short of breath or start to hyperventilate. You are likely to interpret these as signs of some imminent danger,'I'm having a heart attack' or 'I'm going mad'and these panic thoughts will cause you to leave the situation ^ run from the supermarket or leave the meeting at work. This extremely unpleasant experience will usually lead you to avoid the feared event or situation, 'I'll never go in a lift again'. Unfortunately the next time you approach a similar situation the panic will start again.

Panic attacks are often an aspect of most anxiety problems. Sometimes people talk aboutdealing with stress and often if someone is feeling'stressed', they are experiencing symptoms of panic and anxiety.Whatever you call these symptoms, the process of beginning to understand them is the same.

Why do panic attacks happen?

There is some evidence that for those who have a history of anxiety problems, their symptoms can improve in pregnancy. If you are experiencing regular panic symptoms, then this can actually have negative effects on your pregnancy. High levels of anxiety in pregnancy have been linked to higher levels of hypertension in mothers. Often when people are experiencing panic attacks it is because problems are not being addressed or Anxiety and panic attacks during pregnancy 75 fearful thoughts or situations are being avoided. If you are terrified of hospitals, then it doesn't help to avoid the problem until you go into labour.

Facing up to the problem might be as simple as needing to discuss your thoughts and feelings with a trusted friend or partner. It may be that you need to seek professional help if there are more complicated issues that need unravelling or if you need specific help to deal with the anxiety symptoms. (See'Who can help?' on p. 83.) What is OCD?

Another type of anxiety problem is obsessive-compulsive disorder (OCD). This involves the performing of certain compulsions or rituals, such as repeatedly washing your hands or checking that the door is locked.

These rituals are performed in order to avoid or neutralise anxiety-provoking thoughts. These thoughts are so fleeting that you may not even be aware of them. Many people are so anxious they only focus on the fact that if they do not check something, they are overwhelmed by panic and these awful feelings are abated by the checking. However, the rituals can become so time consuming that they bring normal life to a standstill. One lady who worked as a secretary constantly checked her typing to see if she had inadvertently typed a rude word. Eventually she had to give up working as she could finish so little work in the course of a day.The thoughts that underlie these rituals are usually fears about saying or doing something terrible. In pregnancy it seems that often the avoided feared thoughts are about harming the baby or being exposed in some way as a bad person.Very often people do not come for help with OCD until the problem reaches unmanageable proportions. (There are probably many people leading very happy lives who have mild OCD and just about manage to keep the checking going.) However, pregnancy and the imminent life changes may make the performing of rituals impossible. For example, some people with OCD get ready in the mornings in a specific order and if any small factor goes wrong, they will have to start again from the beginning. Not very easy to do if you have a newborn baby. These symptoms tend to get worse when experiencing other life events and there is evidence that OCD gets worse during pregnancy.

Obsessive-compulsive disorder does respond well to therapy but it is important to get the right sort of help. Research has shown that therapy needs to specifically address the behavioural management of the symptoms, counselling alone will not help you to deal with the rituals. Your GP will be able to refer you to a clinical psychologist or other therapist competent in cognitive-behavioural therapy.

76.Specific psychological difficulties in pregnancy Kim's story Kim came to see me in the latter stages of her second pregnancy. She was almost housebound because of her obsessive-compulsive problems, which meant that everything that came into the house had to be thor-oughly washed. Kim was so fraught with worry that she couldn't really acknowledge that there was anything excessive about her behaviour, she was more concerned about the amount of time she was spending cleaning. She had her first child at 16 and with the help of her mother had managed to care for her daughter and keep on her job part-time.

She still lived with her mother but her partner was keen for her to move in with him eventually when they could afford to do so. Kim had been managing quite well before her maternity leave had started but now every time her daughter stepped outside the house she had to change her clothes and bathe her. All shoes had to be washed with bleach before they could come into the house.

These problems had probably been around for some time but Kim had just about managed to keep up all the rituals before. It may have been the imminent arrival of another baby or the fear of moving on and leaving her mother's house that had brought things to a head. However, the most immediate concern was helping Kim to get some sense of control over these cleaning rituals and to try to manage and understand her anxiety problems.

Eating disorders and body image During adolescence women's bodies go through enormous changes as our s.e.xual characteristics develop and our body reaches its full adult size.

These changes to our body can affect how we see ourselves, how happy we are with what we see and they can contribute to the development of an eating disorder. For most women, watching their body change in shape is not easy.The majority of women are probably 'watching what they eat'and so eating in pregnancy can be problematic for most. Every woman will resolve this challenge in different ways. The early pregnancy can be most difficult, as once women 'look pregnant' they become more accepting of their changing shape.

Eating disorders and body image 77.Anorexia nervosa The psychology of anorexia and bulimia is complex and looking at how and why it develops is beyond the scope of this book. However, it is helpful to look at how women with eating problems may approach pregnancy. As discussed earlier, few young women today allow themselves to eat freely and many young women and men are preoccupied with dieting and body shape. Most women are striving to be a bit thinner, to have a smaller bottom or would like bigger b.r.e.a.s.t.s or fuller lips. However, despite their dissatisfaction, most just get on with their lives and these issues just tend to surface at certain times. In anorexia nervosa the issues run much deeper; many women have a totally debilitating obsession with controlling their eating which is the driving force in their life. Often this means they are never able to form adult attachments or have children. For some their starvation has led to infertility.

The seriousness of anorexia is sometimes under-estimated and if you do become pregnant while actively experiencing symptoms of anorexia nervosa, then it is extremely important to have as much support in place as possible. A pregnancy when you have anorexia should be considered a 'high risk' pregnancy medically and be closely monitored by the obstetrician. Most women with severe eating problems are torn in pregnancy between the desire to feed and protect their unborn child and their terror of weight gain. It is important too therefore to be in touch with someone who can help you challenge the psychological aspects of this problem. If you have previously seen a therapist, you should contact them for further help or if you have never sought help before, then the pregnancy might motivate you to try to change things. See your GP first, who will know which services are available locally.

Many women have problems with their eating or maintain a low weight but do not want to be labelled as having 'anorexia' or an eating disorder.

The reasons, however, for acknowledging the problems and seeking help are important.Where women are of significantly low weight when they conceive, then their babies are at greater risk of poor growth in utero, low birth weight and premature birth and a much higher rate of neo-natal death. There are at least two ways of deciding if someone is underweight.

In current diagnostic criteria for anorexia nervosa it is said to be 'body weight less than 85 per cent of that expected for height and age. Most doctors will calculate someone's Body Ma.s.s Index or BMI. You can do this yourself by multiplying your height in metres by itself. You then take your weight in kilograms and divide it by the answer to the first sum. A score of below 20 would be considered underweight and a score of above 78 Specific psychological difficulties in pregnancy 30 overweight. Around 25 is a healthy weight. Over 40 would be considered very overweight. These factors can clearly lead to further physical/ developmental problems for your baby and there is evidence to show that these babies often go on to have poor growth throughout the first year.

In anorexia nervosa there are issues about feeling that you can control the shape of your body by controlling eating, consequently, pregnancy will greatly raise your anxiety. To allow a baby to grow inside of you or to eat freely may be very frightening.This is why it is important to get help and support as soon as possible.

Alicia's story Alicia who was in hospital for treatment of her anorexia told me that she longed to be pregnant again as it was the only time she had ever eaten freely. She was able to imagine that everything she ate went directly into the baby and therefore she would not have gained any weight by the end of the pregnancy. Despite this she ate very little during the pregnancy and was very 'frail' after the birth of her baby and found caring for him an enormous struggle. Her husband had to take an extended leave from work to care for both of them.

Bulimia and binge eating Binge eating is so common in the14^25 age group that it could be considered normal behaviour for young women in the twenty-first century. It is also very common for bingeing to be followed on occasions by vomiting or the use of laxatives or diuretics. Binge eating is always a.s.sociated with restricting your eating: people binge because they restrict and avoid food, leading to cravings and preoccupations with 'forbidden foods'. It is a very acceptable social norm for women to perceive themselves as unable to control their eating. Many will say 'I can't have chocolate in the house or I will binge on it.' However, many fail to link this to the fact that they don't eat regular meals, therefore feel hungry and increase their risk of bingeing.

A binge is followed by guilt and further abstinence, which then perpetu-ates the cycle.

Ideally, during pregnancy, eating should involve regular meals and no long periods of abstinence and certainly no vomiting or laxatives. Most Eating disorders and body image 79.women do seem to be able to get control of their eating during pregnancy or allow themselves to lose the control and eat freely for the sake of the health of their baby.

Bulimia is a more serious form of binge eating where the starving/ bingeing cycle is regular, as are vomiting and the use of laxatives. At the more serious end of the scale bulimia is a.s.sociated with a general impulsiveness, incidents of self-harm and drug use. Bulimia can also appear in low weight/anorexic women. Generally, women with bulimia do not have the problems with conception that is seen in anorexia but many women with bulimia may have conceived impulsively and be ambivalent about the baby. Many manage to control the bingeing and vomiting while pregnant but relapse after the birth of the baby. There is less research into bulimia in pregnancy but there are reports of miscarriage rates being twice as high in bulimia sufferers. Babies of these women do better than the babies of women with anorexia but mothers have more problems coping with the care of the baby rather than problems with the pregnancy.

Consequently it is very important to a.s.sess the nature of your eating problems very early on, perhaps when planning a pregnancy. If you have anorexia or bulimia, then it is important to get professional a.s.sistance both from the obstetrician and some form of psychological support to try to reduce the eating problems while pregnant.

Katrina's story Bulimia and other eating problems are often seen as'teenage problems'

but very many women continue to struggle with eating problems throughout their adult life. Katrina came to see me for help with bulimia. She had never sought help before but she was expecting her third child and finding it difficult to control the problems in the way that she had in the previous pregnancies. Katrina had two teenage sons who both excelled in sport. Her husband was out every night with the boys, taking them to various clubs, training and events.

Katrina said that although she was enormously proud of them and of the efforts of her husband, she felt'left out'and increasingly uninvolved in their lives. She had a very demanding job which she said had helped her to control her bingeing in the day but in the evenings, alone at home, she was regularly bingeing and vomiting. The pregnancy had been something of a surprise but both Katrina and her husband had felt it would be 'good' for her to have another baby. However, the reality 80 Specific psychological difficulties in pregnancy was that Katrina felt even more trapped at home and worried about how she would cope with a baby when she was nearly 40.

Katrina struggled greatly to control her eating and rarely made it to the appointments we had made. After the baby was born, however, her mood improved and she felt that she was coping much better. She was enjoying the baby and feeling more involved in the family again.

Substance use, aggression and acting out In Chapter 3 there was discussion of how to manage drinking and smoking in pregnancy. Clearly, some women and/or their partners will need the support and guidance of a specialist drug advisory service if they are regular users of non-prescribed drugs or heavy drinkers. These behaviours can have very serious consequences for the development of your baby and your pregnancy will definitely need to be monitored closely.

If women are twice as likely as men to be depressed, it is clear that men are much more likely than women to express their own distress in terms of alcohol and drug use and violence. Many women may find themselves pregnant with a partner who uses drugs and/or is violent. For Meg and Richard, who were mentioned earlier, the pregnancy led them to seek help for Richard's angry outbursts and he was very motivated to change.

However, sometimes a pregnancy may lead to much more 'acting out' in the partner: staying out late, excessive drinking, late night rows, and so on. Often where the man's own experience of parenting has been very poor or he has seen his own father behave in this way, then this can be how anxieties about becoming a father manifest. Sometimes with some help and support the father may be able to feel that he has some resources to parent a child. However, if both parents are struggling, then this may result in the relationship ending or remaining poor.

Kate and Grant's story Grant came to see me for help with his drinking and alluded to the fact that it helped him to manage his temper. He eventually admitted that he was separated from his partner who was six months pregnant.

Grant said that he and Kate had always had arguments and they had often erupted into physical violence. He wanted to control his Survivors of childhood s.e.xual abuse 81.drinking because he felt he might soon lose his job as a bank manager because 'he couldn't hack it any more'. He said that heavy drinking was almost part of the job and everyone did it. Grant was stuck in a situation where until he was willing to stop drinking he wasn't able to begin to identify the problems that led him to hide behind alcohol use. He wanted to return to his partner but he couldn't stay sober long enough to sort anything out.

Survivors of childhood s.e.xual abuse With increasing awareness of the occurrence of the s.e.xual abuse of children, more women and some men too are willing to come forward and seek help in dealing with the consequences of abuse in childhood. Often women come for help with depression or an eating disorder and later on in the therapy reveal that they were abused. Many women I have worked with have been able to have a s.e.xual relationship with someone where they were very 'detached' or cut off from their feelings but it was when they become involved in a serious relationship that the s.e.xual relationship triggered anxiety, flashbacks or depression. For some women the thoughts of being pregnant and going through labour are terrifying: women may fear feeling out of control or are terrified of being examined or touched.

These fears can trigger intense anxiety or flashbacks. Many survivors of childhood abuse also worry about their ability to be a parent: will they be too over-protective of a child? Or they worry about not being able to protect them. Some women have dealt with the abuse by a.s.serting a very rigid control over themselves and could not contemplate the idea of a baby growing inside of them. If you look at the statistics for childhood s.e.xual abuse, then there are clearly many women who never seek professional help. Contemplating a pregnancy or struggling with a pregnancy might be the time to think about seeking help.

Maya's story Maya came to this country to marry her husband who was the son of a family friend. Very soon after their marriage she became pregnant and was pleased to give birth to a healthy baby boy. However, during her labour she experienced many complications and had to have an 82 Specific psychological difficulties in pregnancy emergency Caesarean section after failed attempts at a ventouse delivery. She took quite some time to recover but after a few weeks all was well. When her baby was a couple of months old, her husband was keen to begin a s.e.xual relationship again. However, she said that whenever he tried to climb on top of her she felt as if she was being smothered and had flashbacks to how she had felt as they had prepared her for a general anaesthetic to deliver the baby. At the time her blood pressure had risen and she feared for her life as she went under the anaesthetic.

This in turn had reawakened memories of being a very young child and how her teenage brother had come to her room in the night and put his hand over her mouth to keep her silent while he abused her.

Maya made very substantial progress in therapy. The terrible secret that she had hidden for years had finally been brought out. Maya had a lot of things to discuss in terms of how she had feared for her life in labour and how this had mirrored the fear she had felt as a child. Eventually, Maya was able to resume a relationship with her husband but at this time she did not choose to tell him or anyone else about the abuse.

She greatly feared what her husband might do if he found out.

Dealing with the effects of childhood s.e.xual abuse There are many different ways that people come to terms with past experiences of s.e.xual abuse. It is always important to let people do this in their own time and their own way. Some women find solace in reading the stories of other survivors of CSA. Many books have been written by or for survivors of s.e.xual abuse and three are listed in the reading list on p.188.

For others, individual or group therapy can be helpful.This might involve exploring the effects that the abuse has had on your life, looking at destructive ways of coping that might have resulted, i.e. drug use, and trying to move on from feelings of guilt and shame. Not everyone needs the same sort of therapy. Suzanne was referred for help with the effects of CSA and was three months pregnant when she came to see me. After telling me of her experiences as a child she decided that I could 'look after this story for her' until she had more time to deal with it in the future.

Looking beyond pregnancy For many women and their partners, becoming a parent is a challenging time. Pregnancy does, however, last quite a long time, which does give Who can help?

83.people the opportunity to adjust and make changes before the baby arrives. The pregnancy can give a sense of urgency or new motivation to deal with old problems. Pregnancy also does have an end, so if you are not enjoying it, then you may eagerly await your labour.You may feel you have come a long way in these 40 weeks and yet you are facing another new beginning. Your labour may last only a few hours but for most it is probably the most significant transition you will ever make.

Who can help ?

The experience of significant emotional problems in pregnancy can be overwhelming and it really is important that you make the first step and try to talk to someone about how you are feeling. Perhaps that might be your partner, a friend or relative. As we have said, psychological difficulties are very common so maybe people won't be as surprised as you think.

They may just be relieved that you are opening up about what is wrong.

Sometimes you may need more help than a friend can provide so it may be time to approach your GP who can put you in touch with people who are trained to help. If you don't'gel' with your GP, you could try speaking to the midwife or health visitor many of whom will have had specific training in dealing with emotional problems and also are very used to dealing with women who are having difficulties.

Most GPs are aware of local mental health services and many now have a counsellor or psychologist attached to their surgery. Although waiting lists are usually long, most people will try to see a pregnant woman as soon as possible for an initial discussion at least.

5.Birth.

During pregnancy most women will spend a great deal of time antici-pating, thinking about and planning for the birth of their baby. The experience of labour is very different for all women and it is difficult to predict who might have an arduous 24-hour labour and who may have a quick drug-free birth.

There are a number of choices to be considered in pregnancy about the birth of your baby: where should I have my baby? Who do I want present?

Do I want a water birth? An epidural? Many of these initial choices will depend on what facilities are available locally as well as the preferences of the parents. Many of the decisions made in pregnancy may be overturned when labour arrives (or doesn't). Late in pregnancy a baby may appear to be breech and an elective Caesarean may be recommended when you had planned a home birth.The expected contractions may not occur and labour may be induced.You may have contemplated an elective Caesarean because of fears about giving birth and have a quick labour with little intervention.

The unpredictability of labour doesn't mean that you cannot prepare for it. Learning about what is likely to happen in labour, the stages it progresses through and how you might manage the pains will all contribute to your experience of labour. Thinking about your partner's involvement and discussing his role can help improve the experience for both of you. Research has shown that a number of factors can reduce the length of labour and therefore the need for intervention.This includes the quality of the support that you receive in labour so preparation is not a waste of time. For some women the struggles of labour may be over-shadowed by the immediate crisis of a baby needing special care. For some (around 1 per cent) labour may end in the loss of a baby.

86.This chapter will focus on some of the key issues for labour: types of care, managing pain and managing your feelings. It will also touch on the issues of complications and loss.

So what exactly is a domino ? The choices and decisions surrounding birth During pregnancy your ideas will have begun to form about where and how you would like to give birth. Some women will have strong ideas and expectations from the start whereas others will feel confused and uncertain about what the choices are. It is not the purpose of this book to cover these in detail and certainly services are very different from one area to another. Your GP will initially outline what the local services are and your midwife will be able to explain these in more depth when you have your initial 'booking' appointment. These 'choices' are driven to some extent by what is available locally.

Where do I want to have my baby?

Most women will probably not be offered a choice about where they want to have their baby. On the first visit to the GP to announce the pregnancy, the doctor will want to get you 'booked' at the local hospital. From their point of view this is to make sure that you receive all the appropriate care and do not 'fall through the net'.You will be booked for a hospital delivery, at the local maternity hospital unless you specifically ask for something different. Most parents-to-be at this stage will not have thought very far ahead and will not be aware of what choices might be available. It is possible to visit local services, maternity wards usually do 'tours' for prospective parents and some parents-to-be do change their mind about the hospital as the pregnancy progresses. Sometimes the decisions are overturned as the circ.u.mstances of the pregnancy change, for example, a breech presentation late in pregnancy may mean you are booked for an elective Caesarean section.

Hospital birth The vast majority of women today give birth in hospital. This trend grew in the twentieth century to the point where almost all babies were delivered in hospital but is beginning to change with growing numbers of women wanting to have something different from the So what exactly is a domino?