with sore nipples, then you will feel less able to cope with the practical and emotional demands of your baby. Consequently, it's important not to a.s.sume that what you are feeling is normal: check things out with your midwife and see if there are other solutions. You may need iron supple-ments for your anaemia, or to try a different position such as lying down to feed or you may need the midwife to help you with latching the baby onto the nipple.

The emotional recovery of the mother and father Avery wide range of feelings and experiences can be considered a'normal'

reaction to having a baby. For many parents there is an initial period of elation when they finally become a family and when they explore their new baby. For others the experience may be different: more uncertain or overwhelming particularly where there are any concerns over the health of the baby or the mother.The first couple of days can, however, be something of an emotional roller coaster with most new mums shedding a few tears at some point.

The first few hours may be a time when the anxieties of the pregnancy and about the labour are over and the new arrival is safe and well, bringing much relief. There may be feelings of elation about becoming a family and possibly a sense of achievement from having survived the labour and producing a healthy baby, especially if he seems fairly settled.

More negative feelings often stem from problems that occurred in the labour, the emerging relationship with the baby and feelings of being overwhelmed by the responsibilities of becoming a parent. Sometimes too it can be difficult to accept things not being as you had expected: perhaps to do with labour, perhaps to do with your partner, the gender of the baby, the temperament of the baby or how close you do or don't feel to him.

It is probably misleading to separate out physical and psychological recovery since the two have such strong effects on each other. However, emotional recovery is part of all of the areas we have talked about: how well the baby is feeding, his patterns of sleeping and how easily he seems to settle. Emotional recovery from the labour itself may be very rapid for some women as it becomes lost in the new preoccupations of looking after the baby. However, for some the thoughts of the labour just do not go away and can be quite preoccupying in these early days. Sometimes these problems can be resolved simply by the mother (and father too where appropriate) being allowed to recount and discuss their feelings about what happened in labour and to get explanations from the professionals 124 about why things happened as they did. Generally hospital settings do not facilitate this type of approach.You may be in a shared room with nowhere to talk privately and more than likely no one is particularly available to sit and talk with you. A recent government directive has recognised that all new mothers should be encouraged to 'debrief' but psychological work always needs the right time and the right place and therefore this may not always take place.

Whether you feel great or awful initially, this doesn't necessarily last.

This can be emotionally a very turbulent time. Your initial high may disappear: suddenly the baby needs feeding or starts crying, physical discomfort may kick in as the effects of any drugs wear off.Your tiredness may suddenly overwhelm you just as the baby decides to wake up for feeding. Your partner and or visitors may have gone home for the night and you may find yourself left holding the baby and uncertain of what to do. This may be the first night you have spent in a hospital or away from your partner.The care and support of those around you are crucial at this time. In some non-western societies women are given much more s.p.a.ce to get to know their new baby and learn to be a mother without having to return to the demands of the rest of her life.

How do new dads feel?

The stereotype of the role of the new father is that of informing the expectant relatives about the new arrival and then leaving the mother to recover while he 'wets the baby's head' with the well-wishers. Probably most partners today want to remain much more involved with the mother and baby than might have been true in the last century. However, the idea of acting as a buffer to the outside world does still remain important. The partner can therefore dissuade visitors if they are not wanted or contact them when support from them is needed.The partner can organise the situation for the return home or, if necessary, he can just stay supporting and encouraging the mother.

Of course, these issues concern the recovery of the mother. The new father too may be experiencing his own reactions to the labour or fears about being a father and what that means. He may feel very uncertain about holding the baby and avoid doing so if he feels that the mother is doing a good job or if she keeps telling him how to do it. He may have mixed feelings towards the baby too especially if the mother only has time for the baby. There is evidence that being present at birth increases likelihood of bonding with the baby, however, the father may also feel shocked and overwhelmed by what has happened.

'Baby blues', post-natal depression and post-partum psychosis 125 So, to summarize, a range of reactions can take place over the first few days and are all part of recovering from labour and the negotiation of the early tasks of parenting. Sometimes, however, these early problems might be a reflection of more complex problems to follow.

'Baby blues', post-natal depression and postpar tum psychosis : complicated reactions to having a baby The types of reaction that we have talked about so far are not unusual reactions after having a baby. So when do these reactions mean something more or turn into something more serious? It is something of a dilemma whether or not to get into'categorising' women's reactions to having a baby.

Many would argue that all women experience a sense of loss of their former self and life and a deterioration of the quality of their relationship (where they are in one). So maybe all of these reactions should be thought of as post-natal sadness and all women should be ready to experience some difficult times. One of the reasons for making some distinctions is that different types of problem may need different types of solution. Postnatal depression has been shown to have far-reaching consequences for both the mother and her child so if we can prevent it from happening or alleviate it more quickly, then this has positive consequences for all of the family. When suffering from emotional distress people naturally have questions about what is happening to them. How long will this last?

Should I be taking any medication? All these questions are difficult to answer but are somewhat easier if we try to draw definitions between different types of problem.

Therefore, it can be helpful to think of three types of reaction after having a baby that do need to be distinguished from each other. The first is 'baby blues', the second, is post-natal depression, and the third is post-partum or puerperal psychosis. Post-natal depression (PND) will be covered in the next chapter, as it would not be an appropriate way to describe someone's initial emotional response to having a baby. PND develops more gradually over time. Baby blues and puerperal psychosis are usually seen in those early days. In looking at the statistics it is clear that baby blues is extremely common, PND is experienced by about one in ten women and puerperal psychosis by only about one in every thousand new mothers.

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Baby blues ?

What is it?

'Baby blues' refers to a period of low or changeable mood occurring in the first or second week of having a baby. It is something of a dilemma as to whether to put baby blues in a section looking at complicated reactions to having a baby since it is really quite difficult to separate this from the normal feelings and reactions already talked about.

Most women feel tearful, frustrated or overwhelmed at some point in those first couple of days. Baby blues isn't an illness or even a proper psychiatric diagnosis, it is simply a way that people have tried to describe unpleasant feelings that occur shortly after having a baby and tend to resolve in a few days.

How common is it?

Statistically it is very common and levels of 50^80 per cent of new mothers are said to experience baby blues (Kendell et al., 1981). The reason for perhaps labelling baby blues is to differentiate between this and postnatal depression. Baby blues refers to those reactions that occur around the first week after having a baby and tend to disappear in a couple of days. If you are feeling sad and tearful in those first few days, you are not post-natally depressed but if there are issues generating these tears, then they need to be looked at carefully, otherwise this might be an indication that post-natal depression could develop.

What causes it?

Very often feeling tearful or anxious can be after a poor night's sleep or it often coincides with your milk 'coming in' (which can be painful and make feeding more difficult).You may be very emotionally fragile, laughing one moment and crying the next.Trivial matters may provoke an argument or there may be anxiety type symptoms such as confusion or forgetfulness.

These reactions tend to be short-lived and after a couple of days or a good night's sleep, things settle down.

One of the reasons for trying to describe a syndrome is because researchers can then look to see what might be causing these problems.

There is research to look at whether baby blues is hormonally generated, whether it is linked to certain types of personality or, for example, poor experiences in labour. Not surprisingly there is not one clear reason why Baby blues ?

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this happens. Giving birth is such an all-encompa.s.sing experience; it can be physically and psychologically strenuous or sometimes traumatic, you have to learn to look after your baby, accept a totally new routine, deal with feeding anxieties and come to terms with a whole new ident.i.ty. This process is obviously unique for every parent and consequently we should concentrate on the individual difficulties that the new mother is experiencing rather than looking for a single explanation.

Does it need treatment?

The fact that these experiences are not 'serious' in the medical sense does not mean they shouldn't be taken seriously. It is important for those around the mother to try to understand her particular concerns and problems. If this is a lack of sleep issue, then what can be done to help her catch a few more hours? If this is to do with anxieties about feeding, then perhaps more support from the midwife is needed. Or it may be that there is someone else such as a friend with children or one of the grandparents who can provide some perspective on the situation. Often women may fear that they are going mad. One woman confided to me that after two sleepless nights in hospital she kept seeing her (deceased) mother every time she closed her eyes to go to sleep. She had to ask the midwives to feed the baby that night so that she could recover. She was just very tired.

It is important that the partner makes the midwife aware if he is concerned about how the mother is feeling or behaving, since he is the better judge of the mother's reactions. The midwife may not have met the mother before and may not know that someone is 'not themselves'. These early problems may be the roots of longer-term difficulties if not dealt with now.

Davina's story Davina and Mike had been very excited about the arrival of their baby, which they had planned to have at home. Davina had been healthy throughout pregnancy and in her job as a solicitor was used to being in control of what was happening to her. She had read a lot about home births and felt prepared. Davina, however, did not go into labour spontaneously and eventually agreed to come into hospital to be induced. Despite a lot of pain and anguish Davina's labour did not progress and despite attempts to speed up the contractions after 24 hours the baby became distressed and had to be delivered by Caesarean 128 section. Davina and Mike were delighted that they had a healthy baby girl and things seemed to go well initially with feeding. On her last day in hospital Davina waited all day to see the paediatrician and Mike eventually left to buy some food for their return home. When Mike returned Davina was in floods of tears and had apparently told the midwife that she wanted to discharge herself. She refused to wait to see the paediatrician and Mike was concerned that he shouldn't take her home in this emotional condition. They did go home but Davina did not feel better, becoming concerned then that the baby had not been seen by a doctor and was now crying and difficult to settle. Eventually Mike had to call out the GP and after a rea.s.suring visit from him, Davina went to bed and woke feeling much happier. In the next few weeks they were both able to reflect on the stresses and disappointments that had led to Davina's tears.

Puerperal or post-partum psychosis Very few books on pregnancy and childbirth will have a section on puerperal psychosis.This is possibly because it is so rare, affecting only around 1^2 mothers in every thousand. Probably there is a feeling that discussing it might frighten prospective mothers unnecessarily. There used to be a similar att.i.tude to post-natal depression: that it was best not mentioned to mothers. This leaves problems somewhat shrouded in mystery and women who do have these problems are left to feel shameful about what has happened.

So what is puerperal psychosis?

Again, this is a condition that usually develops very rapidly after the baby is born. It may initially look like just the normal emotional struggles after having a baby. The mother may seem very anxious or agitated or tearful but, rather than subsiding, usually these symptoms escalate very rapidly.

There are many different ways that these problems may present but quite quickly it becomes clear to those around the mother that her mental state is quite severely affected.What may start off as a fairly trivial anxiety about the baby may rapidly develop into an unshakeable delusion. For example, an initial concern about the baby's features may develop into an idea that the baby is a devil.The symptoms can be very varied but usually there is an initial 'manic' or excitable phase. The mother's ideas may be racing, her Baby blues ?

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behaviour may be very hurried and inappropriate, for example, she may pick up the baby in a way that alarms those around her. (Almost all new parents worry about how to hold a baby but if you watch them picking him up, they will do it with great caution, adjusting their position in response to the baby or to the advice of others.) Her speech may be rapid and full of confused ideas and contradictions. She may become extremely paranoid about those around her and feel that they wish her or the baby harm.

The term psychosis is used to describe illnesses that are made up of delusions, hallucinations and often extreme paranoia. The symptoms in puerperal psychoses tend to be like those of manic-depression and more rarely schizophrenia. Alternatively the mother may just present as very depressed and unresponsive. Again it is important to emphasise that puerperal psychosis is extremely rare. If the mother has a history of serious mental illness, then both staff and family may have been alerted to the possibility of these problems in pregnancy.

Clearly, this can be very upsetting for partners and relatives who just cannot understand what is happening. These symptoms may initially be seen as just baby blues but it is their failure to resolve and their escalation that should alert everyone to their seriousness.

What causes it?

There is not really s.p.a.ce in this book to cover this issue in depth. Like most psychological problems, a combination of genetic, biological, environmental and social factors has been studied. It is worth emphasising again that these types of illness are extremely rare. Also there are different factors involved depending on whether this is the first time that you have been ill or whether you have a history of (psychotic) mental illness. Where a woman has a history of manic-depression or schizophrenia she is more at risk for developing these problems. However, it is more likely that under these circ.u.mstances your doctors will monitor your pregnancy more closely and it may be that medical treatment is commenced shortly after the baby is born in order to prevent puerperal psychosis taking place.

How is it treated?

Puerperal psychosis needs immediate psychiatric intervention. Women will usually need to go into hospital to be a.s.sessed and monitored. They 130 will usually need drug treatment and intensive support around caring for the baby. The relatives too will need support and information. A GP or a visit from the community midwife cannot provide this level of support.

Because the presentation of post-partum psychosis is so dramatic, usually the services respond very quickly. Often the problems develop before the mother has left hospital, within hours of the birth.

What about the future?

The two main questions that parents have following these experiences are: How long will it take to recover? And, will it happen again if we have more children? To answer these questions a distinction needs to be made as to whether this is the first illness or a recurrence of previous problems.

Recovery for women with a post-natal psychosis is generally better than for someone experiencing a non-birth-related psychotic illness.

However, hospital admissions will run into a number of weeks or months. The prognosis is better where you have only had a psychosis once following childbirth and you have no family history of similar psychiatric problems.With regard to further problems, there is probably around a 1-in-5 chance of this happening again in subsequent pregnancies and the risk is higher if you have had a psychotic illness before. For all women, however, careful support and monitoring are recommended around any future pregnancies.

Tara and Des's story In the hours after her baby was born Tara became increasingly worried about the behaviour of the senior midwife and realised that this woman 'wanted to take her baby away from her'. She said nothing more while in hospital. Although Tara's partner was worried about her silence, he thought 'things would be OK' when they got home.

Quite quickly Tara became convinced that a number of people were trying to steal her baby, including her own father. Tara locked herself and her baby into the bathroom and refused to come out or let anyone else in. After five hours of agonising Des broke the door in and eventually he convinced Tara that they should return to the maternity ward where the baby would be safe. From here Tara was admitted to a mother and baby unit. Her memory of the subsequent weeks was hazy but she made a full recovery.

Who can help?

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I worked with Tara after the birth of her second child where she again became convinced that someone might try to take her child away. She told me that she knew whom to fear because they would say certain code words to communicate with each other and this 'gave them away'. She also told me that as a teenager following the death of her mother she had been tormented by strangers at night who tapped on her bedroom window. However, her fears were much less dramatic this time and she had not needed medication or hospital admission.

Although Tara was unwilling to be dissuaded of her view that certain people wanted to take her children away, she was able to recognise that her 'protectiveness' was in itself, damaging for the children and gradually she began to let them have more freedom. She let them play with other toddlers and she started to mix with other mothers at a group for women with mental health problems. Here she felt a lot of support from other women, many of whom had also struggled with severe emotional problems while becoming a parent.

Those first few days !

So it is clear that those first few days can be quite a roller coaster of emotions and events. This is probably the biggest transition of most people's lives. For some it will be a wonderful time and hampered by few troubles. For most it will be an enormous upheaval but a rewarding one.

For a very few it will signify a new and difficult time or the return of previous problems. Those first few days can seem like a lifetime and our next journey is through the first few weeks.

Who can help ?

If you have your baby in hospital you will have access to both doctors and midwives to support you in those early days. Doctors will be particularly concerned with the medical aspects of your recovery and with the general health of the baby. Where you are recovering well, you may have little contact with the doctor. If you have any questions or concerns about your labour or about the well-being of your baby, then you may need to say that you want to speak to a doctor. The midwives will take the main 132 role in supporting you in caring for your baby and particularly in helping you to negotiate the early stages of feeding your baby.

If you have your baby at home or after your discharge from hospital, you will be supported by the community midwife. The midwife usually visits daily but will be guided by what you need. Sometimes she may want to call when you are about to feed in order to a.s.sess any problems you may be having. The midwife can stay involved for up to 28 days but may sign off with the arrival of the health visitor if all is well.

The health visitor does a'New birth visit'about two weeks after the baby is born and will be involved with your family until your child goes to school. Initially you will probably be visited at home. The health visitor will want to get to know you and find out about your birth and how you are coping with the new baby. If all is well, the health visitor will then encourage you to attend a baby clinic when you need to get the baby weighed or to discuss any specific concerns that you have.

Any problems either to do with the baby or your own physical or emotional well-being should be directed towards the midwife, health visitor or GP. Many health visitors and midwives are trained in counselling skills and will be able to support you with the emotional issues of this time.

However, for a more serious problem, such as puerperal psychosis, an urgent psychiatric a.s.sessment is needed.The hospital or your GP can set this in motion. Services vary from area to area but many districts have special 'mother and baby' units for women with psychotic problems.

Discussion points 1. What sort of help might you need in the first few days? Do you want a relative or friend to stay with you or to visit and cook a meal? Do you want to be left alone, with no visitors, for the first few days until you find your feet?

2. How long do you think you might stay in hospital? What are your feelings generally about being in hospital? What previous experiences, if any, do you have of being in hospital?

3. What things can you arrange to make those first few days easier? Time off work for your partner? Someone to do some shopping?

4. What are your initial thoughts about your baby? Whom do you think he looks like or 'takes after'?

7.The first six weeks.

In the first six weeks of a baby's life he will grow and mature rapidly.

He will begin to feed for longer periods and you may be able to identify a pattern to his sleeping. There is, however, enormous variation: some lucky parents will have a baby that now sleeps through the night but for most there is still a great deal of variability in the feeding and sleeping cycles.

This is when the majority of new mothers will begin to 'settle into'

parenting and grow in confidence as a mother. Even though the baby may not have developed any routines, you may have established some for yourself: about how you manage your life around the baby's needs.

This is also a time when a small but significant number of women will start to show signs of not coping and around 10 per cent of women will have become depressed by the end of these first few weeks.

In this chapter the areas of feeding, sleeping and crying will be revisited to look at questions such as 'Should I feed a baby on demand?' and 'What is colic?' The development and capabilities of the baby will be considered also. Finally, the area of emotional recovery will be explored with particular attention given to post-natal depression.

The previous chapter highlighted some of the issues relevant to caring for your baby in the first few days. So, what are the tasks of the first six weeks? This is a time still largely dominated by feeding and sleeping (and crying) and, to an increasing extent, interacting. It is a time when the mother may find herself doing little more than feeding, trying to sleep and crying!

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Feeding your baby In those first few days you will probably have established whether you will breast-feed or bottle-feed and over the first six weeks feeding will become more firmly established if not perhaps as predictable as you might have hoped or expected. Quite quickly, as the baby grows, he will be able to take in more milk at one time and therefore he may sleep for longer or be able to go for longer periods between feeds. By six weeks the baby may sleep through the night or may wake two or three times to feed.The baby is probably feeding six or seven times in a day and sleeping in total for around 16 hours a day. Feeding initially mainly fills the baby's wakeful periods but gradually the baby becomes more alert and is beginning to explore his environment.

Feeding on demand Fifty years ago you would have been encouraged to feed your baby every four hours or so and bottle-feeding was seen as a positive aspect of this regime. Breast milk is digested more quickly than formula and therefore 4-hour feeding must have been much easier for those bottle-feeding.The thinking behind this was that your baby needed to learn to wait and crying should not necessarily be seen as a signal that your baby needed feeding.

In the 1970s and 1980s these ideas were swept aside and replaced by the belief that babies should be fed 'on demand' for however long they needed.

These trends seem to reflect a more general feeling about who should take the lead when caring for children. Should the child's needs and wishes dominate the parent or the parent's dominate the child? You will be encouraged initially by your midwife to feed the baby whenever he seems to want to.This is because the baby cannot take in much milk initially and because it helps to establish your milk supply. However, you may find over the first six weeks that you want to begin to establish some sorts of feeding and sleeping routines so that you can plan your day. This is particularly important if you have other responsibilities: if you have to pick up a child from school at 3.30 p.m., you can't feed the baby at the same time.

Currently the pendulum seems to be swinging again away from total demand feeding with the idea that, even when breast-feeding it is possible, to introduce some sorts of pattern or routine and not just feed the baby every time he cries or puts his head up to the breast.

Perhaps in a climate where women want to return to work and also to have time for their own needs, the concept of letting the baby dictate Feeding your baby 135.

has become more unworkable. Also for the mother who is struggling with becoming a parent, the idea of imposing some structure must be very appealing. Currently the best-selling book for new parents is The New Contented Little Baby Book (Ford, 2002). This recommends a routine for feeding and sleeping right from birth and its success perhaps reflects a shift away from demand feeding. So how are mothers supposed to decide what is right?

In the early days with your baby, the midwife will encourage you to feed whenever the baby seems to want to, especially if you are breast-feeding as this will help your milk supply to become established. After this, it is up to you, and for many mothers it is something that just evolves without them having decided from the start. It is important to remember that the baby is involved in this decision too. He may quite quickly settle into having long sleeps and feed well at each sitting and therefore be able to go for quite long periods. It may be easy therefore to establish a pattern of 3- or 4-hourly feeding with a long sleep at night. However, many babies seem to want to feed almost constantly at times and there may be days when they seem particularly hungry. Probably if your baby wants to feed a great deal, you will be trying to encourage him to go for longer so that you can get out of the house occasionally! However, if you are determined to set some sort of routine, you may have to put up with your baby not liking it and expressing his displeasure.

Again, it is important to respond to your baby and not to expect him to be the same as your friend's baby. There is enormous variation in what babies do: if your baby doesn't feed very often or feeds continually, this is still considered normal. It may cause you problems if your baby wakes frequently at night but it only makes your stress greater if you persecute yourself with self-doubt about your competency as a mother. Just because someone else's baby sleeps through the night doesn't mean that they have necessarily done anything different from you.

Probably by the end of the first six weeks most mothers are feeling reasonably content about feeding their baby, that he is growing and that life is settling into some sort of pattern. Usually with babies, as soon as you have deciphered some sort of pattern, it changes. You are feeding at regular intervals then suddenly the baby wants to feed all day again ^ probably he is having a growth spurt. Alternatively he may catch a cold and seem sleepier and less interested in feeding. By the time these events have pa.s.sed, the baby will have grown and changed and his routine may now be completely different from before.

As was mentioned in the last chapter, feeding a baby or an infant seems to be a source of anxiety for most parents at some point. It may be 136 concerns about whether he is gaining weight or getting enough milk as an infant. Later on there can be difficulties around introducing solids: when, how much, what he will or won't eat? With toddlers there may be times when they appear to eat next to nothing for weeks, they may refuse fruit and vegetables or eat only a small range of foods. Only a tiny proportion of children have a 'failure to thrive' resulting from a problem around feeding.The vast majority of parents, however, will have at least one period of concern about their children's eating, many are still worrying after their children have left home. Perhaps we have an almost instinctive preoccupation with feeding since it is only in recent years and in the western world that most of us are free from genuine concerns about our children having enough to eat.

Crying As discussed in the last chapter, babies are highly adept at getting their needs met, and crying is an important part of signalling what they need.

At this age crying is still usually a signal that the baby wants feeding.

However, crying may increase over the first six weeks and some babies develop what is known as 'infant colic'. Colic refers to periods of intense crying that seems to continue despite attempts at feeding, holding or rocking. This often occurs in the early evening or is at its worst at this time. It can begin in the first few weeks of life but seems to resolve spontaneously after a couple of months. That might not seem long with hindsight but, at the time, it can be incredibly distressing and stressful for the mother and father. Early evening is often a time when other responsibilities kick in such as preparing a meal or putting other children to bed.

It is also when the mother may feel most tired and her milk supply may be at its lowest, possibly exacerbating the problem.

Although references to infant colic have been around since the ancient Greeks, the reason for it remains elusive. Many physical and psychological hypotheses have been explored. The physical causes can be grouped into immaturity of the gastrointestinal system, cow's milk intolerance, intolerance from foods being eaten by the mother and pa.s.sed via the breast milk or immaturity of the central nervous system. From a psychological perspective there have been suggestions of difficult infant temperament, parent^infant interaction problems or a 'hyper-sensitivity' in the baby so that any interaction, for example, holding or dressing the baby, leads to crying. The fact that the crying resolves at three or four months of age without any intervention makes some of these explanations seem unlikely.

Crying 137.

With regard to the interaction difficulties, there is no consideration of cause and effect: it seems very likely that parents become more anxious in their interactions if their baby is crying a lot for no apparent reason. In fact, research has shown that the mothers of infants with colic are p.r.o.ne to more feelings of anxiety, depression and inadequacy. However, considering that their babies are crying inconsolably, it would seem more worrying if these mothers weren't showing any signs of distress!