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Part 2 book “Biopsychosocial factors in obstetrics and gynaecology” has contents: Psychosexual disorders, psychosocial aspects of fertility control, the psychobiology of birth, maternal psychosocial distress, biopsychosocial care after the loss of a baby, vicarious traumatization in maternity care providers, birth trauma and post-traumatic stress,… and other contents.
Section Sexual and Reproductive Health Chapter Psychosexual Disorders 22 Claudine Domoney and Leila Frodsham Introduction Psychosexual disorders demonstrate the clear link between mind and body Somatization of distress is a common feature of sexual dysfunction in general, even if the primary cause is a physical one Both men and women will present with sexual problems that are contextualized as a physical entity, although their psychological reaction to them may be unrecognized The skills of psychosexual medicine seek to understand the combination of physical and psychological and therefore within the therapeutic relationship between healthcare professional (HCP) and patient, to achieve understanding of both conscious and unconscious responses Presentation may be overt or covert The experienced professional can reduce the exposure of the patient to unnecessary interventions and encourage more rapid resolution of symptoms It is common that women presenting with dyspareunia or pelvic pain are subjected to a number of invasive investigations without any further understanding of their symptoms or their causes Others with vulval pain are sent to clinics for specialist help that may not achieve a return to a normal quality of life until the impact on sexual life is acknowledged and addressed Sexual problems presenting to the doctor, nurse, midwife or physiotherapist can be examined and treated using eyes and emotions as well as ears and hands Prevalence Sexual difficulties are common in both men and women A frequently cited paper from the United States reported a sexual dysfunction rate of 43% in women and 31% in men aged 18 to 59, yet this is frequently criticized as medicalizing normal, temporary changes in sexual function The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [4] published in 2013 categorizes gender-specific sexual dysfunctions with a duration of at least six months with a frequency of 75–100% This precise diagnostic definition has not been used for most prevalence studies but does aim to reduce the burden of disease that should ideally encourage greater health service engagement Most studies, whether in general or diseasespecific populations, report high levels of sexual disorder that impact on well-being, contributing to and/ or secondary to other mental health disorders The questionnaire used in any study is crucial to addressing the appropriateness of many factors These include recall period, validity in the study population, language used, degree of anonymity and assessment of degree of distress felt by the responder The National Attitudes to Sex and Lifestyle surveys of the United Kingdom, initially undertaken at decade intervals from 1990, have shown significant changes in sexual behaviours, with recent additional assessment of older age groups from 45 to 74 Expectations also alter with changing behaviours, and measurement of sexual disappointment or anxiety is an important part of managing the presentation of sexual problems In the most recent survey published in 2013, one in six men and women reported a health condition that affected their sex life in the last year but only 24% of men had reported this to a HCP and only 18% of women [1] With increasing age, sexual dysfunction may maintain similar prevalence rates, but this appears to be explained by the decline in activity and distress associated [2] Key to determining the prevalence of sexual dysfunction is an estimate of distress and persistence Female sexual dysfunction (FSD) studies reassessed using a sexual distress scale to estimate a more realistic prevalence of clinically relevant sexual difficulties indicate much lower rates of dysfunction It is clear that asking patients about their sexual life is generally welcomed and increases the diagnostic rate [3] The opportunity to understand the true complaint of a patient who is unable to voice their fears and anxieties can raise the same feelings in the HCP Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 189 Section Sexual and Reproductive Health However, in clinical practice, treating the patient who reports distress and offering a therapeutic approach to the holistic management of problems is to be expected in twenty-first-century healthcare Psychogenic Aetiology of Psychosexual Disorders Sex is a mind–body activity – a psychosomatic event Even in the absence of a partner, disruption can have a major impact on quality of life and sense of self-worth Perception of difficulties can restrict an individual’s ability to engage in relationships, yet sometimes therapeutic interventions can be limited without a partner Fears and problems encountered in a sexual relationship may be controlled by a defensive retreat into single status A normal sexual response involves evoking feelings that are usually suppressed in a vulnerable, intimate situation requiring an ability to let go and cope with loss of control Demonstrating emotions and allowing the powerful mix of them to cause disorder of the self can be difficult for those uncomfortable with disarray or frightened or overwhelming feelings The tolerance of these feelings may not be fully conscious Psychological defences to protect the individual from harm are normal and can lead to sexual difficulties that then become pathological Emotional development may be influenced by temperament, but the natural progression of a child learning to be independent involves dealing with pain, fear, guilt, shame, anxiety and conflict Difficulty with expressing these feelings may readily be acted out in sexual relationships and result in long-standing problems Presentation of Common Sexual Problems in Women Women may present directly with specific complaints of low libido, loss of sensation or satisfaction, inability to orgasm or pain They may test out the health professional’s receptivity with a ‘calling card’ of another less sensitive complaint or an oblique approach to asking about a sexual problem or ‘hand on the door’ question (so doctor or patient can escape if the query is not received well) Arousal and Desire Disorders Female hypoactive desire dysfunction and female arousal disorder have been combined by DSM-5 [4] to sexual interest/arousal disorder as they are so often coexistent For women, desire disorders or loss of/low libido is a common endpoint of other sexual problems, as it is a defensive mechanism to prevent psychological and/or physical pain It also is a common consequence of partner factor sexual difficulties when a woman may consciously or subconsciously protect her partner from the disappointment and distress the problem causes both of them I have found my mojo again I lost myself for a while as sex has always been important to my husband and I But we sprinkled some fairy dust when we started talking again A perimenopausal woman coming to terms with her bodily changes but unable to discuss with her fearful husband I have blossomed again – I was a husk but now my ears of corn are plump and ripening I am sexy again A tall, pale perimenopausal woman single for years before finding both hormone replacement and a respectful partner Yet making assumptions about sexuality based on a medical model can disempower the woman who has her own construct of sexual identity I’m so worried about my increase in libido An unusual complaint in gynaecology clinics but she was seven years post diagnosis and treatment of ovarian cancer However, explaining her reasoning, she admitted she thought sexual feelings came from her hormones which in turn were produced from ovarian tissue – the logical conclusion for her was a recurrence of disease Hypoactive sexual desire disorder (HSDD) as described in DSM-IV [5] is the persistent or recurrent deficiency or absence of sexual desire or sexual fantasies or thoughts, and/or the desire for or receptivity to sexual activity which causes distress The emphasis on causing distress and focus on sexual thoughts allows the flexibility of definition to include those who are not in a relationship or have lost their relationships secondary to HSDD Arousal disorder was persistent or recurrent inability to attain or maintain sexual excitement causing personal distress, which may be described as subjective feelings and/or lack of physical changes Women will complain of loss of desire or lack of sensation Specific physical problems such as lack of lubrication are easier to treat, but often the primary physical cause may be forgotten over the Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 Psychosexual Disorders passage of time It is important to evaluate any specific somatic causes Many drugs, including some contraceptives (particularly hormonal), antidepressants, antihypertensives, etc., may have an effect on arousal and libido Postnatally, breastfeeding and menopause are times of hormonal fluctuation and changes in the pelvic floor that can impact on the physical elements of sexual response Understanding the impact these conditions may have on the psychosexual functioning of an individual will inform the therapeutic pathway Orgasmic Disorders This is the absence of, or persistent or recurrent difficulty in achieving, orgasm following sufficient stimulation and arousal It may follow from both desire and arousal disorders or be truly independent Lifelong or primary anorgasmia may be due to suppression of feelings – sexual or otherwise The inability to ‘let go’ or excessive control or composure can be the focus of attention Secondary anorgasmia occurs in response to physical (endocrine, neurological, dermatological, pharmaceutical) causes, relationship issues or other psychosexual causes Major life events may be associated with a change in orgasmic potential – sexual abuse, sexual violence and gynaecological operations or conditions Traditionally primary anorgasmia is considered more difficult to treat due to deep underlying psychological problems that are often difficult to elicit The perception of orgasm as a definitive physical event can lead to unrealistic expectations in some women What is imagined may be an altered state that is formed by imagined experiences read about or seen acted out in films rather than a physical reflex chain of reactions accompanied by excitement How women experience orgasm is more varied and less measurable than in men Dyspareunia and Vaginismus These conditions were formerly separate conditions in DSM-IV, but DSM-5 has combined them to genitopelvic pain/penetration disorder Dyspareunia is the medical label for pain during sex described by the patient This can be pain felt psychologically and/or in the pelvis, rather than pain felt at the level of the pelvis, vagina or vulva, although clearly this is more commonly both Vaginismus describes the sign elicited on attempting examination, of resistance – as demonstrated by thigh adductor muscle spasm and pelvic floor muscle spasm This can be accompanied by comments by the patient of distaste for the examination – ‘What a horrible job you have doctor!’ They may be disengaged from the process or very tearful, upset, fearful and hypervigilant Vaginismus may occur not only with sex but also during tampon use and pessary insertion, and the woman often presents to the HCP with inability to have a cervical smear taken The Internet has encouraged self-diagnosis, and many women are encouraged to believe that buying sex aids or dilators will help them retrain their muscles Yet this frequently does not deal with the underlying problem that can be physical and psychological or a combination of both Non-Coital Pain Disorders Non-coital pain disorders cause significant distress in younger women particularly, often because of the impact on sexual functioning These include vulval pain syndromes, chronic bladder pain and pelvic pain They may be psychogenic in origin or organic disease with poorly understood aetiologies and poor diagnostic criteria This often results in delayed diagnosis with a consequent protracted impact on functioning It is imperative that women with any chronic disease, particularly urogenital, are asked about the effect on their sexual life Often it is a source of embarrassment and shame and will not be revealed unless specifically enquired after Sexual well-being is a combination of general well-being, quality of life and relationship satisfaction and is frequently a good reflection of overall quality of life Non-Consummation These are an isolated group with a combination of all or none of the above or may include male factors Presentation may be late or delayed, frequently with time pressure of fertility or end of a relationship at stake Treatment can be also long and protracted, requiring a multifaceted approach Phases of Life Sexuality develops throughout childhood Many theories of child development have had models of sexual maturation superimposed during the twentieth century Commonly the belief that sexual dysfunction is symptomatic of adverse childhood experiences leading to disorders of maturation and personality, with the normal phases of child sexual development disturbed as a reflection of abnormal child–parent Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 191 Section Sexual and Reproductive Health relationships, damaging the model for future intimate relationships, has led to referral for long-term psychoanalysis or psychotherapy Yet this may not be a suitable intervention for many and understanding the sequence of events in the ‘here and now’ may be just as effective for most Puberty and Adolescence Adolescence is a time of massive hormonal upheaval, physical changes, peer group pressure and evolving self-realization Education with respect to genital function, menstrual cycles, sexual behaviour, contraception and functional relationships evolves with both underlying family attitudes and exposure to the Internet Early sexual experiences and relationships can colour all future sexual life, but if there is an element of robust support and self-belief, these can be all part of the normal ‘pushing of boundaries’ and exploration inherent in a healthy adolescence Yet the freedoms of these years can also expose the vulnerable young person to damaging behaviours acted out through a sense of sexual freedom Non-judgemental guidance and easy access to contraceptive services can much to diminish the long-term effects of this period in life The self-harming behaviour of young women can present in many ways The teenager who has multiple sexual partners with little protection against infection or pregnancy may have a different life story thus far compared to the young person who requests labial reduction or, more extremely, ‘closes’ herself with self-administered sutures having been sexually active before an arranged marriage Yet all have roots in self, parental/cultural and peer expectations and their ability to control their own destiny Power and gender relationships may play a large role in sexual feelings Although celibacy may be promoted in many cultures as a method of self- and population control, in practice for many this is not part of exploration this phase represents The cultural setting for these restrictions can have lasting sequelae Reproductive Lifetime Sexual function is inextricably linked with reproductive function despite the ability to control fertility and infection in the modern age This chapter does not have the scope to cover all areas in any depth, but those commonly encountered in healthcare settings are mentioned for discussion Contraception, Sexually Transmitted Infection and Termination of Pregnancy In many countries, contraceptive provision or gynaecologist review can be the window of opportunity for sexual health intervention Prevention of both sexually transmitted infections (STIs) and pregnancy are inherent in healthy sexual practices Access to safe abortion services is not available to all, but it is recognized as key to male and female reproductive and sexual health Control over the consequences of sexual activity prevents long-term psychological sequelae as well as physical Our contribution to damage as HCPs can be significant The poor choices of a long-term hormonal contraception that significantly alters a woman’s mood and bleeding can end relationships – often with a woman feeling she can no longer provide what she perceives her partner to need The nurse told me my body was all wrong She couldn’t find my cervix Then after searching around for half an hour she said I had an erosion I thought I had leprosy of the vagina That bits were going to start dropping out! A woman presenting to a gynaecology clinic with persistent vaginal discharge and superficial dyspareunia that had been investigated with numerous negative STI checks Thoughtless comments about, for instance, the position or appearance of the cervix can embed powerful fantasies that create significant psychosexual symptomatology Symptoms associated with sex create disproportionate fear and elaborate explanations for them Powerful defences are set up to protect the psyche Loss of libido and sensation and an increase in pain perception are common pathways of sexual disturbance Understanding these causes may be therapeutic My mother persuaded me that having an abortion was the right thing I was in such a panic, I just wanted to get it over with Now that I have had a miscarriage, I think of all those dead babies inside me A woman presenting with secondary anorgasmia The ‘womb as a tomb’ in both miscarriage and termination of pregnancy is a significant inhibitor and can have a late impact on sexual functioning The perpetuation of distorted thinking will depend on the ability of the individual and HCP to recognize this Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 Psychosexual Disorders Infertility Sexual function in couples with subfertility or infertility is of such significance that most fertility clinics and should employ counsellors, often persons with experience in psychosexual work It is not uncommon to encounter couples who are not having penetrative intercourse, either consciously or not The demands of performing to specific menstrual cycle dates and maintaining celibacy at other times take their toll on many couples Sex becomes goal orientated and spontaneity disappears The financial, physical and psychological impact of fertility treatment alters the relationship between the couple and for some raise questions regarding their motivation and wishes at odds with previous desires Even if there was not a psychosexual problem before, it is easy to envisage how they may develop Pregnancy and Pelvic Floor Disorders Pelvic floor disorders are common amongst all women One in four adult women will have lifealtering incontinence, and 30% of parous women will have up to a grade cystocoele These may have an impact on sexual functioning The impact of childbirth, body mass index and daily activities including lifting and engagement in sport all affect acclimatization to bodily changes Pregnancy and childbirth herald major changes for a couple, embarking on a different role in society with their first child Their primary position as partner and lover changes to include mother/parent For some, pregnancy increases orgasmic potential, theoretically via an increase in oxytocin receptors, but changes may be secondary to other psychological and behavioural effects such as bonding and protection of the child (which may also be negative) Childbirth itself will alter sexual health, but there is no good evidence to suggest that vaginal delivery decreases postnatal sexual health compared with caesarean section [6], despite claims to justify the increasing caesarean section rate Episiotomy, however, does increase the persistence of superficial dyspareunia In a large longitudinal study, women who breastfed their babies were significantly less interested in sex than those who bottle-fed their babies, irrespective of tiredness or depression, although this was not maintained long term [7] It also revealed 7–13% of women expressed a need for help, but 25% had not sought it Changes and dissatisfaction are common but many factors contribute to this Mind and body doctoring is fundamental in these circumstances Debriefing is commonly a feature of perineal clinics for postpartum injuries and, although not evidence based at present, should be incorporated as far as possible into routine postnatal care Advice regarding sexual function is also reassuring for the pregnant and postnatal, even if they feel it is the ‘last thing on their mind’ Great care should be taken when deciding on operative intervention in those with dyspareunia, particularly if they plan to have more children and are oestrogen deficient Topical oestrogen cream can safely be used in breastfeeding women and can ‘reintroduce’ the woman to her healing vulva and vagina We can’t think of it as a nice place anymore It is red and raw and feels like a bucket A new mother tearfully complaining of painful sex after a traumatic instrumental delivery Women presenting with pelvic floor dysfunction may describe themselves as too big/too loose or alternatively too small, or complain that sex is painful After surgical intervention, perceptions may be of a scarred or small vagina, with consequential dissatisfaction Although the ‘vagina with teeth’ was used as a metaphor in psychosexual medicine, the advent of meshes has introduced a vagina capable of causing ‘hispareunia’ (painful intercourse for the man) It was often assumed that restoration of normal anatomy would improve sexual function, but many urogynaecological studies have shown this to be simplistic The doctor didn’t even have to touch me to see how disgusting I was Presenting with a ‘loose vagina’ according to her partner, this well-presented woman requested a second prolapse operation Her abusive relationship was then addressed once the examination revealed her feelings about herself I can’t feel anything anymore We have made love every day of our 40 year marriage He is very disappointed A patient who had been treated for overactive bladder symptoms successfully and attributed this sexual dysfunction to the treatment, but her husband had retired and requested sex twice daily She was not able to say this to him in words Menopause Am I not too old for that? Isn’t that to be expected at my age? Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 193 Section Sexual and Reproductive Health There have been many studies exploring sexual activity and dysfunction in perimenopausal and ageing women Overall there is a reduction in activity with age, but this correlates with partner status – both those without partners and those whose partners have sexual problems Studies suggest that approximately half of women over 50 will be sexually active if in relationships with a decline over the decades, although there may be some cultural variations in this [8] Some evidence suggests cessation of activity is more likely to be linked to the male partner [9] A reduction or cessation is often linked to general health status of either partner rather than age itself [10] A study of Australian menopausal women aged between 45 and 55 years showed increased rates of FSD from 42 to 88% from the early to late menopause [11], but addition of a sexual distress measurement scale reduced this significantly to approximately onethird [12] Other work from this group seems to indicate that sexual responsivity is related to ageing, but libido, frequency of intercourse and dyspareunia are associated with oestrogen deficiency Simple measures such as topical oestrogen, nonhormonal vaginal remoisturizers and lubricants can improve the physical sequelae of hormone deficiency and tissue ageing Consideration of treatment (surgical and/or conservative) for those with symptomatic pelvic floor dysfunction or correction of other bothersome problems may improve sexual functioning These therapies are complemented by a psychosexual approach Gynaecological Cancers As medical interventions improve the treatment successes from cancer, the study of survivorship becomes more important Aside from the physical effects of surgery, chemotherapy and radiation therapy, the impact of a cancer diagnosis on the patient and her carer is enormous (see Chapter 20) The role of sex in the relationship and the impact of menopause, fertility and physical changes are reflected in the presenting symptoms – postcoital bleeding, pain, etc Guilt at survival, association with sex itself and sex being unimportant compared with life belie the importance of this basic component of a healthy, satisfying life Understanding the individual feelings as experienced by the patient and partner is paramount Encouraging frank discussion about the impact of treatment allows administration of support and other interventions I felt all the doctors who had examined me, operated on me and put things inside me were there in the room with me and my husband I couldn’t it I feel so sorry for him A resentful woman with arousal disorder after successful treatment with chemo-radiation for endometrial cancer The Silent Patient: Psychosexual Disorders and Men As much as we like to try to focus our attention on women, their partners play a large role in women’s obstetric and gynaecological issues There may be a belief that men are less complex than women, but this undermines the man who is equally complex in his sexual response Male partners rarely attend consultations with their wives/partners, but they are frequently ‘in the room’ with us How often are we told that a woman needs her lax vagina tightening as sex doesn’t ‘feel’ as it used to or non-consummators that need assistance in widening a vagina to ‘let their partner in’? In this brief section, it is hoped that the silent partner is given a voice to assist women better with sexual dysfunction Subfertility Services Subfertility clinics are probably the most overt presentation of the male partner The healthcare professional concentrates 90% of clinic efforts on investigation into women and, almost as an afterthought, turns attention to semen analysis In addition to looking at test results, it is essential to ask a couple about sex Approximately 40% of couples with subfertility will have sexual difficulties, and many will find this increases with length of time trying or increasing interventions Every time I go to have sex with my husband, I think about the doctor examining me and our love life has become about failure rather than pleasure A female patient when asked about frequency of sexual intercourse in the fertility clinic It is important to consider not only the psychosexual dysfunction issues such as premature ejaculation, erectile dysfunction, retarded ejaculation and anorgasmia in men, but also the rarer physical anomalies such as hypospadias and neurological inability to ejaculate All of these have been encountered in fertility clinics where an incomplete sexual Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 Psychosexual Disorders history has been taken and their female partners have gone through numerous invasive procedures and treatments completely unnecessarily ‘Doctor,’ embarrassed shuffle of feet and red face, ’I feel that I should tell you that when I come well, it comes out of the bottom of my cock just before my ball sack I’ve tried to tell people but no one has listened before Can you help us?’ A male partner in a couple who had had multiple failed cycles of IVF The psychological impact of azoospermia and oligospermia should not be underestimated and, whilst fertility specialists might notice the impact during treatment in a more protective partner, there are few support services for men My husband couldn’t come here today, I’ve dropped him off in the woods before the hospital He’s so distraught I’m worried about his welfare today He’s taken the sperm test result really bad, doctor A female partner of a man with azoospermia (no sperm seen on his semen sample) Childbirth There is a strong focus on the trauma of childbirth affecting women, but men may present with secondary sexual dysfunction following childbirth Rather than feel that this is rarely seen, the obstetrician and gynaecologist should try to offer support to male partners in debriefing and explore their feelings in relation to the experience There are currently no official support networks for partners of women in maternity services The way I see it, doc, is that I’m here to protect her as her husband but not only did I fail in the maternity ward, I keep seeing it again all day and when I’m trying to sleep, and now I can’t help her because I’m in piecesit’s all my fault A man with erectile dysfunction since a traumatic delivery Following Surgery It is encouraged to give women as much information as possible during diagnostic and therapeutic pathways, but we must consider that the genitalia that we are trying to restore to normal anatomy are used by our women for their own and partners’ sexual pleasure The significant proportion of women that are seen in gynaecology outpatients with pelvic floor symptoms have reduced, if not ceased, sexual function (often since they have been examined by healthcare professionals who have ‘pathologized’ their physical findings) How often are their hushed comments about things not being normal or sex difficult with their husbands ignored? If their phantasies (fantasies with physical manifestation) are transferred to their partners, sexual dysfunction can occur both preoperatively and post-op Healthcare professionals are taught that patients recall just 20% of their consultations, so we give them peer-reviewed leaflets considered useful on their surgery, often not assessed by patients I looked at those pictures and whenever we tried to make love, all I could think about was what was at the top of her vagina now?’ Pause with widened eyes ‘A huge black hole that might eat me up and I lost my erection.’ A male patient with erectile dysfunction after his wife’s vaginal hysterectomy A vital area to consider is when women with vaginismus are ‘treated’ with dilators or surgery, they are frequently discharged after their therapeutic intervention, so we have little personal feedback on efficacy Sadly, these patients are often seen in psychosexual clinics with their partners who can also develop secondary erectile dysfunction or premature ejaculation There is little evidence to support widespread use of these interventions currently The silent patient can in fact be communicating a great deal Sexual Dysfunction and Treatment in Men Premature Ejaculation The medical definition of premature ejaculation (PE) is under three minutes from penetration to ejaculation This is a source of surprise to a number of men who are led to believe that this should be longer Many couples have an enjoyable sex life even with a diagnosis of PE Therefore treatment is not necessary unless it is distressing for men and/or their partners Whilst it is important to consider the cause of this fully (e.g commitment issues/ambiguity about starting a family), there are many treatments that men may source before visiting anyone Masters and Johnson Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 195 Section Sexual and Reproductive Health pioneered the ‘stop/start technique’ where men are encouraged to stop stimulation for thirty seconds as their excitement builds and then restart There is also the squeeze technique where the man or partner withdraws and squeezes the glans penis until the desire to ejaculate is suppressed I’m done just as she is getting started We turn away from each other and I can hear her crying but she refuses to talk to me A couple with PE undergoing fertility treatment There are many sprays, lubricants and condoms with local anaesthetic marketed to reduce sensation and also some mechanical devices such as ‘Prolong’ which appear to be effective in some men More recently, there has been the launch of dapoxetine, a selective serotonin reuptake inhibitor (SSRI) for PE To date, this seems to cause nausea and sleepiness in many patients and so has limited efficacy Men who take an SSRI with a phosphodiesterase inhibitor (e.g., Viagra) might find some benefit, and there are some successes with mindfulness and yoga in some patients There is very little published data on behavioural therapies Retarded Ejaculation Whilst there is a plethora of products for women on the market for anorgasmia, there is little available for men in this situation This presents one of the more problematic sexual issues in men, in part because it is derided in society as being an advantage, rather than disadvantage, to female partners Often these men can ejaculate on their own or with digital or oral stimulation from partners This poses an issue for spontaneous conception and the difficulty that it presents may well be one of the causes Retarded ejaculation management is patient specific, but encouraging penetration at the ‘point of no return’ may help Desensitizing treatments on the glans penis and/or vibratory devices may also help Erectile Dysfunction Whilst 10% of men are said to suffer from erectile dysfunction (ED), this only represents the proportion who present to their primary care doctor for assistance The Massachusetts male ageing study demonstrated rates of up to 40% in men in their forties and increasing with age up to 70% in the seventies [13] Additionally increasing rates are seen in diabetic men (over 51%) and ED is now seen as a strong indicator of cardiac disease [14] Men with ED (particularly gradual onset) must be screened for cardiovascular disease Treatment depends on the cause – a psychosexual pathology should be diagnosed only by exclusion with screening for cardiovascular disease and diabetes with lipids and fasting blood glucose Additionally an androgen profile should be checked to exclude low testosterone or panhypopituitarism Men with psychosexual dysfunction often retain their morning erections and ability to masturbate, but men with physical causes find that they lose all ability to penetrate as the erection becomes gradually less firm I keep thinking when I’m with her that I am useless and it (sic-the erection) goes It’s fine when I’m on my own I love this girl but why should she stay with me when I can’t satisfy her? A male patient with anxiety-related ED Men with diabetes are eligible for prescription phosphodiesterase inhibitors, but it should be remembered that they have a higher incidence of microvascular disease and may have limited response Men with microvascular disease should be encouraged to purchase a pump to improve blood flow to the penis and use this daily However they should be warned that the pump produces a cold, blue erection that often points down The pump is not the most romantic thing but it’s given us back what we thought we might never regain-big grin to partner A male diabetic patient with ED An important patient group to remember are those men who are survivors of prostatic carcinoma Sadly, many are affected by nerve degeneration secondary to radiotherapy or surgical damage Whilst it is important to give patients a realistic idea of the risk of ED, it is also important to encourage them to have regular erections to keep their penis exercised Retrograde ejaculation is common in this group and in those who have had surgery for benign prostatic hypertrophy Many of these men also find benefit from a penile vacuum pump, and this should be used regularly, post surgery to limit progression of microvascular disease Since he had surgery and lost this little piece of him, he feels like a different man to me and the spark of our relationship has gone I have to keep reminding myself that we should be grateful that he is still with us Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 Psychosexual Disorders A partner of a man with ED post nerve-sparing prostate surgery Summary Male sexual dysfunction impinges on gynaecological practice both directly and indirectly It is vitally important to take a sexual history in all areas of our work and refer to a psychosexual service if problems are too complex to be managed locally Management of Psychosexual Disorders There are many approaches to the diagnosis and treatment of psychogenic sexual disorders This should include the establishment of the absence or impact of organic disease on sexual functioning despite a more dominant psychological effect Differing disciplines will have varying emphasis of focus on aspects of behavioural control – early experiences, world vision, quality of relationship, impact of ongoing sense of self-worth, etc However, treating a patient as the ‘expert’ in their condition, despite lacking the insight and perspective to understand the impact of these factors, will facilitate the therapeutic relationship between the healthcare professional and the patient to achieve these ends The key tenets of the psychosexual approach are: Listen to the patients ‘story’ and view of their problem/s Observe the effect of the patient and their presentation on the doctor and seek to understand the patient’s body language Feel the effect of the doctor’s comments/questions and interventions on the patient (especially examination) Think about the feelings generated during the consultation and/ or examination Interpret the observations and reflect on their revelations of the sexual issues Using these components of a consultation with reflection of the most revealing features can open an understanding of the issues and allow resolution A simple approach to asking about sexual problems will facilitate greater diagnosis • Are you in a sexual relationship? • Do you have any difficulties? • Are they a problem for you? • Do you have pain during sex? Putting the problems into context by trying to understand when the problem started (lifelong or acquired), whether there are trigger factors, and if it is situational is more helpful than a sexual biography The language used by health professionals is very different from that of patients and assuming that the meaning of words used without seeking clarification is likely to limit understanding of the patient’s complaints Basic language and euphemisms can allow misinterpretation and often prove difficult with patients whose native language is different from that of the health professional This works both ways Never assume we understand what the patient means! Let her explain the meaning in her own words and feelings Use the words the patient uses ‘The patient is the expert.’ The doctor often needs to assume a position of ignorance to interpret the patient’s symptoms and feelings This is difficult when we are trained to be the expert and ask closed questions to streamline care down preplanned pathways All circumstances and individuals are unique, particularly with respect to sexual difficulties Just as expectations and frequency of intercourse are individual to a particular woman or couple, so are the difficulties that ensue The key component of a psychosexual consultation may be the examination, when the patient’s vulnerabilities can be exposed The ‘moment of truth’ can be a therapeutic event in itself if used appropriately rather than an opportunity to reassure and exclude physical causes The body can express feelings that the patient cannot Observing body language and behaviour can unlock fantasies, fears and defences [15] Summary It is important to routinely ask about sexual activity Possible physical factors should be assessed, but the psychological impact must be addressed Symptoms should be acknowledged even if they seem outside of the doctor’s expertise Treat the physical factors in addition to, rather than instead of, the psychological as sex is the ultimate biopsychosocial event Key Points • The natural progression of a child learning to be independent involves dealing with pain, fear, guilt, shame, anxiety and conflict Difficulty with expressing these feelings may readily be acted out in sexual relationships and result in long-standing problems Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 197 Section Sexual and Reproductive Health • It is imperative that women with any chronic disease, particularly urogenital, are asked about the effect on their sexual life • There is no good evidence to suggest that vaginal delivery decreases postnatal sexual health compared with caesarean delivery, despite claims to justify the increasing caesarean delivery rate • The needs and complex sexual response of the male partner should be addressed He is often the ‘silent’ patient in the psychosexual consultation • Increasing rates of erectile dysfunction (ED) are seen in diabetic men, and ED is now seen as a strong indicator of cardiac disease Men with ED (particularly gradual onset) must be screened for cardiovascular disease References Field N, Mercer CH, Sonnenberg P, et al Associations between Health and Sexual Lifestyles in Britain: Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) Lancet 2013;382 (9907):1830–44 Hayes RD, Dennerstein L The Impact of Aging on Sexual Function and Sexual Dysfunction in Women: A Review of Population-Based Studies J Sex Med 2005;2:317–30 Bachmann GA, Leiblum SR, Grill J Brief sexual inquiry in gynecologic practice Obstet Gynecol 1989; 73(3 Pt 1): 425–7 American Psychiatric Association (2013) DSM-5: Diagnostic and Statistical Manual for Mental Disorders 5th edition American Psychiatric Press, USA American Psychiatric Association (1984) DSM-IV: Diagnostic and Statistical Manual for Mental Disorders 4th edition American Psychiatric Press, USA De Souza A, Dwyer PL, Charity M, Thomas E, Ferreira CH, Schierlitz L The effects of mode delivery on postpartum sexual function: a prospective study BJOG 2015;122(10):1410–8 Glazener CM Sexual function after childbirth: women’s experiences, persistent morbidity and lack of professional recognition Br J Obstet Gynaecol 1997;104(3):330–5 Nicolosi A, Laumann EO, Glasser DB, et al Global Study of Sexual Attitudes and Behaviors Investigators’ Group Sexual behavior and sexual dysfunctions after age 40: The global study of sexual attitudes and behaviors.Urology 2004;64(5): 991–7 Beckman N, Waern M, Gustafson D, Skoog I Secular trends in self reported sexual activity and satisfaction in Swedish 70 year olds: Cross sectional survey of four populations, 1971–2001 BMJ 2008;337:a279 10 Lindau ST, Schumm LP, Laumann EO, et al A Study of Sexuality and Health among Older Adults in the United States Stacy N Engl J Med 2007; 357:762–74 DOI: 10.1056/NEJMoa067423 11 Dennerstein L, Randolph J, Taffe J, Dudley E, Burger H Hormones, mood, sexuality and the menopausal transition Fertil Steril 2002;77(Supp4): S42–8 12 Hayes RD, Dennerstein L, Bennett CM Fairley CK What is the ‘true’ prevalence of female sexual dysfunctions and does the way we assess these conditions have an impact? J Sex Med 2008;5(4): 777–87 13 Feldman HA, Goldstein I, Hatzichristou DG, et al Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study J Urol 1994;151:54–61 14 McCabe MP, Sharlip ID, Lewis R, et al Segraves RT Risk Factors for Sexual Dysfunction Among Women and Men: A Consensus Statement from the Fourth International Consultation on Sexual Medicine 2015 J Sex Med 2016;13(2):153–67 15 Smith A The skills of psychosexual medicine In Psychosexual Medicine Ed H Montford, R Skrine 2001 Oxford University Press Downloaded from https://www.cambridge.org/core Stockholm University Library, on 02 Nov 2017 at 00:41:54 23 Appendix: RCOG Checklist of Hints and Tips to Support Clinical Practice in the Management of Gender-Based Violence Get knowledgeable Find out how domestic and sexual violence affects women and girls Broaden your understanding of domestic and sexual violence Find your local and domestic abuse professional support services and ask their advice Encourage colleagues and reception staff to the same What is the situation in your local community? Be open-minded and ready for the unknown Think about missed opportunities Learn to recognize behaviours Make sure you’re not stereotyping – you can’t tell by looking at people Be prepared for hidden stories – don’t make assumptions Create a safe and welcoming environment Display information and helplines for patients in waiting rooms Remember what your options are – e.g chaperone, translator, panic button, inviting a female colleague Avoid escalating the situation Build rapport and trust Think about your body language – is it encouraging your patient to trust you? Show you care, understand and believe your patient Give your patient your full attention and explain you can and will help Recognize that your patient has strength and courage Keep an eye out for red flags Multiple attendances for different problems (or non-attendance) 43 ‘Inexplicable’ or ‘vague’ symptoms invite deeper enquiry – other vulnerabilities, repeat terminations or losses, no contraception, a ‘controlling’ partner Review a patient’s notes – the red flags may appear Think about the danger your patient might be in Use the word ‘harm’ rather than ‘violence’ Note down potential patterns of abuse Trust your instincts Listen to your gut feelings or hunches about a situation Pay attention to that ‘uneasy’ feeling when you think something is wrong BUT don’t leap to a diagnosis – it’s better to say ‘I don’t know’ than get it wrong Alert the next person about your concerns and feelings Your responses – what you when a patient discloses? Listen, validate and don’t judge Avoid clumsy responses, e.g looking shocked Protect confidentiality but check with your patients what they consent to being disclosed to other agencies – e.g police, social services Have telephone numbers to hand for help, especially if the patient is in immediate danger and needs a refuge Tell the patient what you are going to next Remember – doing a little is better than nothing but doing nothing is better than harm Safe reporting and safe referral Is this an emergency? Is there immediate danger? 11:58:08 377 Appendix Think about referrals and ongoing care Are there any children involved? Document everything and share with colleagues if given consent to so Document potential patterns to avoid missed opportunities in future Follow up Involve a wider sphere of professionals, including domestic violence experts Try to arrange another appointment with the patient at a suitable time and follow up Don’t act alone, discuss cases in confidence with supervisors/trusted experts 43 Remember – social service referral is available at any stage 10 Strengthening systems Seek training for you and your team from experts in domestic violence Be especially aware and informed of vulnerability of younger girls Work together as a team with colleagues (medical and admin) to provide a safe, informative environment Demonstrate and encourage professional curiosity among your colleagues Look to institutionalize the practice of reflective learning 11:58:08 Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index abnormal uterine bleeding see also dysmenorrhoea introduction, 102t, 102–3 key points, 108 menorrhagia overview, 103–5, 104t summary, 108 abortion eating disorders and, 35 legal and ethical concerns, 213–14 mental health issues and, 204–5 overview, 192 religious concerns over, 212 Academy of Postgraduate Medical Colleges, 258 Acceptance and Commitment Therapy (ACT), 321 accidental pregnancy, 121 Acknowledge, Introduce, Duration, Explain, Thank you (AIDET), 23, 24 acquired immune deficiency syndrome (AIDS), 211 acupuncture, 51 adaptive behaviour to stress, 273 adenomyosis, 107 adolescence see also paediatric and adolescent gynaecology assessment and treatment, 82 contraception, 88 health in, 82 menstruation suppression, 86 psychosexual disorders, 192 sexual activity, 199–200 adrenocorticotropic hormone (ACTH), 43 adverse mood effects, 203 Advisory Council on the Misuse of Drugs (ACMD), 282 African American women, 15 ageing concerns, 17, 123, 151, 193–4 alcohol abuse abortion and, 204 breastfeeding, 284 parenting skills, 258 pregnancy and, 280, 284 alcohol use disorders, 126 alkaline haematin test, 104 All-Party Parliamentary Group, 222 allostasis concept, 264 amenorrhoea, 34, 35, 85–6, 103 American Medical Association, 21 amniocentesis, 240 amphetamine use, 287 amygdala, 41 Androgen Insensitivity Syndrome Support Group, 78 androgen receptors, 203 aneuploidies screening, 240–1 anorexia nervosa (AN), 32t, 85, 87, 309 anovulatory cycles, 85 antenatal depression (AND), 228–9, 232 antenatal education, 258, 342, 352, 373 antenatal interventions, 266, 354 Antenatal Psychosocial Health Assessment (ALPHA), 233 Antenatal Risk Questionnaire (ANRQ), 233 anti-epileptic mood stabilizers, 316 anti-social behaviour, 44 antibiotic use, 221 antidepressants, 313 antiemetics, 182, 183 antipsychotic medications, 314, 315 anxiety abortion and, 204 childbirth, 11, 223 fetal anomaly screening, 237–8 gynaecological cancer, 172–3 maternal anxiety and stress, 293–4, 319–20 maternal cortisol and, 265 ultrasound, 238–9 perinatal period health assessment, 231 post-traumatic stress disorder and, 301 pregnancy stressors, 293 psychiatric disorders in pregnancy and lactation, 308–9 psychotherapy in pregnancy, 322 treatment, 314 unwanted pregnancy, 213 urinary incontinence and, 152 anxiolytic medication, 316 arousal/desire disorders, 190–1 assessment and treatment see also perinatal period health assessment; screening and detection; treatment acceptability and effectiveness, 233–4 adolescence and young children, 82 electronic pelvic floor assessment questionnaire, 148 nausea and vomiting during pregnancy, 180, 181–2 in perinatal period, 231, 312–13 psychosocial issues, 233 assisted reproductive technologies (ART), 125, 141t, 247 athlete triad, 87 attachment see also maternal-fetal relationship birth trauma and post-traumatic stress, 349, 353–4 mother-infant attachment, 118, 305 postnatal care, 343 attention deficit hyperactivity disorder (ADHD), 265 AUDIT-C screening tool, 281 Australian Routine Psychosocial Assessment (ARPA), 233 autonomic nervous system, 41, 44, 146 Ayurvedic medicine, 49 B-vitamins, 17, 18f Baby M child custody trials, 215 Background, Affect, Trouble, Handling, Empathy (BATHE) technique, 23, 24 bacterial vaginosis, 296 Balint, Michael (Balint groups), 24, 25 bariatric surgery, 35, 36 Barker hypothesis, 19 basal ganglia, 41 Beck Depression Inventory, 231 behaviour and nutrition, 44–5 behavioural activation, 267 behaviour therapy, 321 Beijing Declaration, 212 Belfast Elderly Longitudinal FreeLiving Ageing STudy (BELFAST study), 17 benzodiazepine use, 287 Beyondblue study, 232 binge eating disorder, 32, 37 biochemical screening, 238 biomedical perspective on care, biomedicalisation of labour, 329 379 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index biopsychosocial model of care brain, 45 chronic pelvic pain, 133–4 intrapartum care, 329 menopause, 160, 163–4, 163f, 164f urinary incontinence, 148 vasomotor symptoms, 163–4, 164f biopsychosocial role in obstetrics and gynaecology implications and future strategies, key points, necessity of, 1f, 1–2, preparatory tasks, 2t, 2–4 promotion and implementation of, 4–6 bipolar disorder, 310 birth see also childbirth; preterm birth breastfeeding, 222 complications, 221–2 experience see negative birth experience fear and pain, 220–1 health professional and, 222–3 infection, 221 institution and, 223–4 introduction, 219 key points, 224 litigation concerns, 223 oxytocin, 219–20 psychosexual disorders, 195 stress and, 223 summary, 224 women and, 219 birth trauma and post-traumatic stress after childbirth, 348 antenatal factors, 352 antenatal prevention of, 354 attachment and, 349, 353–4 case example, 350 cognitive behavioural therapy, 355 cognitive model, 349 defined, 348 Eye Movement Desensitisation and Reprocessing, 355, 356 impact of, 349–50 intervention, 355 key points, 355–6 longitudinal course, 351 overview, 319, 348–50 perinatal factors, 352 perpetuating/maintaining factors, 353 postnatal factors, 352–3 postnatal prevention of, 354 precipitating factors, 353 predisposing factors, 353 prevalence of, 350–1 prevention, 354 risk factors, 351, 352t screening issues, 354 summary, 355 theoretical understanding, 349 Birth Trauma Association, 348 black and minority ethnic (BME) groups, 257 black cohosh herb, 49 bladder pain, 191 blue cohosh herb, 48 body image issues, 31, 37, 173 Body Mass Index, 125 body weight during postnatal period, 37 bone mineral density, 34 borderline personality disorder, 314–15 brain basic anatomy, 41 biopsychosocial model of care, 45 cognitive vs emotional brain, 42 conclusion, 45 emotional brain, 42, 44 hormones and, 42–3 introduction, 41 key points, 45 limbic system, 41–2, 42f nutrition and behaviour, 44–5 breast cancer survivors, 174 breast cancer treatment, 160 breastfeeding see also psychiatric disorders in pregnancy and lactation alcohol abuse, 284 among disadvantaged women, 258 amphetamine use, 287 benzodiazepine use, 287 birth and, 222 cocaine use, 287 continuation of, 338 impact on sexual response, 191, 193 medication during, 316 opioid abuse, 288 oxytocin, 43, 219 postnatal care, 340 postnatal period, 37 tobacco use, 286 bulimia nervosa (BN), 32t, 35, 87, 309 buprenorphine use, 288 burnout, 360, 362 C-reactive protein (CRP), 296 caesarean section (CS), 300, 301, 304, 324, 338, 370 Camberwell Assessment of NeedsMothers (CAN-M), 233 cancer/cancer therapies, 124–5 see also gynaecological cancer cannabis use, 286 cardiotocography, 330 care-eliciting behaviour, 245 care-planning in perinatal period, 312–13 Catholicism, 200 cell-free DNA (cfDNA), 240, 242 central nervous system (CNS), 84, 146 cervical cancer, 169, 172 chemokines, 296 chemotherapy, 170, 171 childbirth see also birth; pregnancy; preterm birth anxiety, 11, 223 depression, 11, 223 experiences of, 328–9 fear of childbirth, 300 introduction, 10–12 post-traumatic stress after, 348 psychosexual disorders, 195 childhood sexual abuse (CSA), 142, 302 children/childhood see also paediatric and adolescent gynaecology loss of a baby – impact, 369 paediatric and adolescent gynaecology, 83 parents with eating disorders, 37–8 protection interventions, 59 cholinergic anti-inflammatory pathway (CAP), 296 chorioamniotic membranes, 296 Chorionic Villus Sampling (CVS), 237 chronic pain and marriage, 108 chronic pelvic inflammatory disease, 107 chronic pelvic pain (CPP) background, 131 biopsychosocial approach, 133–4 diagnosis of, 131–2 as emergency, 142 introduction, 131 key points, 136 self-management, 134–5 summary, 135–6 treatment/intervention approaches, 132–3 chronic stress effects, 295–6 cingulate gyrus, 41 clinical implications of epigenetics, 17 clinical practice and perinatal period health assessment, 232 clitoridectomy, 66, 67, 74 co-twin loss, 372 cocaine use, 286–7 cognitive behavioural therapy (CBT) defined, 321 gynaecological cancer, 170 maternal distress, 267 menopause, 165 overview, 10, 38 post-traumatic stress, 355, 356 premenstrual syndrome, 97 substance abuse, 282 cognitive brain, 42 380 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index cognitive empathy, 22 cognitive-existential group therapy, 173 cognitive impairment, 174 coital incontinence, 151 collaborative communication, 22 combined oral contraceptive pills (COCP), 98, 104 communication see patient–clinician communication community based midwifery care, 339 compassion fatigue (CF), 360 compensating mechanisms, 273 complementary medicine (CM) communication and information, 48 conclusion, 51 evidence-based medicine, 47–8 key points, 51 natural products, 48–9 overview, 47 patient safety, 47–8 during pregnancy, 47 prevalence and motivation of, 47 women’s health conditions, 48–51 complete androgen insensitivity syndrome (CAIS), 75 comprehensive care model, 282–3 compulsory psychosomatic training, concentrative meditation, 50 Confidential Enquiries in Maternal and Child Health report, 228, 229 congenital adrenal hyperplasia (CAH), 74 conscientious objection, 212–13 Consensus Statement on the Management of Intersex Disorders, 73 consent concerns, 209, 332 Consumer Satisfaction Questionnaire (CSQ), 328 Contextual Assessment of Maternity Experience (CAME), 233 continuous medical education (CME), continuous support in intrapartum care, 331 contraception see also fertility control in adolescents, 88 arousal/libido impact by, 191 choice of, 200 combined oral contraceptive pills, 98 conclusion, 99 danazol, 99 depression and, 201 education, 127 Estradiol, 98–9 GnRH analogues, 99 hormonal contraceptives, 200, 201–2 key points, 99–100 mental health impact on, 201 psychosexual disorders, 192 psychotropic drugs, 98 religious concerns over, 212 socioeconomic status, 200 surgery and, 99 by teens, 200 conversion disorder, 178 Copenhagen child cohort study, 343 coping mechanisms, 139, 149–53, 264 core premenstrual disorder, 95 corticotropin-releasing hormone (CRH), 112, 295 counselling for infertility, 114–15, 116t, 117t CRAFFT screening tool, 281 crisis intervention, 259–60 Critical Incident Stress Debriefing (CISD), 363–4 cultural competencies, 26–7, 283 culturally and linguistically diverse (CALD) backgrounds migrant/refugee women, 323–4 overview, 319, 323 psychotherapy, 324–5 culture of secrecy, 134 cyclizine, 182 cytokines, 266, 296 daily record of severity of problems (DRSP), 95 danazol, 99 death/dying concerns, 173 deinfibulation in female genital cutting, 69, 70 delayed puberty in girls, 84 deoxyribonucleic acid (DNA), 16 depot medroxyprogesterone acetate (DMPA), 86, 89, 202 depression abortion and, 204 childbirth, 11, 223 contraception and, 201 emergency gynaecology, 139 fetal anomaly screening, 237 gynaecological cancer, 172 infertility, 111, 112 maternal cortisol and, 265 menopause, 10 menstrual disorders and, 104, 105 non-psychotic disorders, 313–14 perinatal depression, 308 perinatal period health assessment, 231 post-traumatic stress disorder and, 301 postnatal post-traumatic stress disorder, 12 pregnancy, 11, 126 preterm birth, 294 psychiatric disorders in pregnancy and lactation, 308, 313–14 tokophobia, 300, 301 ultrasound, 239 urinary incontinence and, 152 desensitization technique, 321 detection questions, 230 detoxification treatment, 282 developmental disabilities, 86 developmental implications of epigenetics, 17 Developmental Origins of Health and Disease (DOHAD), 19 diabetic patients, 224 Diagnostic and Statistical Manual of Mental Disorders (DSM), 189, 213, 302, 350 Dialectical Behaviour Therapy (DBT), 321 diet and epigenetics, 17–18, 18f dimorphic sex categories, 73 direct therapeutic work, 90 disruptive behaviour, 44 distress, 272 diverse sex development (DSD) emotional safety, 76 feminising surgery on girls, 74–5 gender assignment, 76 informed choice, 77–8 initial presentation, 75 key points, 79 managing stigma, 76–7 medical management of, 73 multidisciplinary team, 75–6 overview, 73 phallocentric gender assignment, 73–4 public engagement and education, 78–9 reconsidering sex, 77 summary, 79 DNA methyltransferases (DNMTs), 16, 17 domestic violence and abuse (DVA) barriers to, 54–5, 55t benefit of clinician inquiry, 60 changing practices, 60 clinician role, 55–8, 57t conclusion, 61–2 evidence of, 57t, 58f, 59–60 front-line doctors’ engagement in, 61–2 introduction, 54 key points, 62 management changes, 59 mechanisms for harm, 57t, 59 patient and provider similarities, 60–1 381 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index domestic violence and abuse (cont.) reframing of, 60–1 time concerns, 58–9 victims, 210 working through barriers, 55, 56f Down Syndrome, 237, 240–1 drospirenone, 98, 202 drugs and alcohol during pregnancy addiction treatment, 282 amphetamine use, 287 benzodiazepine use, 287 brief intervention, 281–2 buprenorphine/naloxone use, 288 cannabis use, 286 cocaine use, 286–7 comprehensive care model, 282–3 conclusion, 288–9 cultural competency, 283 introduction, 280 key points, 289 methadone use, 288 opioid abuse, 287–8 opioid pharmacotherapy, 288 physiological considerations, 284–8, 285t postpartum maintenance, 283–4 psychiatric disorders, 283 SBIRT approach, 280–2, 281t slow-release morphine, 288 tobacco use, 284–6 Dutch Famine Birth Cohort Study, 16 dysfunctional labour, 333–4 dysfunctional uterine bleeding see abnormal uterine bleeding causes, 106 complementary medicine, 47 defined, 102 as emergency, 143 impact of, 85–6 introduction, 105–6 in nonverbal patients, 86 psychosocial aspects, 107–8 treatment, 106–7, 107t dyspareunia, 191 early pregnancy complications, 139–42, 140f, 141t Early Years Agenda, 222 eating disorders (EDs) anorexia nervosa, 32t, 85, 87, 309 binge eating disorder, 32, 37 body image, 31, 37 bone mineral density, 34 bulimia nervosa, 32t, 35, 87, 309 causes of, 33 children of parents with, 37–8 defined, 31 eating during pregnancy, 37 exercise disorder, 32t functional gastrointestinal disorders, 32–3 getting pregnant, 35–6 gynaecological examinations, 35 key points, 38 low bone density, 34 management during pregnancy, 36t menarche and menstruation, 33–4 normal eating, defined, 36t paediatric and adolescent gynaecology and, 86–7 polycystic ovarian syndrome, 34–5 postnatal period, 37–8 in pregnancy and lactation, 309–10 premenstrual syndrome, 9–10, 35 presentation of, 31 reasons for, 33 recovery from, 35 risk factors, 33 sexuality and, 35 treatment of, 38, 314 types, 32t weight gain during pregnancy, 37 eating disorders not otherwise specified (EDNOS), 87 ectopic pregnancy, 141 Edinburgh Postnatal Depression Scale (EPDS), 126, 230–1, 239, 303 education antenatal education, 258, 342 continuous medical education, contraception, 127 diverse sex development, 78–9 female genital cutting, 69 intrapartum care, 330–1 parenting skills, 342 premenstrual syndrome, 97 psycho-sexual education, 77 effective evaluation, efficient evaluation, elective caesarean section, 304 elective termination of pregnancy, 142 Electronic Medical Records (EMR), 26 electronic pelvic floor assessment questionnaire (EPAQ), 148 embryo cryopreservation, 172 embryos, legal and ethical concerns, 214–15 emergency gynaecology assisted reproductive technologies complications, 141, 141t chronic pelvic pain, 142 common emergencies, 139t, 139 early pregnancy complications, 139–42, 140f, 141t endometriosis, 142 genital tract tumours, female, 143–4 introduction, 139 key points, 144 menstrual problems, 143 pelvic inflammatory disease, 143 pelvic pain, 142 summary, 144 emotional brain, 42, 44 emotional distress in pregnancy, 11 emotional impact of losing a baby, 368 emotional safety, 76 emotional support for loss of a baby, 369–70 empathy after stillbirth, 373 in communication, 22 intrapartum care, 331 patient–clinician relationship, 22 teaching of, 23 training in, 23, 24 vicarious traumatization, 362 employment and urinary incontinence, 150 endocrine gynaecological cancer, 171–2 endometriosis, 131, 132, 142 Entonox use in labour, 332 epidural use in labour, 333 epigenetics ageing, 17 conclusion, 19 defined, 16–17 developmental and clinical implications, 17 diet, 17–18, 18f exercise, 18 fetal programming, 19 genome, genes, DNA, 16 introduction, 15 maternal smoking, 18 psychosocial health, 15–16 sleep, 18 social environment, 18–19 episiotomy, 193 erectile dysfunction, 195, 196–7 Essential Communication Competencies, 23–4, 25, 27 estradiol, see oestradiolestrogen, oestrogen ethinylestradiol, 98 European Board and College of Obstetrics and Gynaecology (EBCOG), European Consensus on Learning Objectives for Core Communication Curriculum, 23 European Court of Human Rights, 215 European Network for Psychosocial Studies of Intersex/Diverse Sex Development, 76 European Network of Trainees in Obstetrics and Gynaecology (ENTOG), 382 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index European Society for Human Reproduction and Embryology (ESHRE), 113–14 European Society of Contraception (ESC), European Society of Human Reproduction and Embryology (ESHRE), 214 eustress, 264, 272 evidence-based medicine (EBM), 47–8, 184 excision of clitoris, 67 exercise and epigenetics, 18 exercise and urinary incontinence, 150 exercise disorder, 32t existential therapy, 321 exogenous estrogen, 203 eye movement desensitisation and reprocessing (EMDR), 355, 356, 365 faecal incontinence, 340 false positive screening, 241 family-centered approach to postnatal care, 344 family therapy, 282 fatherhood, 121–3 fear during birth, 220–1 fear of birth (FOB) see also tokophobia childhood sexual abuse, 302 Female Genital Mutilation, 302–3 mother infant attachment, 305 post-traumatic stress disorder, 301–2 tokophobia as, 300, 301 treatment studies, 303–4 fear of childbirth (FOC), 300 (see also fear of birth) Fear of Childbirth Visual Analogue Scale, 301 FECOND survey, 121 female genital cutting (FGC) see also ‘female genital mutilation’ antenatal care, 69 care of women with, 68–9 complications of, 67 conclusion, 69–70 deinfibulation, 69, 70 educational resources, 69 gynaecological interventions, 69 illegality of, 67–8 intrapartum care, 69 introduction, 66 key points, 70 knowledge about, 66 postnatal care, 69 reasons for, 66–7 recording information, 68 reporting requirements/referrals, 68 types of, 67 female genital mutilation (FGM), 66, 302–3, 332 see also female genital cutting female genital tract tumors, 143–4 Female Sexual Function Index (FSFI), 151, 171 feminising surgery on girls, 74–5 Fertility Awareness Survey, 125 fertility control see also contraception adverse mood effects, 203 choice of contraception, 200 conclusion, 205 introduction, 199 key points, 206 legal and ethical concerns, 211–12 mental health and abortion, 204–5 mental health and contraception, 201 psychological functioning and hormone contraception, 201–2 psychosocial influences, 199–200 sterilization, psychological consequence, 204 fertility preservation, 124 fertility-related knowledge, 125 fetal anomaly screening and diagnosis anxiety over, 237–8 depression and, 237, 239 impact of, 239–40 introduction, 237 key points, 242 non-invasive prenatal testing, 240–1 summary, 241–2 ultrasound, 238–9 fetal growth restriction see intrauterine growth restriction fetal movements, 250 fetal neurobehaviour, 267 fetal programming, 11, 19 fetal stress during pregnancy, 273 fetoplacental blood flow, 266 finances and urinary incontinence, 150 “first-responder” role, 61 5-cytosine DNA methyltransferase (DNMT), 18 5-methyl-tetrahydrofolate (THF), 18 5Rs (Relevance, Risks, Rewards, Roadblocks and Repetition), 281 folate, 18 follicle-stimulating hormone (FSH), 43, 112, 161 Fragile X syndrome, 88 FRAMES model (Feedback, Responsibility, Advice, Menu of Options, Empathy, Self-Efficacy), 281 Fraser guidelines, 88–9, 89t Freud, Sigmund, 4, 107 functional gastrointestinal disorders (FGID), 32–3 functional magnetic resonance imaging (fMRI), 147, 295 GABA (gamma aminobutyric acid), 94 gametes, legal and ethical concerns, 214–15 gastrointestinal effects of gynaecological cancer, 171 gay men and fatherhood aspirations, 122–3 gender assignment, 76 gender-based violence checklist, 377–8 gender differences/roles, 113, 134, 209–10 gender-specific programming, 283 generalized anxiety disorder, 173 Generalized Anxiety Disorder scale (GAD-2), 180, 230 genes, 16 genital ambiguity, 74 genital intercourse, 77 genital tract tumors, female, 143–4 genitourinary effects of gynaecological cancer, 171 genome, 16 German Criminal Code (StGB), 67 Gestalt therapy, 321 glycoproteins, 296 GnRH analogues, 99, 104, 133 GnRH-independent precocious puberty, 84 gonadal dysgenesis, 78 grief over loss of baby, 368 group therapy, 282 guilt feelings, 363 gut microbiota, 221 gynaecological cancer anxiety, 172–3 body image issues, 173 cervical cancer, 169 cognitive behavioural therapy, 170 death/dying concerns, 173 depression, 172 endocrine and sexual functioning, 171–2 gastrointestinal/genitourinary effects, 171 health disparities, 174 key points, 174–5 loss/grief, 173 lymphatic system effects, 171 neurological effects, 170 physical sequelae, 169–70 psychological factors, 172 psychosexual disorders, 194 quality of life, 169 role changes/social isolation, 174 sexual relationship changes, 174 sexuality/sexual relationships, 174 383 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index gynaecological cancer (cont.) social factors, 174 statistics on, 169 summary, 174 treatment for, 169 urinary incontinence, 169 gynaecological exams, 35 gynaecological morbidity, 105 hypothalamic-pituitary-adrenal (HPA) axis, 11, 293, 295 hypothalamic-pituitary-ovarian axis, 85 hypothalamus, 42, 43 hysterectomy, 106, 160 hysteroscopic resection of fibroid, 104 hands-on training, health, defined, 8–9 Health and Social Care Information Centre (HSCIC), 68 health care professional (HCP), 189 health disparities in gynaecological cancer, 174 health professional and birth perspective, 222–3 health-related behaviours, 125 healthcare and patient–clinician relationship, 22 heart rate variability (HRV), 44, 296 help-seeking behaviors, 60 hepatitis, 280, 281 herbal medicines, 49 hermaphroditism, 73 Hippocratic Oath, 212 hispareunia (painful intercourse for men), 193 histone modification, 16 HIV infection, 211, 257, 280, 281 holistic therapy, 321–2 home-away-from-home environment, 329–30 honour killings, 211 hormone contraceptives, 200, 201–2, 203–4 hormone therapy, 98–9, 133 hormone therapy (HT) for menopause, 165 hormones and brain, 42–3 Hospital Anxiety Depression Scale (HADS), 231 Hot Flush Rating Scale (HFRS), 164 hot flushes, 161–2 human chorionic gonadotropin (hCG), 179 Human Fertilisation and Embryology Authority (HFEA), 115 humanistic therapy, 321 Hyperemesis gravidarum (HG) see nausea and vomiting during pregnancy hyperhomocysteinemia, 18 hypnosis treatment, 50, 178–9 hypoactive sexual desire disorder (HSDD), 190 hypoestrogenism, 87 hypothalamic-adreno-cortical axis, 112 immoral behaviour, 209 Improving Access to Psychological Therapies (IAPT) strategy, 320 in vitro fertilization (IVF), 111, 214 incontinence see urinary incontinence incontinence impact questionnaire (IIQ), 148 Incontinence Quality of Life instrument (I-QOL), 148 indirect trauma, 359 Individual Consultant Obstetricians, 312 inequality concerns and health, 255 infection during birth, 221 infectious pathways, 296–7 infertility conclusion, 118 defined, 110 fatherhood aspirations among men, 123 impact of, 110–11 introduction, 110 key points, 118–19 legal and ethical concerns, 214–16 male aspects, 112–13 psychosexual disorders, 193 psychosocial care in practice, 113–15, 115t, 116t, 117t reproductive life events among men, 126–7 stress and, 111–12 surrogacy and, 115–18 treatments for, 110 infibulation of clitoris, 67 information giving in intrapartum care, 331–2 informed choice, 77–8 injectable contraceptives, 200 Institute of Medicine, 23 Integrative Medicine (IM), 47, 51 integrative therapy, 321–2 intercultural communication programs, 24 interleukins, 296 International Association for Women’s Mental Health (IAWMH), International Classification of Diseases (ICD10), 301 International Continence Society, 146, 147 International Federation of Gynecology and Obstetrics (FIGO), International Fertility Decision Making Study, 125 International Pelvic Pain Society (IPPS), 135 International Society for Clinical Densitometry, 87 International Society for Premenstrual Disorders (ISPMD), 94 International Society for Psychosomatic Obstetrics and Gynaecology (ISPOG) current achievements, educational committee, goals of educational committee, 4–5 introduction, 2, role of, stress and, 271 intersex, 73 intervention and treatment see treatment intestinal obstruction symptoms, 171 intracytoplasmic sperm injection (ICSI), 76 intrapartal care in relation to WHO recommendations (IC-WHO), 328 see also intrapartum care Intrapartal-Specific QPPquestionnaire (QPP-I), 328 intrapartum care biopsychosocial model of, 329 childbirth experiences, 328–9 conclusion, 334 consent, 332 continuous support, 331 dysfunctional labour, 333–4 education of, 330–1 empathy in, 331 engagement of partner, 333 environment of, 329–30 female genital cutting, 69 information giving, 331–2 key points, 334–5 pain relief, 332–3 person-centred care, 329 intrauterine contraceptives, 200 intrauterine growth restriction (IUGR), 277, 373 irritable bowel syndrome (IBS), 135 job stress, 11 Journal of Psychosomatic Obstetrics and Gynecology (JPOG), 4, 275 King’s Health Questionnaire (KHQ), 148 384 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index Labour and Delivery Satisfaction Index (LADSI), 328 lactation see breastfeeding; psychiatric disorders in pregnancy and lactation laparoscopic uterosacral nerve ablation (LUNA), 132 laparoscopy, 132, 134, 143 learning parenting skills, 342 legal and ethical concerns abortion, 213–14 conscientious objection, 212–13 consent, 209 fertility control, 211–12 gametes, embryos, parenthood, 214–15 infertility, 214–16 introduction, 209 key points, 216 medically assisted reproduction, 214 sex and gender, 209–10 sexual violence, 210–11 sexuality, 209–11 sexually transmitted infections, 211 surrogate motherhood, 215–16 levonorgestrel intrauterine system (LNG-IUS) endometrial hyperplasia, 98 oestradiol/estradiol and, 98 hysterectomy rates and, 103 medications and, 259 for menstrual suppression, 86 ovulation and, 106 for premenstrual disorder, 98 progestin component, 202 success of, 104 lichen sclerosus (LS), 84 lifestyle advice for menopause, 164 limbic system, 41–2, 42f listening skills, 22 lithium, 316 litigation concerns, 223 long acting reversible contraception (LARC), 259 loss/grief with gynaecological cancer, 173 loss of a baby administrative matters, 371 clinical management, 370 communication over, 369 conclusion, 373 contact concerns, 371–2 emotional impact, 368 emotional support, 369–70 impact on couple’s relationship, 369 impact on other children, 369 introduction, 368 investigations, 370–1 key points, 373–4 loss of co-twin, 372 paternal impact, 369 peri-partum care after, 369 post-mortem examination, 372 pregnancy after, 372–3 prolonged grief, 368 psychological impact, 368–9 training of doctors and midwives, 373 low bone density, 34 lubrication concerns, 190 luteinizing hormone (LH), 43 lymphatic system effects, 171 lymphedema, 171, 173, 174 major depressive disorder (MDD), 95, 213 maladaptive health behaviour, 15 male aspects of infertility, 112–13 malnutrition and abnormal uterine bleeding, 102 marriage and chronic pain, 108 Massachusetts male ageing study, 196 massage therapy, 50, 332 masturbation, 103 Maternal Adjustment and Maternal Attitudes (MAMA), 303 Maternal Antenatal Attachment Scale (MAAS), 246, 249 maternal anxiety and stress, 293–4, 319–20 maternal caregiving, 43 maternal cortisol, 265 Maternal-Fetal Attachment Scale (MFAS), 246 maternal-fetal relationship (MFR) defined, 245–6 healthcare professionals, 251 impact of, 247 introduction, 245 key points, 251–2 measuring of, 246–7 physical/psychological health, 248 postnatal links, 248–9 pregnancy-specific contextual factors, 247 reasons for measuring, 249–50 social support and relationships, 247–8 summary, 251 when to measure, 250–1 maternal mental health, 319–20, 320f maternal microbiome, 221, 296–7 maternal mortality/morbidity, 304 Maternal Mortality Report, 261 maternal psychosocial distress child development and, 265 conclusion, 268 definitions and concepts, 263–5 effects on offspring, 266 guided self-help, 268 impact on mother and baby, 265 interventions, 266–7 introduction, 263 key points, 268 screening and detection, 266 Maternal Representations during Pregnancy-Revised Version, 246 Maternal Satisfaction for Caesarean Section (MSCS), 328 maternal smoking, 18 maternity services, 12 Maternity Social Support Scale, 181 matrix metalloproteinases (MMPs), 296 Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, 75, 78 MBRRACE-UK report, 311 mechanisms for harm, 57t, 59 medically assisted reproduction (MAR), 214 medically unexplained symptoms, medication anti-epileptic mood stabilizers, 316 antipsychotic medications, 314, 315 biomedicalisation of labour, 329 during breastfeeding, 316 lithium, 316 psychotropic medication, 315–16 selective serotonin reuptake inhibitors, 98, 196, 315 sleep-inducers and anxiolytics, 316 meditation practice, 50 Melbourne Women’s Midlife Health Project (MWMHP), 161 menarche, 33–4, 86 menopause attitudes and beliefs, 162 biopsychosocial approach, 160, 163–4, 163f, 164f chemotherapy and, 171 cognitive behavioural therapy, 165 complementary therapies, 165 conclusions, 165 defined, 160–1 hormone therapy, 165 impact on sexual response, 191 introduction, 9, 10 key points, 166 lifestyle advice, 164 mood and, 162–3 physiological changes, 161 premature menopause, 43 psychosexual disorders, 193–4 surgical menopause, 162 vasomotor symptoms, 161–2 menorrhagia, 102, 103–5, 104t, 143 menstruation see also dysmenorrhoea amenorrhoea, 34, 35, 85–6, 103 disorders, 85 385 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index menstruation (cont.) eating disorders, 33–4 emergency problems, 143 introduction, normal menstruation, 85–6 premenstrual symptoms without, 96 suppression in adolescents, 86 mental health see also psychiatric disorders in pregnancy and lactation abortion, 204–5 community based midwifery care, 339 effect on urinary incontinence, 152–3 male fertility and, 123–4 maternal mental health, 319–20, 320f needs in pregnancy, 304–5 non-psychotic mental disorders, 308–10, 313–14 postnatal care, 37, 340–1 prolonged grief, 368 psychosomatic issues, 2t, 2–3, 41, 274 urinary incontinence effect on, 152 mentalized experiences of stress, 274 methadone use, 288 methylation modification, 16 microvascular disease, 196 midwifery-led units, 329, 338 midwives, 339, 361, 363, 373 migrant pregnant women, 323–4 Million Women Study, 165 mind-body therapies, 49, 153, 163 Mind resilience-building programme, 267 Mindfulness-Based Cognitive Therapy (MBCT), 321 Mindfulness-Based Stress Reduction (MBSR), 24 mindfulness meditation, 25, 50 Mirena coil see levonorgestrel intrauterine system miscarriage, 139–40, 140f, 141 mixed urinary incontinence (MUI), 147 mood and menopause, 162–3 mood disorder, 142 morbidity gynaecological morbidity, 105 maternal mortality/morbidity, 304 neonatal morbidity/mortality, 292 postnatal care, 337 urinary incontinence, 152–3 mother-infant attachment, 118, 305 motivational interviewing, 282 multidisciplinary team (MDT), 75–6 naloxone use, 288 Narrative Med workshop, 24 National Attitudes to Sex and Lifestyle surveys (Natsal), 189 National Cancer Institute, 281 National Center for Complementary and Integrative Medicine (NCCIM), 49 National Child and Maternal Health Intelligence Network, 90 National Childbirth Trust, 342 National Institute for Health and Care Excellence (NICE) antenatal and postnatal mental health, 180 fear of birth and, 300, 304 intrapartum care, 330, 331 pregnancy risk factors, 233 recommendations for tokophobia, 305 staff attitudes, 256–7 National Survey of Family Growth (NSFG), 122 nausea and vomiting during pregnancy (NVP) antiemetics, 182, 183 assessment, 180, 181–2 etiology of, 178–80, 179f introduction, 178 key points, 184–5 medical history, 180 medical management, 182–3 mild to moderate symptoms, 182 psychological difficulties, 180–1 psychological management, 183–4 severe and persistent symptoms, 183 social support, 181 summary, 184 triggers for, 183 negative birth experience, 328 neonatal morbidity/mortality, 271, 292 neuro-behavioural development of offspring, 308 neuroinflammatory pathways, 296 neurological effects of gynaecological cancer, 170 neuroticism and dysmenorrhoea, 107 non-coital pain disorders, 191 non-consummation, 191 non-hormonal medications, 165 non-hormonal treatment for PMS, 97–8 non-invasive prenatal testing (NIPT), 240–1 non-mentalized experiences of stress, 274 non-neuronal cells, 147 non-opioid analgesics, 170 non-ovulatory premenstrual disorders, 96 non-psychotic mental disorders, 308–10, 313–14 non-steroidal anti-inflammatory drugs (NSAIDs), 104 non-surgical treatment of PMS, 97–9 nonspecific abdomino-pelvic pain, 142 normal eating, defined, 36t normal menstruation, 85–6 North American Society of Psychosocial Obstetrics and Gynecology (NASPOG), nutrition and behaviour, 44–5 nutritional medicine, 49 obesity and abnormal uterine bleeding, 102 obesity and urinary incontinence, 150 obsessional thoughts, 308 obsessive compulsive disorder (OCD), 309 occipito-anterior position, 334 oestradiol, 161 oestrogen deficiency of, 88 menopause and, 161 pelvic floor dysfunction, 193 plasma oestrogen, 161 vaginal oestrogen, 171 oestrogenic environment, 83 oestrone, 161 oligomenorrhoea, 35, 87 omega-3 fatty acids, 44–5 Oncotalk program, 24, 26 one stage genitoplasty, 74 oophorectomy, 160 opioid abuse, 287–8 opioid pharmacotherapy, 288, 333 organisational stress, 362 orgasmic disorders, 191 ovarian cancer, 143, 170, 172 ovarian hormones, 10 ovarian hyperstimulation syndrome (OHSS), 111, 141 ovarian insufficiency, 85 overeating disorder, 32t ovulation anovulatory cycles, 85 Mirena coil, 106 non-ovulatory premenstrual disorders, 96 sexual behaviour, oxytocin birth and, 219–20 breastfeeding and, 43 effects of, 43 maternal distress, 266 paediatric and adolescent gynaecology (PAG) athletic triad, 87 communicating with children, young people and parents, 82–3 386 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index contraception in adolescents, 88 delayed/precocious puberty in girls, 84–5 eating disorders, 86–7 examination of children, 83 Fraser guidelines, 88–9, 89t introduction, 82 key points, 91 lichen sclerosus, 84 menstrual disorders, 85 menstruation suppression in adolescents, 86 normal menstruation, 85–6 physical or developmental disabilities, 86 premature ovarian insufficiency, 87–8 sexual abuse, 89 sexual competence and the law, 88 transition/transfer to adult care, 89–90, 90t traumatic injury, 84 vulvovaginitis, 83–4 paediatric organ retention, 372 pain during birth, 220–1 pain of labour, 332 pain relief in intrapartum care, 332–3 panhypopituitarism, 196 parasympathetic division, 44 parenting, legal and ethical concerns, 214–15 parenting skills, 342 partner engagement in intrapartum care, 333 Paternal Antenatal Attachment Scale, 246 Paternal Fetal Attachment Scale, 246 paternal-fetal relationship, 251 paternal impact of loss of baby, 369 patient-centered care, 21, 114 patient–clinician communication cultural communication competencies, 26–7 Electronic Medical Records, 26 empathic communication, 22 Essential Communication Competencies, 23–4, 25, 27 healthcare and, 22 introduction, 21–2 key points, 27 skills in, 22–3 specific communications, 25–6 strategies for, 23 summary, 27 teaching communication and empathy, 23 Patient Health Questionnaire, 230 Patient Perception Score (PPS), 328 patient safety and complementary medicine, 47–8 pelvic floor dysfunction, 171, 193 pelvic floor muscle training, 149 pelvic inflammatory disease (PID), 143 Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ), 151 pelvic pain, 142, 189, 191 see also chronic pelvic pain Pelvic Pain Support Network UK (PPSN UK), 135 pelvic vein incompetence (PVI), 131 Perceptions of Care Adjective Checklist (PCACL-R), 328 peri-partum care after loss of a baby, 369 periaqueductal grey (PAG), 147 perimenopause, 160, 190 perinatal depression, 308 perinatal factors in post-traumatic stress, 352 Perinatal Grief Scale, 371 perinatal mental health problems (PMHP), 228–9 perinatal mental health services, 312 perinatal mental illness (PMI), 228–9 perinatal period health assessment anxiety and depression, 231 clinical practice, 232 conclusion, 234 detection questions, 230 identifying risk factors, 232–4 introduction, 228 key points, 234–5 maternity context, 228 prediction questions, 230 previous or current problems, 228–9 psychological health assessment, 232–3 Whooley questions, 180, 229, 230 women’s psychological status, 229 Perinatal Psychology, 271 Perinatal Substance Abuse Screen (5Ps), 281 peripartum period disorders, 310–11 person-centred therapy, 321, 329 personal ethics (microethics), 209 personality disorders, 310 phallocentric gender assignment, 73–4 pharmacological treatment, 314 phenothiazines, 182 phobic anxiety disorders in pregnancy, 303 phosphodiesterase inhibitors, 196 physical disabilities, 86 physical disease coping abilities, 139 physical symptoms and postnatal care, 339–40 Physician’s Foundation, 21 physiological changes of menopause, 161 Pictorial Representation of Attachment Measure (PRAM), 246 Pinard, Adolphe (Perinatology), 276 pituitary-adrenal axis dysfunction, 105 Plain Language, Engagement, Empathy, Empowerment, Respect (PEEER) training, 24, 26 plasma oestrogen, 161 polycystic ovarian syndrome (PCOS), 34–5 pontine micturition centre (PMC), 147 positive birth experience, 328 positron emission tomography (PET), 295 post-abortion stress syndrome, 213 post-mortem examination in loss of a baby, 372 post-traumatic stress disorder (PTSD) see also birth trauma and posttraumatic stress anxiety and depression with, 223 birth trauma, 319 clinical recommendations, 364–5 conclusion, 365 defined, 301–2 fear of birth, 302 following caesarean section, 324 following childbirth, 302 HRV levels, 44 introduction, 12 key points, 365 in pregnancy and lactation, 309 recommendations for research, 364 tokophobia, 301–2 vicarious traumatisation in maternity care, 359–60 postmenopause, 160 postnatal care body weight, 37 bonding and attachment, 343 breastfeeding, 37, 340 conclusion, 343 eating disorders and, 37–8 female genital cutting, 69 introduction, 337–8 key points, 344 learning parenting skills, 342 lifestyle and expectations, 341–2 mental health, 37, 340–1 physical symptoms and, 339–40 post-traumatic stress, 352–3 prevention of post-traumatic stress, 354 relationships and, 342 structure of, 338–9 postnatal depression (PND), 341 387 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index postpartum blues, 308 Postpartum Depression Screening Scale (PDSS), 231 postpartum maintenance, 283–4 postpartum psychosis, 310–11 poverty concerns and health, 255, 257 pre-conception stress, 112 pre-menstrual tension (PMT), pre-pregnancy care for vulnerable women, 260 precocious puberty in girls, 84–5 prediction questions, 230 prefrontal cortex (PFC), 295 pregnancy see also birth; childbirth; drugs and alcohol during pregnancy; fertility control; nausea and vomiting during pregnancy; psychiatric disorders in pregnancy and lactation; stress/ stressors in pregnancy accidental pregnancy, 121 alcohol abuse, 284 amphetamine use, 287 benzodiazepine use, 287 body image and, 37 cannabis use, 286 cocaine use, 286–7 complementary medicine, 47 domestic violence and abuse, 57 early pregnancy complications, 139–42, 141t eating disorders, 309–10 eating during, 37 ectopic pregnancy, 141 elective termination of, 142 experiences among men, 126 getting pregnant with eating disorder, 35–6 hyperemesis gravidarum, 141–2 introduction, 10–12 management of eating disorder during, 36t maternal smoking, 18 mental health needs in, 304–5 miscarriage, 139–40, 141 opioid abuse, 287 overview, 10–12 postnatal period and eating disorders, 37–8 premature delivery, 271 psychosexual disorders, 193 psychosocial stress during, 292–3 tobacco use, 284–6 unintended pregnancy, 127 urinary incontinence, 148 weight gain during, 37 Pregnancy Risk Questionnaire (PRQ), 233 pregnancy-specific contextual factors, 247 Pregnancy-Unique Quantification of Emesis (PUQE), 180 premature delivery, 271 premature ejaculation, 195–6 premature menopause, 43 premature ovarian insufficiency, 87–8 premenopause, 160 premenstrual dysphoric disorder (PMDD), 9–10, 12, 202 premenstrual symptom screening tool (PSST), 95 premenstrual syndrome (PMS) cognitive behavioural therapy, 97 comorbidity with psychiatric conditions, 95 complementary therapy, 97 core premenstrual disorder, 95 diagnosis and classification, 95 hormone therapy, 98–9 hormones related with, 43 introduction, 9–10, 35, 94 lifestyle changes and education about, 97 management of, 96–7 measurement of symptoms, 95 non-hormonal treatment, 97–8 non-ovulatory premenstrual disorders, 96 non-surgical treatment, 97–9 physical symptoms, 94 progestogen-induced premenstrual disorder, 96 psychological/behavioural symptoms, 94–5 types of symptoms, 94–5 variant premenstrual disorders, 95–6 Prenatal Attachment Inventory (PAI), 246 preparatory tasks, 2t, 2–4 preterm birth (PTB) corticotropin-releasing hormone, 295 introduction, 292 key points, 297–8 maternal anxiety and stress, 293–4 methodological concerns, 294 other psychosocial factors, 294 psychosocial issues and reproductive health, 294–7 psychosocial stress during, 292–3 stressful life events, 293 summary, 294, 297 prevention of post-traumatic stress, 354 prevention vs crisis intervention, 259–60 previous postpartum depression (PPD), 228–9 primary dysmenorrhoea, 105, 106 primary tokophobia, 300–1 prior trauma exposure, 362 professional experience, 362–3 professional quality of life (ProQOL), 360 progestogen-induced premenstrual syndrome, 96 Prohibition of Female Genital Mutilation (Scotland) Act (2005), 67 prolonged grief, 368 prophylactic gonadectomy, 78 prostaglandins, 106 proximity-seeking behaviour, 245 psychiatric disorders in pregnancy and lactation anxiety disorders, 308–9 assessment and care-planning, 312–13 bipolar disorder, 310 borderline personality disorder, 314–15 depression, 308, 313–14 eating disorders, 309–10 identification of, 311–12 interventions for, 313 introduction, 308 key points, 316–17 non-psychotic mental disorders, 308–10, 313–14 obsessive compulsive disorder, 309 organization of, 312 perinatal mental health services, 312 personality disorders, 310 post-traumatic stress disorder, 309 postpartum blues, 308 postpartum psychosis, 310–11 psychotic disorders during peripartum period, 310–11 psychotropic medication, 313, 315–16 schizophrenia, 311 stepped care, 312 suicide, 311 tokophobia, 309 treatment for anxiety disorders, 314 treatment for eating disorders, 38, 314 psychiatric disorders with substance abuse, 283 psychoprophylactic preparation course, 303 psycho-sexual education, 77 psychoanalysis, 320–1 psychodynamic therapy, 320–1 psychogenic agalactia, psychogenic model of infertility, 111–12 psychological care in diverse sex development, 75–6 psychological debriefing processes, 140 388 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index psychological health assessment, 232–3 psychological impact of losing a baby, 368–9 psychological morbidity and urinary incontinence, 152–3 psychological perspective on care, psychosexual disorders after surgery, 195 arousal/desire disorders, 190–1 childbirth and, 195 contraception, STIs, and pregnancy termination, 192 dyspareunia and vaginismus, 191 erectile dysfunction, 195, 196–7 gynaecological cancer, 194 infertility, 193 introduction, 189 key points, 197–8 management of, 197 in men, 194 menopause, 193–4 non-coital pain disorders, 191 non-consummation, 191 orgasmic disorders, 191 phases of life, 191–2 pregnancy and pelvic floor disorders, 193 premature ejaculation, 195–6 presentation of, 190 prevalence, 189–90 psychogenic aetiology, 190 puberty/adolescence, 192 reproductive lifetime, 192 retarded ejaculation, 196 subfertility clinics, 194–5 summary, 197 psychosocial competence, 1, 2, psychosocial issues, illness and well-being assessment measures, 233 dysmenorrhoea, 107–8 epigenetics, 15–16 infertility, 113–15, 115t, 116t, 117t introduction, overview, 8–9 precocious puberty, 85 summary and conclusion, 12–13 women’s reproductive health, 9–12 psychosocial issues, reproductive health antenatal education, 258 attitudes to different problems, 257–8 early intervention, 259 engagement with services, 255–6 introduction, 255 key points, 261–2 pregnancy, 292–3 preterm birth, 294 prevention vs crisis intervention, 259–60 reasons for non-engagement, 256 reproductive choices, 260 risk reduction, 260 service delivery, 261 staff attitudes and service adjustments, 256–7 staff attitudes and training, 258 summary, 261 uptake of services, 261 violence and trauma, 258–9 psychosocial stress during pregnancy (PSP) chronic stress effects, 295–6 corticotropin-releasing hormone, 295 hormonal and neurological correlates, 295 infectious pathways and maternal microbiome, 296–7 neuroendocrine pathways linking, 295 neuroinflammatory pathways, 296 preterm birth, 294–7 psychosomatic issues, 2t, 2–3, 41, 274 psychotherapy in pregnancy see also culturally and linguistically diverse (CALD) backgrounds anxiety and stress, 322 building resilience, 325 conclusion, 325 defined, 320 introduction, 319 key points, 325–6 maternal mental health, 319–20, 320f types of, 320–2 psychotic disorders during peripartum period, 310–11 psychotropic medication, 313, 315–16 puberty, 84, 192 public ethics (macroethics), 209 puerperal psychosis, 341 purging disorder, 32t quality of life concerns, 8, 148 Questionnaire to assess clients’ satisfaction (CliSQ), 328 radiation therapy, 169, 171 radiofrequency ablation of fibroids, 104 Rand Corporation, 21 randomised control trial (RCT), 47, 51 rape victims, 210 re-traumatising fears, 59 REDE training, 24 Reflection Rounds, 25 refugee pregnant women, 323–4 relapse prevention, 282 reproductive life events among men age concerns, 123 cancer/cancer therapies, 124–5 clinical practice, 127–8 fatherhood, 121–3 fertility difficulties, 123 fertility-related knowledge, 125 gay men, 122–3 infertility/infertility treatment, 126–7 introduction, 121 key points, 128 mental health concerns, 123–4 policy on, 127 pregnancy experiences, 126 summary, 127–8 unintended pregnancy, 121 reproductive safety of pharmacological treatments, 315–16 reproductive tourism, 215 RESPECT model, 24 retarded ejaculation, 196 risk factors birth trauma and post-traumatic stress, 351, 352t eating disorders, 33 perinatal period health assessment, 232–4 psychosocial issues and reproductive health, 260 role changes in gynaecological cancer, 174 Roman Catholic church, 212, 214 ROME III questionnaire, 32 Royal College of Obstetricians and Gynaecologists, 66 S-adenosyl-L-methionine (SAM), 16, 17 sacral parasympathetic neurones, 147 SBIRT application, 282 scenarios concept, 276–7 schizophrenia, 311, 314 Schwartz Center, 21 Schwartz Reflection Rounds, 24 Screening, Brief Intervention and Referral to Treatment (SBIRT), 280–2, 281t screening and detection see also assessment and treatment; fetal anomaly screening and diagnosis aneuploidies screening, 240–1 biochemical screening, 238 birth trauma and post-traumatic stress, 354 false positive screening, 241 maternal psychosocial distress, 266 substance abuse, 280–1, 281t secondary dysmenorrhoea, 105, 106 389 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index secondary tokophobia, 301, 350 secondary traumatic stress (STS), 360 secrecy in management of intersex, 75 selective serotonin reuptake inhibitors (SSRIs), 98, 196, 315 self-blame feelings, 363 self-determination in pregnancy care, 332 self-efficacy in patient care, 3, 340 self-empowerment behaviours, 60 self-fulfillment, 272 self-induced vomiting, 33 self-management of chronic pelvic pain, 134–5 sense of coherence (SoC), 330 sepsis during birth, 221 serotonin and norepinephrine reuptake inhibitor (SNRI), 98, 165 serum dehydroepiandrosterone sulphate (DHEA-S), 265 severe mental illness (SMI), 229 sexual abuse, 89 Sexual Assault Referral Centres (SARCs), 83, 89 sexual competence and the law, 88 sexual function and gynaecological cancer, 171–2 sexual function and urinary incontinence, 151–2 Sexual health in Young People statement, 88 sexual side effects of hormone contraceptives, 203–4 sexual violence, 210–11 sexuality/sexual relationships eating disorders, 35 gynaecological cancer, 174 legal and ethical concerns, 209–11 ovulation, transgender, 209–10 sexually transmitted infections (STIs), 192, 211, 280 Short Form Social Support Questionnaire, 181 Six Simple Questions (SSQ), 328 sleep and epigenetics, 18 sleep and urinary incontinence, 151 sleep-inducing medication, 316 slow-release morphine, 288 social activities and urinary incontinence, 150–1 social autism, 272 social dysfunction, 142 social environment and epigenetics, 18–19 social exclusion and health, 255 Social Functioning Questionnaire, 181 social infertility, 110 social isolation in gynaecological cancer, 174 social isolation in pregnancy, 323 social tolerance concerns, 78 somatic fibres, 146 somatisation disorder, 178 somatisation of distress, 189 ‘special needs’ mothers, 258 specific communications, 25–6 spectrum disorder and classification, 300 sperm banking, 124 Spielberger State Trait Anxiety Index (STAI), 237–8, 239 SPIKES program, 24, 26 spinal manipulation/mobilization, 51 staff attitudes and training, 258 staff well-being, 359 Stages of Reproductive Ageing Workshop (STRAW), 160 stepped care, 312 sterilization, psychological consequence, 204 stigma in diverse sex development, 76–7 stillbirth – see loss of a baby stillbirth rates, 123 Stillbirth and Neonatal Death Society (SANDS), (now known as Sands), 370 stress/stressors abnormal uterine bleeding, 103 birth and, 223 infertility, 111–12 maternal anxiety and stress, 293–4, 319–20 maternal psychosocial distress, 263–5 organisational stress, 362 pre-conception stress, 112 stress/stressors in pregnancy cause and effect of, 275–6 compensating mechanisms, 273 conclusions, 277 as construct, 272 degrees of, 274–5 evidence of, 275 intrauterine growth restriction, 277 introduction, 223 key points, 278 mentalized experiences, 274 methodological issues, 275 Perinatology and, 276 preterm labour and, 293 psychotherapy in pregnancy, 322 scenarios concept, 276–7 voluntary vs involuntary, 273–4 women’s liberation, 272–3 stress urinary incontinence (SUI), 147–8, 151, 152 Study for Future Families, 123 Study of Women’s Health Across the Nation (SWAN), 161 subfertility clinics, 194–5 substance abuse, 280 suicidal behaviour, 204 suicide, 311 surgery bariatric surgery, 35, 36 chronic pelvic pain, 132–3 contraception, 99 feminising surgery on girls, 74–5 psychosexual disorders, 195 surgical menopause, 162 surrogacy and infertility, 115–18, 215–16 Sustainable Development Goals (SDGs), 66 sympathetic division, 44 sympathetic neuronal synapse, 146 T-ACE screening tool, 281 Tai chi practice, 50–1 terminal illness, testosterone, 99, 203 tetrahydrocannabinol (THC), 286 thelarche, 84 thermoneutral zone in women, 162 thyroid-stimulating hormone (TSH), 43 tobacco use, 284–6 tokophobia see also fear of birth defined, 309 depression, 300, 301 discussion, 305 elective caesarean section, 304 as fear of birth, 300, 301 introduction, 300 key points, 305–6 mental health needs in pregnancy, 304–5 NICE recommendations for, 305 post-traumatic stress disorder, 301–2 primary tokophobia, 300–1 recommended treatment times, 305 secondary tokophobia, 301, 350 spectrum disorder and classification, 300 touching without consent, 209 Traditional Chinese Medicine, 47, 49, 51 Transcendental Meditation (TM), 50 transgender, 209–10 transition/transfer to adult care, 89–90, 90t transvaginal uterine artery occlusion, 104 trauma-focused cognitive behavioural therapy (TF-CBT), 365 Traumatic Events Scale (TES), 303 390 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Index More Information Index traumatic gynaecological injury, 84 travel and urinary incontinence, 150–1 treatment see also assessment and treatment antenatal interventions, 266, 354 antenatal therapeutic interventions, 266 anxiety disorders, 314 birth trauma and post-traumatic stress, 355 chronic pelvic pain, 132–3 dysmenorrhoea, 106–7, 107t eating disorders, 38, 314 fear of birth studies, 303–4 gynaecological cancer, 169 hypnosis, 50, 178–9 infertility, 110 infertility/infertility treatment, 126–7 maternal psychosocial distress, 266–7 non-hormonal treatment for PMS, 97–8 non-psychotic disorders, 313 non-surgical treatment of PMS, 97–9 pharmacological treatment, 314 reproductive safety of pharmacological treatments, 315–16 vasomotor symptoms, 164–5 tubo-ovarian abscess, 143 tumour necrosis factor (TNF), 296 Turner Syndrome, 85, 90 TWEAK screening tool, 281 UK Confidential Enquiries into Maternal Deaths, 15 ultrasound anxiety, 238–9 ultrasound depression, 239 UN International Conference on Population and Development, 211 UN International Conference on Women, 211 unauthorised paediatric organ retention, 372 Understanding Fertility Management in Contemporary Australia national survey, 121 unintended pregnancy, 121, 127 United States Food and Drug Administration (FDA), 103 unmet survivorship needs, 172 unsaturated fatty acids, 44–5 uptake of services, 261 urgency urinary incontinence (UUI), 147–8, 151, 152 urinary incontinence ageing and later-life care, 151 biopsychosocial impact of, 148 conclusion, 153–4 coping strategies, 149–53 effect on mental health, 152 employment and finances, 150 exercise and obesity, 150 gynaecological cancer, 169 introduction, 146 key points, 154 mental health effect on, 152–3 mind-body therapies, 153 overview, 146–7 postpartum, 340, 344 psychological morbidity, 152–3 quality of life concerns, 148 relationships and, 150 self/body image, 150 sexual function, 151–2 sleep and, 151 social withdrawal, 174 travel and social activities, 150–1 treatment-seeking behaviour, 148–9 types of, 147–8 British Society of Urogynaecology, 147 Uruguayan Ministry of Health, 276 uterine bleeding see abnormal uterine bleeding uterine hyperstimulation, 219 vaginal construction, 75 vaginal oestrogen, 171 vaginismus, 191 vagus nerve, 296 valsalva manoeuvre, 149 variant premenstrual disorder, 95–6 vasomotor symptoms (VMS) biopsychosocial approach, 163–4, 164f mood and, 163 overview, 161–2 treatment approaches, 164–5 vicarious traumatisation in maternity care burnout, 360, 362 compassion fatigue, 360 defined, 360 empathy, 362 experience and impact of, 361 implications, 363 indirect trauma, 359 interventions, 364 introduction, 359 organisational stress, 362 post-traumatic stress disorder, 359–60 prevalence of, 361–2 prior trauma exposure, 362 professional experience, 362–3 recommendations for research, 364 secondary traumatic stress, 360 summary, 360–1 supportive strategies, 363–4 theoretical issues, 359–61 type of events, 361 vulnerability increases, 362–4 VitalTalk program, 24 vulval pain, 189, 191 vulvovaginitis (VV), 83–4 Waddington, Conrad H., 16 waist-hip ratio (WHR), 265 weight gain during pregnancy, 37 well-being, defined, 15 Western herbal tradition, 49 Whole Medical Systems, 47 Whooley questions, 180, 229, 230, 304–5 Wijma Delivery Expectancy/ Experience Questionnaire (W-DEQ), 301, 303 women’s health acupuncture, 51 complementary medicine, 48–51 herbal medicines, 49 hypnosis, 50 liberation and stress during pregnancy, 272–3 massage and, 50 meditation practice, 50 mind-body therapies, 49 natural products, 48–9 nutritional medicine, 49 psychological status, 229 reproductive health, spinal manipulation/mobilization, 51 Tai chi practice, 50–1 yoga practice, 50 Women’s Health Initiative, 165 Women’s Reproductive Health Service (WRHS), 256 Working Model of the Child Interview, 246 World Association for Infant Mental Health (WAIMH), World Health Organisation (WHO) female genital cutting, 66 fertility control, 211, 214 HIV transmission, 281 introduction, 9, 15 menopause, 160 preterm birth, 292 quality of life concerns, 146 world of women concept, 108 writing therapy, 133 yoga practice, 50 z-score for mean stress, 293 Zung Self-rating Depression Scale, 231 391 © in this web service Cambridge University Press www.cambridge.org ... Bankole E Induced abortion: Incidence and trends worldwide from 1995 to 20 08 Lancet 20 12; 379 (9816): 625 – 32 19 Appleton SF Reproduction and regret Yale J Law and Feminism 20 11; 23 : 25 5–333 20 Vandewalker... Midwifery 20 12; 28 (2) : 21 6? ?21 38 Jomeen J, Martin CR Developing specialist perinatal mental health services Practising Midwife 20 14; 17(3): 18? ?21 11:51:50 Chapter 27 Biopsychosocial Factors in Prenatal... 5(4) :20 8? ?21 1 23 Ogden J, Shaw A, Zander L Part Deciding on a homebirth: Help and hindrance British Journal of Midwifery 1997; 5(4) :21 2? ?21 5 24 Ogden J, Shaw A, Zander L Part A decision with a lasting