Learning Outcome
- Recall the presentation of postpartum depression
- List the risk factors for postpartum depression
- Summarize the treatment of postpartum depression
- Recall the nursing management role in postpartum depression
Introduction
Childbirth is a difficult and exhausting process. A female goes through a lot of hormonal, physical, emotional, and psychological changes throughout pregnancy. Tremendous changes occur in the mother's familial and interpersonal world. After childbirth, a mother can experience varied emotions ranging from joy and pleasure to sadness and crying bouts. These feelings of sadness and tearfulness are called "baby blues," and they tend to decrease over the first 2 weeks after delivery.
Around one in seven women can develop postpartum depression (PPD). While women experiencing baby blues tend to recover quickly, PPD tends to be longer and severely affects women's ability to return to normal function. PPD affects the mother and her relationship with the infant. Maternal brain response and behavior are compromised in PPD. According to Beck in 2006, as many as half of PPD in new mothers go undiagnosed because of conflict in privacy and not wanting to disclose to close family members. There is also a stigma around new mothers in that disclosure may lead to abandonment and fear of lack of support. [1]
Nursing Diagnosis
- Impairment in parenting
- Impairment in bonding with the child
- Deficient knowledge
- Imbalance in mood and behavior
Causes
PPD can occur in females having depression and anxiety in any trimester of pregnancy.
Risk Factors
Psychological: History of depression and anxiety, premenstrual syndrome (PMS), Negative attitude towards the baby, the reluctance of baby gender, history of sexual abuse are perpetual factors for developing postpartum depression.
Obstetric risk factors: Risky pregnancy which includes emergency cesarean section and hospitalizations during pregnancy. Meconium passage, umbilical cord prolapse, preterm or low birth infant, and low hemoglobin are associated with PPD.
Social factors: Lack of social support can cause postpartum depression. Domestic violence in the form of spouse sexual and physical and verbal abuse can also be a causative factor in the development of the disease. Smoking during pregnancy is a risk factor for developing PPD.
Lifestyle: Eating habits, sleep cycle, physical activities, and exercise may affect postpartum depression. Vitamin B6 has known to be involved in postpartum depression via its conversion to tryptophan and later on serotonin, which, in turn, affects mood. The sleep cycle is among the factors influencing the risk of depression. It is evident that decreased sleep is associated with postpartum depression. Physical activity and exercise decrease depressive symptoms. Exercise decreases low self-esteem caused by depression. Exercise increases endogenous endorphins and opioids which brings positive effects on mental health. This also improves self-confidence and increases problem-solving capacity and helps in focusing on their surrounding environment. [2]
Risk Factors
Postpartum depression most commonly occurs within 6 weeks after childbirth. PPD occurs in about 6.5% to 20% of women. It occurs more commonly in adolescent females, mothers who deliver premature infants, and women living in urban areas. African American and Hispanic mothers reported onset of symptoms within 2 weeks of delivery, unlike Caucasian mothers, who reported onset of symptoms later as one study reports.
Assessment
Postpartum depression is diagnosed when at least five depressive symptoms are present for at least 2 weeks. In Diagnostic and Statistical Manual of Mental Disorders (DSM–5), postpartum depression is considered when a patient has a major depressive episode along with the peripartum-onset, and it is not mentioned as a separate disease. By definition, it is defined as a major depressive episode with the onset of pregnancy or within 4 weeks of delivery. The nine symptoms are present almost every day and represent a change from the previous routine. The diagnosis should include either depression or anhedonia (loss of interest), in addition to the five symptoms to be diagnosed.
- Depressed mood (subjective or observed) present most of the day
- Loss of interest or pleasure, most of the day
- Insomnia or hypersomnia
- Psychomotor retardation or agitation
- Worthlessness or guilt
- Loss of energy or fatigue
- Suicidal ideation or attempt and recurrent thoughts of death
- Impaired concentration or indecisiveness
- Change in weight or appetite (weight change 5% over 1 month)
These symptoms can lead to significant distress and/or impairment. Furthermore, these symptoms are not attributable to a substance or medical condition. A psychotic disorder does not cause the episode, nor has been a prior manic or hypomanic episode.
In the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), a postpartum onset is defined to be within 6 weeks after delivery. ICD-10 describes a depressive episode as follows:
- In typical mild, moderate, or severe depressive episodes, the patient has a depressed mood with a decrease in activity and energy.
- Capacity for enjoyment, interest, and concentration is reduced. The patient feels very tired after the minimum effort along with sleep disturbance and a decreased appetite. Guilt or worthlessness are commonly present, along with reduced self-esteem and self-confidence.
- Somatic symptoms, such as anhedonia, unusual walking in the very early morning, along with agitation, weight loss, loss of libido, decreased appetite and marked psychomotor retardation. These symptoms vary little from day-to-day, and not responsive to circumstances.
- A depressive episode may be classified as mild, moderate, or severe and it depends on the severity and number of the symptoms.
The signs and symptoms of PPD are identical to non-puerperal depression with an additional history of childbirth. Symptoms include depressed mood, loss of interest, changes in sleep patterns, change in appetite, feelings of worthlessness, inability to concentrate and suicidal ideation. Women may also experience anxiety. Patients having PPD may also have psychotic symptoms which include delusions and hallucinations (voices saying to harm infant).
PPD may lead to poor maternal-infant bond, failure of breastfeeding, negative parenting practices, marital discord, as well as worse outcomes concerning child physical and psychological development. Remission of symptoms will reduce the risk of behavioral and psychiatric problems in the offspring.
A prior episode of PPD increases future risk of major depression, bipolar disorder, and PPD.
Past personal and family history of postpartum depression and postpartum psychosis should also be noted.
Evaluation
During the evaluation, it is important to include drug and alcohol history, smoking habit, and all prescription and over-the-counter-drug medications. Screening for PPD can be done 2 to 6 months after childbirth. There are several screening tools available, and one of the most frequently used is the Edinburgh Postnatal Depression Scale (EPDS). It is a 10-item questionnaire filled out by patients and takes a few minutes to complete. An EPDS cutoff score of equal to or greater than 13 is a required to determine if patients are at risk for developing PPD.
This screening test provides the basis for additional clinical tests. The objectives of the clinical evaluation are to constitute the diagnosis, assess suicidal and homicidal risks, in this case usually infanticide, and to rule out other psychiatric illness. [3]
Medical Management
First-line treatment for peripartum depression is psychotherapy and antidepressant medications. Psychosocial and psychological psychotherapy is the first-line treatment option for women with mild to moderate peripartum depression especially if mothers are hesitant about starting on medications and are going to nurse the newborn. A combination of therapy and antidepressant drugs is recommended for women with moderate to severe depression. Selective serotonin reuptake inhibitors (SSRI) are the first choice. Consider switching to serotonin-norepinephrine reuptake inhibitors (SNRIs) or mirtazapine if SSRI is ineffective. Once an effective dose reached, continue treatment for 6 to 12 months to prevent relapse of symptoms.
Pharmacologic recommendations for women who are lactating should include discussing the benefits of breastfeeding, the risks of antidepressant use during lactation, and the risks of untreated illness. Repetitive transcranial magnetic stimulation (TMS) is a treatment that may provide an alternative option for women who breastfeed and are concerned about their babies being exposed to medication. There is the most data for the use of sertraline for the prevention and treatment of postpartum depression. The risk of breastfeeding while taking a serotonin reuptake inhibitor is relatively low, and women can be encouraged to breastfeed while on antidepressants. After 12 weeks CBT mono-therapy was found to be remarkable to both sertraline mono-therapy and combination therapy. The CBT mono-therapy group found the most accelerated initial gains after treatment startup. An important factor in the duration of postpartum depression is delayed treatment.
Transcranial Magnetic Stimulation (TMS)
TMS is a procedure that is noninvasive and uses magnetic waves to stimulate and activate nerve cells. These cells are underactive in people with major depression. It is usually done five times a week for 4 to 6 weeks to be effective. It is done in patients who are not responding on anti-depressants and psychotherapy. Generally, TMS is safe and well tolerated, but there can be some side effects which include headaches, lightheadedness, scalp discomfort, and facial muscle twitching. Some serious side effects are rare including seizures, hearing loss if ear protection is not adequate, and mania in people with bipolar disorder. [4]
Nursing Management
- Assess the mental status, behavior, and mood
- Educate the patient on postpartum depression
- Encourage a healthy diet
- Provide support and encourage self-care
- Involve social worker who can provide support groups
- Encourage the patient to speak up about help
- Encourage patient to engage in social activities
- Ensure patient is closely followed by the postpartum nurse
- Refer the patient to a therapist or a psychiatrist
- Encourage patient to take a break from baby care frequently
Outcome Identification
Unfortunately, there are no good randomized clinical trials that show that screening postpartum women for depression is of any benefit. While the topic remains debatable, there are many small case series revealing that treatment of postpartum women for depression is of some benefit. As to which type of therapy is ideal for these women is still not known. [5][6][7](Level III)
Coordination of Care
Because of the high morbidity of postpartum depression, the focus today is now on prevention. Unlike the psychiatrist, the nurse is in a primary position to identify women at high risk for postpartum mood disorders before delivery. During the admission, the nurse may identify the female with a prior history of depression or postpartum blues. Further, any female who develops depression during pregnancy can be identified. These women need education and support on available treatments. Some of these women may benefit from a consult with a therapist and others may need a referral to a psychiatrist for treatment with an antidepressant after delivery. Both pharmacological and nonpharmacological prophylaxis have been used in such settings with variable success. There is also a large body of evidence that postpartum women with depression who are treated have a much better mother-infant bonding experience than those women who forego treatment. More important, infants of mothers who are depressed may also develop a variety of mood and behavior problems, as well as obesity later in life. Despite awareness of postpartum depression, many women miss out on treatment because they are simply not followed after pregnancy. Thus, the role of the postpartum visiting nurse is critical. [8][9][10](Level V)
Health Teaching and Health Promotion
Before delivery, many females who are at risk of developing PPD can be identified. These females, along with their families, should be provided with information and education regarding PPD prenatally. The information should be reinforced during postpartum hospitalization and after discharge. [1]
Childbirth education classes teach new mothers to seek help and support that they might need for the childbirth. By teaching women and their spouses about the signs and symptoms of PPD, educators can increase the chance that the woman suffering will receive proper management and treatment.
Screening for depressive symptoms can be done during pregnancy. This screening can identify women who are at increased risk for developing PPD.
Exclusive breastfeeding has a positive effect on reducing depressive symptoms from childbirth to 3 months.
Postpartum depression can be prevented when parents are given positive parenting lessons and when the maternal-infant bond is promoted and increased. This can be achieved through social support from family and healthcare providers. Along with this, good maternal sleep can also help in preventing PPD.
Pearls and Other issues
Before delivery, many females who are at risk of developing PPD can be identified. These females, along with their families, should be provided with information and education regarding PPD prenatally. The information should be reinforced during postpartum hospitalization and after discharge. [1]
Childbirth education classes teach new mothers to seek help and support that they might need for the childbirth. By teaching women and their spouses about the signs and symptoms of PPD, educators can increase the chance that the woman suffering will receive proper management and treatment.
Screening for depressive symptoms can be done during pregnancy. This screening can identify women who are at increased risk for developing PPD.
Exclusive breastfeeding has a positive effect on reducing depressive symptoms from childbirth to 3 months.
Postpartum depression can be prevented when parents are given positive parenting lessons and when the maternal-infant bond is promoted and increased. This can be achieved through social support from family and healthcare providers. Along with this, good maternal sleep can also help in preventing PPD.
