Learning Outcome

1. Recall the presentation of postpartum depression.
2. List the risk factors for postpartum depression.
3. Summarize the treatment of postpartum depression.
4. 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. The exact cause of PPD is not fully understood, but potential underlying etiologies contributing to the development of this condition include hormonal changes, genetic predisposition, and psychosocial stressors. The rapid drop in estrogen and progesterone levels after delivery, coupled with the stress and sleep deprivation that often accompany caring for a newborn, can trigger depressive episodes in susceptible people.

In a meta-analysis of 33 studies, gestational diabetes, male gender infants, history of depression, and epidural anesthesia use were noted as risk factors. However, further research is needed to assess the true significance of these reported risk factors, especially the sex of the infant and the use of epidural anesthesia.[2] Besides hormonal changes, changes in many metabolic pathways may be associated with the development of postpartum depression, including alterations in energy metabolism, the purine and amino acid cycles, steroid and neurotransmitter metabolism, and exposure to xenobiotics.[3]

Risk Factors

According to studies, PPD occurs in about 6.5% to 20% of women, more commonly in adolescents, patients who deliver premature infants, and people living in urban areas. The average time of onset of postpartum depression is 14 weeks postpartum.[2] Overall, African American and Hispanic patients tend to report the onset of symptoms within 2 weeks of delivery, unlike White patients, who more frequently report the onset of symptoms later.

Postpartum Depression Risk Factors

Factors associated with a high risk of developing postpartum depression include:

• Psychological: A personal history of depression and anxiety, premenstrual syndrome, a negative attitude towards the baby, the reluctance of the baby's gender, and a history of sexual abuse 

• Obstetric risk factors: A high-risk pregnancy, hospitalization during pregnancy, and traumatic events during childbirth, which include emergency cesarean section, in-utero meconium passage, umbilical cord prolapse, preterm or low birth weight infant, and low hemoglobin 

• Social factors: Lack of social support, domestic violence in the form of spousal abuse (eg, sexual, physical, or verbal), smoking, and young maternal age during pregnancy [3]

• Lifestyle: Poor eating habits, decreased physical activity and exercise, vitamin B6 deficiency (via its conversion to tryptophan and, later on, serotonin, which, in turn, affects mood), and lack of sleep; exercise decreases low self-esteem caused by depression and increases endogenous endorphins and opioids, which brings positive effects on mental health and improves self-confidence and problem-solving capacity.[4]

• Family history of psychiatric disorders: Recent studies have shown that a family history of psychiatric disorders is a risk factor for the development of postpartum depression. This increased risk is likely due to genetic and environmental factors during childhood and later life associated with a lack of social support, which is a risk for PPD.[5]

Assessment

PPD is diagnosed when at least 5 depressive symptoms are present for at least 2 weeks. Most experts include the onset of symptoms that occur up to 12 months postpartum.[6] The following 9 symptoms in affected people may be present almost daily and represent a change from the previous routine; however, a PPD diagnosis should include either depression or anhedonia:

1. Depressed mood (subjective or observed) is present most of the day
2. Loss of interest or pleasure (anhedonia), most of the day
3. Sleep disturbances (insomnia or hypersomnia)
4. Psychomotor retardation or agitation
5. Worthlessness or guilt
6. Loss of energy or fatigue
7. Suicidal ideation or attempt and recurrent thoughts of death
8. Impaired concentration or indecisiveness
9. Change in weight or appetite (weight change 5% over 1 month)

The symptoms can lead to significant distress and impairment. Furthermore, these symptoms are not attributable to substance use or a medical condition. A psychotic disorder does not cause the episode, nor has there been a prior manic or hypomanic episode.[7] 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 tired after minimum effort, with sleep disturbance and a decreased appetite. Guilt, worthlessness, lowered self-esteem, and lowered self-confidence are commonly present.
• Somatic symptoms, including anhedonia, unusual waking in the very early morning, agitation, weight loss, loss of libido, decreased appetite, and marked psychomotor retardation are noted. These symptoms may vary daily and are not responsive to a change in circumstances.
• A depressive episode may be classified as mild, moderate, or severe, depending on the severity and number of the symptoms.

The signs and symptoms of PPD are identical to nonpuerperal 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 with PPD may also have psychotic symptoms, which include delusions and hallucinations, such as voices saying to harm infants. PPD may lead to poor maternal-infant bonds, failure of chestfeeding, harmful parenting practices, marital discord, as well as worse outcomes concerning the child's physical and psychological development. The remission of symptoms reduces the risk of behavioral and psychiatric problems in the offspring. A prior episode of PPD increases the future risk of major depression, bipolar disorder, and PPD. Past personal and family histories of PPD and postpartum psychosis should also be noted.

Evaluation

The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the American Academy of Family Medicine (AAFP) all recommend screening every patient for postpartum depression using the EPDS.[2] During the evaluation, the inclusion of drug and alcohol history, smoking habits, and all prescription and over-the-counter drug medications is essential. PPD screening should be performed during pregnancy and postpartum.[8] 

Several screening tools are available, though the most frequently used is the EPDS, a 10-item questionnaire completed by patients within a few minutes. A score ≥13 is associated with an increased risk of developing PPD and provides the basis for additional clinical assessment. The objectives of the clinical evaluation are to constitute the diagnosis, assess suicidal and homicidal risks, and rule out other psychiatric illnesses.[9]

Medical Management

The 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 (SSRIs) are the first choice. Consider switching to serotonin-norepinephrine reuptake inhibitors (SNRIs) or mirtazapine if SSRI is ineffective. Once an effective dose is 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 monotherapy was found to be remarkable in both sertraline monotherapy and combination therapy. The CBT monotherapy group saw the most accelerated initial gains after treatment startup. An essential factor in the duration of postpartum depression is delayed treatment.

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) is a noninvasive procedure that 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. TMS is performed in patients who are not responding to antidepressants 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 severe adverse effects are rare, including seizures, hearing loss if ear protection is not adequate, and mania in people with bipolar disorder.[10]

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 a social worker who can provide support groups.
• Encourage the patient to ask for help.
• Encourage the patient to engage in social activities.
• Ensure the patient is closely followed by the postpartum nurse.
• Refer the patient to a therapist or a psychiatrist.
• Encourage the 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 the 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.[11][12][13]

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. Several studies have demonstrated 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 importantly, 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 not followed after pregnancy. Thus, the role of the postpartum visiting nurse is critical.[14][15][16]

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 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 clinicians. 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 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 clinicians. Along with this, good maternal sleep can also help in preventing PPD.