Postpartum depression (PPD) has been called “the thief that steals motherhood” and is defined as a temporary episode of major depression associated with childbirth. It is one of the most common childbirth-related conditions, affecting 13 to 19% of childbearing women. While PPD has been called “the baby blues,” describing it as such negates the serious impact this significant depressive disorder can have on both the mother and the child. While the pathogenesis of PPD is not understood, the research suggests that psychological and social stressors, hormones, and genetics play a role in its development.

What are the complications of postpartum depression?

The complications of PPD are numerous for both the mother and the infant. Postpartum depression has been associated with long-term maternal depression, increased risk of suicide, increased risk for substance abuse, decreased milk production, inability to breastfeed, decreased quality of infant care, and disruptions in maternal-infant bonding. 

Complications for the child include increased risk for behavioral or emotional issues, delays in language development, learning delays, and increased crying, which can cause additional stress in the mother. A study conducted in 2010 found that 41% of mothers with PPD thought about harming their infant, and other studies showed that basic things like well-child visits and vaccinations are also negatively impacted. Child safety is affected as well, with research showing decreased adherence to safety practices such as using car seats, lowering the water heater temperature, covering electrical outlets, and utilizing safety latches on cabinets. Overall, mothers with PPD tend to display more irritability and decreased engagement and warmth toward their infants.

What are the contributing factors for postpartum depression?

While the cause of PPD is not well understood, some contributing factors have been identified. These include: 

  • Hormones – Drastic decreases in estrogen and progesterone as well as thyroid hormone can all contribute to feelings of depression and fatigue.
  • Vitamin B6 – Deficiencies in this key vitamin can contribute to PPD. Vitamin B6 is converted into tryptophan and then serotonin, which is associated with mood. 
  • Disrupted sleep cycles – Sleep deprivation leads to emotional and physical exhaustion, and has been linked to suicidal ideation in women with postpartum depression.
  • Expectations of motherhood – Societal expectations of what it means to be “a good mother” can lead to the individual sacrificing their own self care, sleep, and favorite activities so they can devote 100% of their effort and attention to the newborn. Combine this with the increased demands that come with parenting, and the individual is understandably at risk for feelings of overwhelm, exhaustion, and depression.

Who is most at risk for postpartum depression?

Individuals at risk for postpartum depression include those with a prior history of depression or other mental health concerns such as anxiety or bipolar disorder. Additionally, individuals with weak support systems, financial stress, or who are experiencing stressful life events such as losing a job or giving birth to multiples are at higher risk for PPD. A high-risk pregnancy with complications such as emergency cesarean section has also been associated with PPD. Having an infant with special needs, who was born preterm or who is hospitalized can increase the risk for PPD or exacerbate the depression. It is also more prevalent in lower socioeconomic populations, which may be due to lack of resources and less access to healthcare and childcare.

Three related conditions are postpartum anxiety, postpartum PTSD, and postpartum psychosis.

Postpartum anxiety – Postpartum anxiety is closely related to PPD in that it is thought to be associated with the same causative factors and many who have PPD also have anxiety. The research shows that women with more severe symptoms of depression tend to be the ones who also have anxiety symptoms, though postpartum anxiety can occur on its own and affects between 11 and 21% of postpartum women. Many women with postpartum anxiety have symptoms that align with obsessive compulsive disorder (OCD). These individuals have intrusive thoughts focused on their infant’s safety and may involve thoughts of infant harm. Note that these are worries or fears about harming their child and not actual plans to follow through.

Postpartum PTSD – This condition can affect up to 6% of mothers and is usually triggered by real or perceived trauma associated with childbirth. The affected individual feels that her life or the life of her infant is at risk during labor or in the period after childbirth. Symptoms include nightmares or flashbacks, difficulty sleeping, irritability, anxiety and intrusive thoughts of the trauma experience. 

Postpartum psychosis – Postpartum psychosis is a severe form of mental illness that is thought to be associated with the same factors as postpartum depression.The condition has a sudden onset and, on average, occurs within two weeks of giving birth. It affects between 0.09 and 2.6 of every 1000 births and is a serious disorder that involves extreme confusion, delusion, disorganized thought processes, and hallucinations. Postpartum psychosis is a life threatening emergency that is dangerous for both the parent and infant. It requires immediate intervention.

What about the dads?

New fathers can also experience postpartum depression. Those at risk include fathers experiencing financial instability, those with a history of depression or a partner with PPD, and fathers of younger age. 

Now that you understand the basics of postpartum depression, it’s time to learn about the care of these individuals using the Straight A Nursing LATTE Method.

L: How does the patient LOOK?

Postpartum depression is characterized by irritability, sadness, changes in appetite and sleep disturbance. It’s important not to mistake PPD for the “baby blues,” which typically last up to two weeks and involve crying spells, mood swings, difficulty sleeping and anxiety. Postpartum depression differs in that the symptoms increase in intensity and duration. Specific signs and symptoms of PPD include: 

  • Depression that interferes with childcare and/or self care
  • Severe mood swings and frequent crying
  • Difficulty concentrating
  • Withdrawing from social events
  • Anxiety
  • Not eating enough or eating too much
  • Difficulties bonding with the infant
  • Sleep disturbances
  • Feelings of shame, guilt or hopelessness
  • Loss of interest or pleasure in activities
  • Some individuals experience thoughts of harming themselves or their baby.

The signs and symptoms can present soon after delivery or up to a year later. In most cases, PPD occurs within three months of giving birth.

A: How do you ASSESS a patient with postpartum depression?

The priority assessment for a patient with postpartum depression is to assess the individual for suicidal and homicidal ideation. If the patient states they are having these thoughts, direct questions should be asked to clarify the patient’s intent, desire, plans, and whether they have access to any lethal means. Any patient experiencing suicidal or homicidal ideation needs immediate intervention and close monitoring.

Screening for postpartum depression is commonly conducted utilizing a standard tool called the Edinburgh Postnatal Depression Scale (EDPS). This is a self-reporting questionnaire that consists of ten statements and four possible response options. An EDPS score greater than 13 signifies the individual is at risk for postpartum depression.

PPD is diagnosed when at least five depression symptoms are present for at least two weeks post childbirth. 

Unfortunately, it is estimated that up to 50% of individuals with PPD are not diagnosed because they are either uncomfortable discussing their symptoms when other family members are present, or they are not screened routinely. In fact, a study conducted in 2023 revealed that one in eight women were not asked about depression symptoms at postpartum visits. All postpartum individuals should be privately screened at every visit using standardized tools such as the EDPS. 

T: What TESTS may be ordered for a patient with postpartum depression?

Diagnosis for PPD is achieved through evaluation of the patient’s symptoms, though a few diagnostic tests may be ordered to identify potential underlying causes or other conditions that can mimic the symptoms of PPD.

  • Blood or urine tests may be utilized to rule out other medical conditions such as hepatic encephalopathy, uremia, hypercalcemia, hypo/hyperthyroidism, hypo/hypernatremia, hypo/hyperglycemia, and illicit substance use.
  • Brain imaging may be conducted to look for changes in brain structure in cases of postpartum psychosis.

T: What TREATMENTS will be provided for a patient with postpartum depression?

Treatment for postpartum depression can include antidepressants and/or psychotherapy. The recommended therapeutic approaches are cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). In therapy sessions, patients work to disrupt thought patterns, increase positive activities in their lives, and learn skills to address interpersonal difficulties.

Pharmacologic treatment may include the IV antidepressant medication brexanolone (Zulresso), which is the first FDA-approved medication specifically for PPD. It works by modulating the GABA-A receptor and restoring GABA to third-trimester levels. Serious side effects can occur and include sudden loss of consciousness, excessive sedation, and increased risk for suicide. For this reason, patients must have continuous pulse oximetry monitoring and be evaluated for excessive sedation and loss of consciousness at least every two hours during the 60 hour infusion. Because it is a high-risk medication that requires hospitalization, it is generally used in patients with a history of severe PPD or in those who have not been responsive to other medications or psychotherapy in the past.

Other antidepressants, which are more commonly used, include SSRIs such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac) and sertraline (Zoloft). Note that while the risk associated with breastfeeding while taking an SSRI is considered to be relatively low, these risks must be balanced with the overall benefit to the mother. 

Individuals who also experience anxiety may be prescribed anti anxiety medication such as lorazepam for short-term use.

E: How do you EDUCATE the patient about postpartum depression?

The key to managing PPD is talking about PPD. Encourage new and expectant mothers to share symptoms with their healthcare provider and talk with them about the risks to themselves and their baby that come with avoiding treatment. It’s also important that new mothers understand the importance of attending all follow-up appointments, and that more frequent visits may be warranted for those with a history of mental health issues.

For patients taking antidepressants, ensure they understand how and when to take their medication and that SSRIs can be passed through the breastmilk. If the mother has questions about the risks and benefits of taking an antidepressant, encourage them to speak to their prescribing physician.

Lifestyle modifications that can help with symptoms of PPD include:

  • Incorporate physical activity into their routine, such as taking a walk with the baby.
  • Eat a healthy diet that provides excellent nutrition.
  • Avoid using alcohol as a way to cope with the stress of parenting.
  • Let go of being “perfect” and realize that self care and infant care are more important than a spotless house or expertly folded laundry.
  • Reach out to loved ones and ask for help when it is needed. Examples include meal preparation and babysitting.
  • Seek assistance with parenting skills such as soothing a fussy baby or improving a baby’s sleep habits.
  • Make time for doing enjoyable activities away from the house and baby.
  • Cuddling the infant stimulates the release of oxytocin, which can have a calming effect and decrease maternal anxiety.
  • Share nocturnal care responsibilities with a partner or another caregiver to get at least one uninterrupted four-hour period of sleep.
  • Avoid using caffeine to manage daytime sleepiness as this can exacerbate sleep disruption at night.
  • When possible, weaning gradually from breastfeeding can minimize sudden drops in hormone levels.
  • When possible, exclusive breastfeeding has been shown to decrease depressive symptoms up to three months postpartum

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Review postpartum depression for your exams, clinicals, and NCLEX while you’re on the go by tuning in to episode 312 of the Straight A Nursing podcast. Tune in wherever you get your podcast fix, or straight from the website here.

 


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