Postpartum Blues

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					                                                           Why Treat in Pregnancy/
 Postpartum Depression:                                    Postpartum?
 Overview of clinical signs and symptoms                    May interfere with the woman’s ability
                                                            to enjoy her pregnancy
    Screening and assessment tools
                                                            May interfere with daily functioning or
         Glenda Carson, CNS, Perinatal                      the ability to work
Deborah Salyzyn, CNS, Reproductive Mental Health            May predispose the woman to increased
                                                            symptoms postpartum
              IWK Health Centre
                                                            May lead to self-medication with alcohol
                                                            and/or drugs

 Why Treat in Pregnancy/
 Postpartum?                                             Postpartum Blues
  May result, in some severe cases, in self-harm and
  suicide as coping strategies
  May interfere with bonding – this can have long-term
  cognitive and behavioral consequences for the child


 Postpartum Blues Is NOT a                                 Features
 Psychiatric Disorder
                                                            Emotional lability
  It is a period of emotional lability                      Sad, teary
that starts shortly after childbirth                        Irritability
and can last a few days or 1-2                              Overwhelmed
weeks, resolving spontaneously. It                          Fatigue, poor sleep
affects up to 80% of women.
                                                            Negative feelings towards baby
                                                            Poor concentration

                                                 Major Depression can begin in
       Major Depression                          pregnancy, right after birth, or any
                                                 time in the first year.

                                                 It lasts two weeks or more, with
                                                 sadness and anxiety that is more
                                                 intense than with the blues.

                                                 It affects the mother’s ability to
                                                 care for herself and her baby.

 10%-12% will experience during
 pregnancy                                  Depressed mood, tearfulness
 10%-20% will experience in the              Overwhelmed
 postpartum period
 30% of women with a prior history of
 depression will develop postpartum         Irritable
 depression                                 Inability to sleep or excessive sleep
 50% of women with a history of
                                            Daytime fatigue + + +
 postpartum depression will develop PPD
 in a subsequent pregnancy                  Loss of interest or initiative

                                                Treatment Options:
 Excessive worry about baby's well-being   1.   Psychosocial approaches – may
 Social withdrawal                              include psycho-education,
                                                involvement of significant others,
  Negative, pessimistic thinking
                                                teaching improved coping
 Physical slowing or agitation                  strategies or individual, couple or
 Thoughts of death or suicide                   group therapies.
 Appetite increase or decrease             2.   Biological approach – may use
 Panic attacks                                  antidepressants in conjunction
                                                with anti-anxiety or other types
                                                of medications.

Obsessive-                                An anxiety disorder characterized by
Compulsive Disorder                       obsessions and compulsions which
                                          cause marked distress, are time
                                          consuming, and interfere with the
                                          woman’s daily activities.

                                          1-3% of the general population has

                                           Treatment Options
Signs and Symptoms:
                                            1. Psychosocial approaches – may
Obsessions: recurrent, intrusive               include psycho-education,
                                               involvement of significant others,
thoughts or images causing marked
                                               teaching improved coping strategies
anxiety or distress.                           or individual, couple or group
Compulsions: repetitive behaviors or
                                            2. Biological approach – may use
mental acts the person feels driven to
                                               antidepressants in conjunction with
perform to lessen distress or prevent a        anti-anxiety or other types of
dreaded event or situation                     medication.

 Generalized Anxiety                      Generalized anxiety is excessive anxiety
                                           and worry, about a number of events
  or Panic Disorder                        or activities, that a person finds
                                           difficult to control.

                                          Panic disorder involves recurrent,
                                           unexpected panic attacks which may
                                           include persistent concern about
                                           additional attacks, worry about the
                                           consequences of the attacks or
                                           significant behavioral changes related
                                           to the attacks.

Incidence                                    Signs and Symptoms of
                                             a Panic Attack
2 - 4% of pregnant women will experience           Shortness of breath
generalized anxiety or have panic disorder
                                                   Choking or smothering sensation
40% of these women will have the onset
prior to pregnancy                                 Chest pain or discomfort
                                                   Trembling or shaking
4 - 6% of these women will have an onset           Numbness or tingling
of panic disorder in the postpartum period

 Feeling dizzy, lightheaded or faint         Treatment Options
 Nausea or abdominal distress                1.    Psychosocial approaches – may
 Sweating                                          include psycho-education,
                                                   involvement of significant others,
 Feelings of unreality or
                                                   teaching improved coping strategies
 detachment from oneself                           or individual, couple or group
 Fear of dying                                     therapies.
 Fear of losing control or going
 crazy                                       2.    Biological approach – may use
                                                   antidepressants in conjunction with
 Chills or hot flashes
                                                   anti-anxiety or other types of

Postpartum                                        A postpartum psychosis is the most
                                                    severe postpartum illness, usually
Psychosis                                           requiring hospitalization. It affects 1-2
                                                    in every 1000 women. The onset is
                                                    often within the first month
                                                    postpartum. There is a risk of suicide or

                                                  A postpartum psychosis must be treated
                                                    as a psychiatric emergency.

Features                                    Treatment Options
 Extreme restlessness                       1.   Psychosocial approaches – may
 Confusion                                       include psycho-education,
                                                 involvement of significant others,
 Manic or depressed mood                         teaching improved coping strategies
 Delusional thinking                             or individual, couple or group
 Possible hallucinations
 Can include euphoric mood,
                                            2.   Biological approach – will most likely
 agitation,grandiosity                           need antipsychotic medications,
 Reduced need for sleep                          possibly in conjunction with other
 Suicidal ideation                               types of medication. Electroconvulsive
                                                 therapy is often used.

 Nursing Assessment                         Assessment Tools
 Identify red flags/ risk factors                Evaluated on:
 Assess mood in context of care situation          Sensitivity – identification of who will
                                                   develop PPD
 Establish trusting/ empathetic
                                                   Specificity – identification of who will not
                                                   develop PPD
 Nonjudgmental, engaging and
 supportive approach
 Questions/ assessments are part of
 “caring”, normal in practice

                                            Postpartum Predictors
 Depression Scales                          Inventory
                                                 Can be used in pregnancy (1st six
Usually self administered/ self scoring          predictors) and postpartum
Gives picture of mood at point in time           Used by professional
of assessment (past 7 days)                      Indentifies risk factors around which
Commonly used: Edinburgh Postnatal               nurses can plan assessment/ support/
Depression Scale                                 referrals

Nursing Interventions                                    Scenarios
   Know limits of your knowledge and skill
   Maintain open relationship – arrange perinatal
   follow up if referral/ support refused.
   Referrals to other team members: Mental
   health teams, family physicians, public health
   nurses, social workers
   Explanations should emphasize common
   concerns among mothers, physiology of
   postpartum period.
   Supportive care for family/ significant others

Susan                                                    Susan
32 years old, G4 P1. Married to an                       Sought grief counseling after last loss –
accountant for 7 years – describes him as                stating found it difficult to come to terms with
supportive but “pragmatic”. “Doesn’t get                 losing another baby. No antidepressants/
caught up in emotion”                                    anti-anxiety medications prescribed at that
History of miscarriages – 16 and 18 weeks;               time.
NND at 22 weeks.                                         Felt anxious coming into this pregnancy –
Cerclage put in place at 14 weeks; removed               describes her pregnancy as “difficult to get
at 34 weeks. Spontaneous vaginal delivery at             into – felt at a distance from the experience”.
37 weeks.

Susan                                                    Angela

2 days postpartum – presents as very “needy” –
requesting assistance from nurses consistently,          35 years old, G1 P1
despite being able to manage care of baby                Described as always being a worrier; anxious
independently when they are in the room.
Consistently expresses concern about the baby’s          throughout her first pregnancy; worried that
health – afraid to take baby home. Describes             her baby would not be normal
thinking constantly that baby may die. Afraid to be      Anxiety increased as birth approached,
alone with the baby – finds she constantly alert to
the baby, unable to relax.                               started having panic attacks.
Very tearful, crying when she rings out for help.        After normal delivery, she expressed relief at
Reported to be sleeping well at night if baby is taken   having a normal son.
out of the room.

 Angela                                          Angela

 Mood deteriorated one month postpartum;         Aware that the images she was seeing were
 experienced images of harming her sone by       irrational.
 drowning him in the bath. She could not         The more she tried not to see them, the more
 understand why she was having these images      they occurred.
 as she wanted nothing more than to have a
                                                 She was afraid to talk about the images
 healthy,happy son.
                                                 because she didn’t want others to think that
 Became increasingly anxious and was afraid      she was crazy. Fearful her baby would be
 to be alone with her son, especially when she   taken away from her.
 was bathing him.

   34 year old G2, P2 – stay at home mom           Escalating intrusive obsessional thoughts
   Presented 9 wks. postpartum                     Images of harm coming to baby due to
   Sudden, unexpected concerns at 31 weeks         “errors” in her care
   which led to emergency C-section                Compensatory compulsive checking, washing,
   Baby in NICU for 7 weeks – many daily           counting
   changes with which to cope                      Racing thoughts, tension, hypervigilance
   Home for 2 weeks – increased childcare          Past history of OCD symptoms since age 12-
   demands, sleep deprivation                      13 years – sister with OCD symptoms

 Breastfeeding just well-established at
 time of referral
 Had extra support in home – mother
 visiting for 3 weeks
 Reluctant to take medication while