More Than the Baby Blues: What Nurses Need to Know


More Than the Baby Blues: What Nurses Need to Know

Be on the lookout for signs that your patient needs help

By Christine Contillo, RN, BSN
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There may still be health professionals that will never believe postpartum depression is anything more than a bad case of the baby blues. To them, no one with a healthy baby has any reason to be unhappy. That kind of thinking should be left outside the door of the women’s health unit. Having a baby is a stressful and emotional time for all concerned, so it’s not surprising to see new mothers having a few days of emotional disequilibrium.

They face changes in identity as they lose their independence and their figures. They may see economic losses if they leave the job market or if they are returning to work and dealing with high childcare costs. Their relationships with their spouses or partners will certainly be affected. And on top of all this, they have decisions to make: Should they bottle feed or breast feed? How do they select a pediatrician? And how can they accommodate a round-the-clock feeding schedule while riding the hormone roller coaster? Up to one fifth of all new mothers will experience postpartum depression within the first six weeks after delivery, and in light of the amount of change taking place within such a brief time for adaptation, it’s almost surprising that the figure isn’t higher.

What Is PPD?

Researchers still debate whether true PPD is just a mood disorder that happens to occur postpartum, or whether it’s a distinct mental health entity. Studies show that most depression in women occurs between the ages of 15 and 44, which coincides with the childbearing period. But the fact remains that childbirth itself prompts a period of peak prevalence for psychiatric illness in women; hospital admissions increase sevenfold in the first three months after delivery. This is important to understand because PPD can ultimately lead to an alteration in maternal child bonding and in the ability to attend to and form a family, so the identification of mothers at risk should be a high priority for nurses. Women receiving prenatal care have multiple opportunities to be screened by their obstetric care provider.

What puts a woman at high risk for depression or other mental illness? A previous postpartum depression is a significant red flag. While only one to three per 1,000 mothers face true PPD, after the first event the figure jumps to one in seven. Expressed differently by another researcher, they have a 30 to 50 percent chance of recurrence with the second pregnancy, and even higher if the prior pregnancy was less than two years earlier. Mothers already diagnosed with bipolar illness face five times the risk.

True postpartum psychosis is a less common but an even more significant health risk. These mothers have a break with reality, experience cognitive disorganization, and are at great risk for killing themselves or the baby. A study published in The New England Journal of Medicine in 1999 found that during the years 1983–1991, approximately one infant a day was killed. This figure doesn’t include hidden pregnancies that culminate with abandoned babies or questionable SIDS deaths, so the total may be even higher. Think of mothers like Andrea Yates, who had been hospitalized several times for mental illness before killing her children.

Cheryl Tatano Beck, CNM, DNSc, a researcher at the University of Connecticut, has recognized that PPD leaves new mothers overwhelmed by the responsibility of childcare and deprived of any sense of joy in their lives. They fail to respond to their childrens’ cues, and in response those children develop more behavioral problems and early cognitive deficits. Her research led her to develop a screening questionnaire that elicits responses in seven specific areas: sleeping/eating disturbance, anxiety/insecurity, emotional liability, mental confusion, loss of self, guilt/shame and suicidal thoughts.

Further analysis of the existing research and interviews with hundreds of mothers led Ms. Beck to realize that some mothers even exhibit symptoms of post-traumatic stress after delivery because they have felt a powerful loss of control and found delivery dehumanizing and painful.

What Nurses Can Do

Nurses can identify these mothers by simply asking what their last delivery was like and noting whether or not the response is appropriate. The relevant fact is how the delivery is experienced by the mother, not whether the outcome is considered successful by the physician. Mothers who have experienced a birth that was markedly different from their expectations may be set up for PPD if the next birth is also an unhappy experience for them, even if the baby is healthy. Hospital staff need to be attentive to these facts.

The implications for nurses and healthcare workers are clear: They must be prepared to screen maternal patients for potential psychiatric illness. During the antepartum period, they should ask the mother if she has a personal or family history of depression, or has experienced depression with the last pregnancy. If the mother is a single parent, has poor social support, severe morning sickness or if the pregnancy is unplanned, it should be noted and the patient watched carefully.

When necessary, a referral to a mental health counselor can be made, or social services called in for additional observation and care after delivery. A personal history of substance abuse, or a history of psychotic medication use is a red flag, as is a history of sexual/physical/emotional abuse. Use of any medication during the pregnancy should be questioned and the purpose of all drugs unfamiliar to the staff should be discussed with the patient.

At the time immediately following delivery, nurses should be on the lookout for signs of incipient bipolar illness. This is the patient who is literally dancing on the delivery bed, up at all hours with endless energy, or crying and laughing continually. Obsessive-compulsive disorder may also first be detected during this time period, so watch for the mother who is washing her hands inappropriately and cannot pick up or change her newborn or touch doorknobs, silverware or railings.

Finally, watch for the rare signs of maternal psychosis. A psychotic mother would be one with bizarre behavior due to the visual, tactile or olfactory hallucinations that she is experiencing; self-neglect beyond what might be expected from being overtired; agitation; or loss of any sense of time and space. Pay close attention and observe for the signs of positive maternal-infant bonding and attachment. We know that infants are abandoned every day, so it’s crucial to note which mothers and babies are at risk before they leave your facility, or when you are doing a home visit.

Christine Contillo, RN, BSN, has worked as a nurse since 1979 and has written extensively for various nursing publications, as well as The New York Times.

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