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The shifting of hormones, anxiety of the impending birthing process, and the anticipation of seeing their new baby can all lead to differing levels of depression in many women. Early assessment of mothers with increased risk, as well as watching for signs and symptoms of possible developing postpartum depression can lead to early treatment and care for these women, providing a more positive outcome for mother and baby. 

What is Postpartum Depression? 

It is estimated that approximately one in seven women postpartum will develop some degree of postpartum depression (PPD) within the first year after birth (1,2,3). In the United States, PPD is the most among the most underdiagnosed, yet most common postpartum complication. Exact rates of PPD vary widely, as many women struggle with the stigma of mental health during pregnancy and postpartum, social stigma, and lack of adequate diagnosis and care for this condition (1).

The hormone changes in pregnancy affect the brain’s chemical makeup, which can lead to depression and anxiety. Difficult life situations, such as poverty, or stressors, such as relationship issues, may also intensify these reactions to the hormonal shift (1). In addition, a history of depression or anxiety before pregnancy, prenatal or delivery complications, infant health complications, and lifestyle can also influence one’s likelihood of PPD (1).  

Mental health changes can occur after birth, and there are usually three different levels: mild—known as “baby blues,” moderate—postpartum depression, and severe—postpartum (or ‘puerperal’) psychosis (1). There are also other variations of postpartum mental health, such as postpartum rage and postpartum anxiety. However, more evidence-based research is needed to determine those conditions’ prevalence and clinical manifestations (1,2,3).  

Baby blues, also known as mild PPD, can occur as quickly as 2-5 days and last up to two weeks. Possible baby blues symptoms include: 

• Rapid mood swings 
• Anxiety 
• Irritability 
• Decreased concentration 
• Crying spells 
• Sleep disturbances 

It is important to note that baby blues do not interfere with the mother’s daily activities, functioning, or ability to care for the infant.  

In women with PPD, the symptoms last for at least two weeks postpartum and include at least five depressive symptoms from the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Possible PPD symptoms include (1): 

• Extreme sadness 
• Loss of interest or pleasure (anhedonia) 
• Mood changes 
• Uncontrollable crying 
• Changes in appetite (eating too little or too much) 
• Changes in weight 
• Changes in concentration and decision-making 
• Alterations in sleep patterns (insomnia or sleeping too much) 
• Irritability 
• Anger 
• Anxiety or panic attacks 
• Unrealistic worries about their baby 
• Disinterest in the baby 
• Fear of being an inadequate mother  
• Fear of being incapable of caring for their baby 
• Fear of harming the baby  
• Guilt over her feelings 
• Suicidal ideation (1) 

Postpartum or puerperal psychosis is rare, affecting only 1-2 women for every 1,000 births. Most of the time, it will appear without any warning (1,4). Postpartum psychosis is a medical emergency, and women suspected of postpartum psychosis should be referred to urgent medical and psychiatric care immediately. Possible postpartum psychosis symptoms include: 

• Delusions 
• Hallucinations 
• Mania 
• Severe mood changes 
• Paranoia 
• Confusion 
• Danger to self or infant (1,4) 

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Assessment 

Given that depression can develop throughout pregnancy, evaluation of each mother needs to start at her first prenatal visit. A complete history is required, including their previous history of depression, anxiety, or bipolar diagnosis. Discussion about changes in her body that might affect sleep and moods should also occur early in the pregnancy (1,4). The patient should monitor these and let her caregiver know if any of it becomes overwhelming (1,4).  

Upon admission to the hospital, either for labor or any concerns, the admitting nurse should reevaluate the patient for depression symptoms and risk factors, along with any medical problems or medications that might also signal a possible issue with depression. 

Case Study #1

Mary, an 18-year-old 40-week G1P0 patient, presents for induction of labor. Her pregnancy is only complicated by a history of smoking that ceased at the beginning of pregnancy. Some drug use of marijuana also ended before pregnancy. Mary reports that the father of the baby was abusive, both physically and emotionally, and is no longer around. She is accompanied by her mother, who will support her throughout labor. The pair appear to have a good relationship and have attended birthing classes in preparation for delivery. 

Mary states she is giving her baby up for a private adoption. The adoptive mother will be present at birth. Mary requests to be able to hold the baby and see the baby during her stay in the hospital. A social worker and counselor have both been working with Mary during her pregnancy. Mary has put her college courses on hold until after the baby is born and is currently working full-time in retail. 

Risk Factors for Postpartum Depression

Because of the sudden decrease of hormones, such as progesterone, estrogen, relaxin, and HPL (human placental lactogen—a hormone that helps the baby grow during pregnancy), lost with the placenta’s separation, all women are at risk for PPD (1,2,3,4).  

Women with the following are at a higher risk of PPD (1,2,3,4): 

• Baby blues 
• Prior episode of postpartum depression 
• Previous diagnosis of depression or anxiety 
• Family history of depression, including PPD 
• Significant life stressors (e.g., marital conflict, stressful events in the last year, unemployment of partner, partner with depression) 
• Lack of support from partners or family members 
• Financial problems or childcare issues 
• Prior history of mood changes temporarily associated with the menstrual cycle 
• Prior or current adverse obstetric outcomes (e.g., previous miscarriage, preterm delivery, infant with health complications, vaginal laceration, unplanned C-section, maternal infection) 
• Problem with breastfeeding 
• History of domestic violence 
• Maternal anxiety 
• Lower-income 
• Lower education 
• Smoking 
• Drug abuse 
• Single 
• Traumatic birth experience 
• Preterm birth/infant admitted to neonatal intensive care 
• Unintended pregnancy 
• Younger than 20 years of age 

In the above case study, Mary has many risk factors that can make her prone to developing PPD. She is under 20, single, and has a history of smoking and some drug use. The father of her baby was both physically and sexually abusive to her. Mary’s decision to give her baby up for adoption adds a significant life stressor for her. These are clues to the nurses to observe her for possible postpartum depression.  

Mary also has a steady job and the support of her family. She has also been working with a social worker and counselor to help her through the adoption process. Her physician is aware of the planned adoption and increased risk for Mary to develop PPD. His plan of care is to schedule her for a follow-up visit in two weeks to be sure she is handling all the changes in her life. 

Treatment of Postpartum Depression

Baby Blues 

It is estimated that almost all women experience some level of emotional changes after giving birth, with the exact prevalences ranging significantly because of lack of disclosure of mental health and emotional health from new mothers, social stigma, and lack of adequate access to postpartum care (1,2,4). Because of these emotional and other changes associated with pregnancy, it is estimated that up to 20% of these mothers can develop more severe and often debilitating forms of depression, such as PPD (1). Mental health-related symptoms may appear as early as 48 hours after delivery (usually when the endorphins of the labor process have subsided) and peek around day four or five. Mental health changes can continue for the next week, slowly subsiding and resolving by the end of the second week postpartum.  

No medical intervention is required as a result of suspected baby blues. In general, for baby blues, it is recommended to have assistance and reassurance from the patient’s support system, including help with infant care, household chores, and talk therapy with family and friends (1,2,4). In the immediate postpartum time before discharge, the nurse can also educate the mother, her partner, and support person(s) on possible increased symptoms. The nurse can also give the patient tools to help deal with and ease the severity of her symptoms, such as discussing the importance of: 

• Getting good nutrition, balanced protein, fats, and carbohydrates, and continued use of prenatal vitamins for at least six weeks to replace nutrients depleted from the mother’s body during pregnancy. Recommend a prenatal vitamin as well.  

• Doing some mild exercise, such as walking, especially outside in the fresh air if the weather permits 

• Talking with someone about how they are feeling and possibly refer to a mental health counselor or psychiatry if available 

• Journaling thoughts and feelings 

• Sleeping adequately  

• Asking for help to keep from feeling overwhelmed (e.g., have family or friends do a meal train for the first few weeks at home, someone to come in and help with laundry or caring for the baby so that mom can get a nap) 

• Limiting expectations as a new baby is an adjustment, whether it’s the first or the fourth 

• Establishing routines and new skills, such as feedings or diaper changes. 

It is essential to educate the patient that things will take time to adjust and get used to. New mothers shouldn’t expect to be perfect at any of it (1) 

Postpartum Depression 

Some patients may have mild symptoms, while others may develop more severe symptoms that interfere with daily function and the ability to care for themselves or their infant (1,2,3,4). 

Since symptoms of baby blues subside two weeks post-delivery, all women should see their healthcare provider for a follow-up visit. If her symptoms have continued, the health care provider should do an assessment, including a physical evaluation and blood tests, to rule out medical causes, such as thyroid dysfunction or anemia caused by the pregnancy. In addition, a healthcare provider should also make a thorough history to screen for any additional risk factors for postpartum mental health conditions, such as previous depressive episodes, life-changing stressors, or possible self-harming ideations (1). 

The severity of the PPD and other postpartum mental health conditions will determine the method of therapy used, but a good prognosis is associated with the early onset of treatment (1,2,3,4). The resulting deterioration of the patient’s relationship with her infant or her partner can be linked to failure for early intervention or an inadequate therapy plan (1). 

Mild to moderate symptoms of depression can be treated with non-pharmacologic modalities, such as individual or group psychotherapy. For women who are breastfeeding and worry about passing any medications to their baby through breastmilk, this approach may be their choice (1). Besides psychotherapy, other modalities—such as light therapy, exercise therapy, massage therapy, acupuncture, and even transcranial magnetic stimulation (TMS)—have shown benefits (1). 

For moderate to severe depression, pharmacological therapy along with non-pharmacological strategies are indicated. Antidepressants have long been the first line of treatment in more severe cases (1). In addition, FDA-approved therapies for PPD include brexanolone and zuranolone (5,6). 

SSRIs 

Selective serotonin reuptake inhibitors—Prozac, Zoloft, Paxil, Celexa, and Lexapro—are the first-line drugs used for postpartum depression patients. Not only do they show sound effects, but for the mothers wishing to breastfeed, Prozac, Zoloft, and Paxil show low serum levels in breastfed infants (1,7). 

Side effects of SSRIs can include insomnia, jitteriness, headache, appetite suppression, nausea, and sexual dysfunction (1,7). 

SNRIs 

Serotonin/norepinephrine reuptake inhibitors—Effexor or Cymbalta—also show effective treatment of postpartum depression in moderately depressed mothers (1,8). 

Side effects for SNRIs are the same as for SSRIs but also include constipation and changes in vision. These agents have been associated with hepatotoxicity in infants, especially premature infants and those with hepatic insufficiency, and should be avoided for use in breastfeeding mothers (1,8).  

FDA-Approved Treatments for PPD 

Brexanolone is a recently FDA-approved treatment for moderate-to-severe PPD administered via a continuous intravenous (IV) solution. While the exact action method is unknown, brexanolone is thought to influence PPD based on its influence on the GABA receptors. Possible side effects of brexanolone include IV site reaction, sleepiness, dry mouth, sudden loss of consciousness, and changes in skin tone. Because of its cost, administration route, and possible side effects, many women do not consider brexanolone a first-line option for their PPD (5).  

Zuranolone is another recently added FDA-approved treatment for PPD administered orally via a pill. Like brexanolone, zuranolone is thought to influence PPD based on its influence on the GABA receptors. Possible side effects of quinolone include sleepiness, confusion, fatigue, urinary tract infection (UTI), and abdominal pain (6).  

Severe Postpartum Depression and Postpartum Psychosis 

Puerperal psychosis, also known as postpartum psychosis, is the most severe form of postpartum depression. It is a rare condition, occurring in only 1-2 out of 1000 women after delivery, usually in women with a personal history of bipolar disorder or a previous episode of postpartum psychosis (4). 

Nurses need to be particularly attuned to a patient developing postpartum psychosis in the immediate postpartum period. Most of these patients claim they started having symptoms as early as day three postpartum. Women diagnosed with postpartum psychosis stated they felt excited, high, or elated, not being able to sleep, being energetic or extremely active, and excessively talkative (4). Delusions (e.g., believing their baby is defective, belonging to Satan or God) or auditory hallucinations (voices telling her to harm herself or her baby) also can occur in women with postpartum psychosis. 

Mothers diagnosed with postpartum psychosis are at significant risk of committing infanticide or suicide if left untreated. In most instances, this condition develops immediately postpartum; postpartum psychosis can occur up to one year later. Because postpartum psychosis is a medical emergency, these mothers need to have in-patient care. Since most mothers with this condition have a bipolar diagnosis, they are treated with mood stabilizers, such as lithium, carbamazepine, or valproic acid, as well as other antipsychotics and benzodiazepines (4). 

Breastfeeding is not recommended for mothers with postpartum psychosis being treated with lithium, as lithium is secreted in high levels in breast milk and could lead to toxicity in the infant. ​

Case Study #2

Korina, a 32-year-old G4P2Ab1L3, 39-week gestation patient, presents to Labor and Delivery in early labor. Her cervix is 3cm/50/-1. She has a history of a late-term miscarriage and “baby blues” after her other two deliveries, one of which was a twin gestation. Korina has been seen in L&D several times in the third trimester for various complaints of pain or dizziness. 

After a standard delivery, her husband must leave to care for their other three children. The postpartum nurses noticed that Korina sent her baby back to the nursery as soon as the feeding time was over, interacting with her child as little as possible. She spends most of her time sleeping. When asked how everything is going, Korina bursts out in tears, saying, “I have no idea why we had another baby. How am I going to take care of four kids under five?” 

Mother and Infant Bonding 

The initial time after delivery is the most important to the mother-infant bond. This is why new parents are encouraged to hold their baby immediately after birth, if possible, and why breastfeeding is started within the first hour of birth. It’s also why many hospitals have rooming-in opportunities for their mothers and fathers. These mother-infant interactions may be affected by postpartum mental health conditions (1,2,3,4). 

PPD can cause these mothers to react negatively to their infants. Whether they cannot care for their infant or are unwilling to hold their child, these actions can interfere with the bonding necessary to help these infants’ good emotional, educational, and physical development (1,2,3). 

Nurses can watch for other clues that postpartum depression is occurring, such as extreme frustration with breastfeeding or negative facial expressions of the mother when interacting with her child (1). Because of the impact on mother-infant bonding and childhood development, children of mothers with moderate to severe PPD display more behavioral problems, such as tantrums, eating challenges, and hyperactivity, than children born to non-depressed mothers (1). 

Conclusion 

While many women experience some form of depression during and after the delivery of their baby, most instances of “baby blues” are self-limiting and resolve themselves within the first two weeks. This allows for the mother-infant bonding experience to go unaffected.  

Despite the observation of mothers during their prenatal and postnatal experience, symptoms can be missed by healthcare professionals unless an intentional evaluation of the mother’s mental health is undertaken. Assessment can include observation, a self-monitoring questionnaire, or screening for possible symptoms and risk factors. 

Failure to diagnose postpartum depression and treat it accordingly can deepen the condition, placing both the mother and infant at risk for increased morbidity and possible mortality.  

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