Screening for Postpartum Depression
- In this course we will learn about mild, moderate, and severe postpartum depression and why it is important for nurses to recognize the signs and symptoms.
- You’ll also learn the basics of how to assess patients, as well as common risk factors and treatments.
- You’ll leave this course with a broader understanding of how to recognize postpartum depression in new mothers.
Contact Hours Awarded: 1.5
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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?
According to the American Congress of Obstetricians and Gynecologists (ACOG), depression can occur throughout pregnancy in 14-23% of women. In the U.S., it is the most underdiagnosed complication of pregnancy (16). The hormone changes in pregnancy affect the brain’s chemical makeup that can lead to depression and anxiety. Difficult life situations or stressors may also intensify these reactions to the hormonal shift.
Postpartum depression occurs in greater than 3 million women in the U.S. yearly, and the American Academy of Pediatrics (AAP) estimates that about 400,000 infants are born to mothers with depression each year (1). It can occur within one to three days after birth and there are usually three different levels, mild—known as “baby blues,” moderate—postpartum depression, and severe—postpartum (or ‘puerperal’) psychosis.
Mild postpartum depression or “baby blues” can occur as quickly as 2-3 days and last up to two weeks. Symptoms for “baby blues” include:
- Rapid mood swings
- Decreased concentration
- Crying spells
In women with moderate postpartum depression, the symptoms last for more than a 2-week postpartum period. Symptoms for moderate depression include:
- Extreme sadness
- Mood swings
- Uncontrollable crying
- Changes in appetite (too little or too much)
- Alterations in sleep patterns (insomnia or sleeping too much)
- Irritability or 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
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 (2). Severe postpartum depression or postpartum psychosis is a medical emergency. Symptoms include:
- Elated mood
- Danger to self or infant
Given that depression can develop throughout pregnancy, evaluation of each mother needs to start at her first prenatal visit. A complete history is needed, including their previous history of depression or bipolar diagnosis. Discussion about changes in her body that might affect sleep, moods and increase anxiety should also occur early in the pregnancy. The patient should monitor these and let her caregiver know if any of it becomes overwhelming (17).
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 problem with depression.
What questions should the admitting nurse or physician ask the patient regarding her emotional and psychological status?
What medications might signal an issue?
Is there anything that might suggest the patient is have undiagnosed depression or a bipolar condition?
Are there any patterns in the patient’s behavior or changes in her life stressors that might signal a need for closer monitoring?
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 that also ended prior to 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 serve as her support person 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.
What factors of Mary’s history could be a risk factor for developing postpartum depression?
What factors in Mary’s situation could help decrease the severity of depression post-delivery?
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 postpartum depression (3).
Women with the following are at a higher risk:
- Baby blues
- Prior episode of postpartum depression
- Prior diagnosis of depression
- Family history of depression
- Significant life stressors (e.g. marital conflict, stressful events in the last year, unemployment of partner, partner with depression)
- Lack of support from partner of family members
- Financial problems or childcare issues
- Prior history of mood changes temporarily associated with menstrual cycle or contraceptives
- Prior or current poor obstetric outcomes (e.g. previous miscarriage, preterm delivery, infant with a congenital malformation)
- Problem with breastfeeding.
- History of domestic violence
- Maternal anxiety
- Lower income
- Lower education
- Drug abuse
- Traumatic birth experience
- Preterm birth/infant admitted to neonatal intensive care
- Unintended pregnancy.
- Younger than 20 years of age (4, 5)
In the above case study, Mary has many risk factors that can make her prone to developing postpartum depression. 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 major 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 postpartum depression. 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
Mild Postpartum Depression
Up to 85% of all women experience some level of emotional changes after giving birth. 10-15% of these mothers can develop more serious and often debilitating forms of depression (1, 5, 6). 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. They can continue for the next week, slowly subsiding and resolving by the end of the second week postpartum.
No medical intervention is required due to the mild symptoms, other than assistance and reassurance from the patient’s support system, including help with infant care, household chores, and talk therapy with family and friends. In the immediate postpartum time prior to discharge, the nurse can also educate the mother, her partner, and support person(s) on the possibility of increased symptoms. The nurse can also give the patient tools to help deal with and ease the severity of her symptoms such as:
- Good nutrition, with a balance of protein, fats, and carbohydrates, as well as continued use of prenatal vitamins for at least six weeks to replace nutrients depleted from the mother’s body during pregnancy.
- Mild exercise such as walking, especially outside in the fresh air if weather permits.
- Talking with someone about how they are feeling.
- Journaling thoughts and feelings.
- Adequate rest.
- 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 mom can get a nap).
- Limit expectations-a new baby is an adjustment, whether it’s the first or the fourth.
- Routines and new skills, such as feedings or diaper changings; it will take time to adjust to them. New mothers shouldn’t expect to be perfect at any of it (12).
Moderate Postpartum Depression
Some patients may have mild symptoms, while others may develop more severe symptoms that interfere with daily function and ability to care for herself or her infant (7, 8).
Since symptoms of baby blues usually subside by two weeks post-delivery, all women need to see their obstetrician for a follow-up visit at that time. If her symptoms have continued, the physician should do an assessment including a physical evaluation, blood tests to rule out medical causes such as thyroid dysfunction or anemia caused by the pregnancy, and thorough history to screen for any additional risk factors such as previous depressive episodes, life-changing stress, or possible self-harming ideations (9).
The severity of the illness will determine the method of therapy used, but a good prognosis is associated with the early onset of treatment (10). Resulting deterioration of the patient’s relationship with her infant or her partner can be linked to failure to treat or an inadequate therapy plan.
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 (11). Besides psychotherapy, other modalities—such as light therapy, exercise therapy, massage therapy, acupuncture, and even supplementing the diet with omega-3 fatty acids—have shown some benefits in small studies (5).
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 serious cases.
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 good effects, but for the mothers wishing to breastfeed, Prozac, Zoloft, and Paxil show low serum levels in breastfed infants (13).
Side effects can include insomnia, jitteriness, headache, appetite suppression, nausea, and sexual dysfunction (14).
Serotonin/norepinephrine reuptake inhibitors—Effexor or Cymbalta—also show effective treatment of postpartum depression in moderately depressed mothers.
Side effects for SNRIs are the same as for SSRIs, but also include constipation and abnormal vision. These agents have been associated with hepatotoxicity in infants, especially with premature infants and those with hepatic insufficiency, and should be avoided for use in breastfeeding mothers (13).
Severe Postpartum Depression
Puerperal psychosis (PP) 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 PP (5, 15).
Nurses need to be particularly attuned to a patient developing PP in the immediate postpartum period. Most of these patients claim they started having symptoms as early as day three postpartum. Women diagnosed with PP stated they felt excited, high, or elated; not being able to sleep; being energetic or extremely active; and excessively talkative (14). 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 PP.
Mothers diagnosed with PP are at great risk of committing infanticide (4%) or suicide if left untreated. While most instances, this condition develops immediately postpartum, it can occur up to one year later. Because PP is an emergency, these mothers need to have in-patient care. Since most mothers with this have a bipolar diagnosis, they are treated with mood stabilizers such as lithium, carbamazepine, or valproic acid, as well as other antipsychotics and benzodiazepines (5).
Breastfeeding is not recommended for mothers with PP being treated with lithium as it is secreted in high levels in breastmilk 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 normal delivery, her husband must leave to take care of their other three children. The postpartum nurses notice that Korina sends her baby back to the nursery as soon as the feeding time is 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?”
What about Korina’s history might signal to the labor nurse to be sure she is monitored for depression throughout her stay in the hospital?
What level of depression is Korina potentially at risk to develop?
What steps should the nurse take to be sure Korina gets the appropriate care?
Is there anything else the nurse should be concerned about?
Mother and Infant Bonding
The initial time after delivery is the most important to the mother-infant bond. It is why new parents are encouraged to hold their baby immediately after birth, if possible, why breastfeeding is started within the first hour of birth. It’s why many hospitals have rooming-in opportunities for their mothers and fathers. These mother-infant interactions may be affected by postpartum depression (17).
Postpartum depression can cause these mothers to react negatively to their infant. Whether it is their inability to care for their infant or an unwillingness to hold their child, these actions can interfere with the bonding necessary to help with good emotional, as well as educational and physical development of these infants.
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 (4). Because of the impact on mother-infant bonding and childhood development, children of mothers with moderate to severe postpartum depression display more behavioral problem such as tantrums, eating disorders, and hyperactivity than children born to non-depressed mothers (18).
While many women experience some form of depression during and after delivery of their baby, most instances of mild depression or “baby blues” are self-limiting and resolve themselves within the first two weeks and the mother-infant bonding experience goes 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—by 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.
References + Disclaimer
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- Heron, J., McGuinness, M., Blackmore, E., Craddock, N. and Jones, I., 2021. Early postpartum symptoms in puerperal psychosis.
- Daley, K., 2021. How pregnancy hormones affect your body in each trimester. [online] Today’s Parent. Available at: <https://www.todaysparent.com/pregnancy/pregnancy-health/how-pregnancy-hormones-affect-your-body-in-each-trimester/> [Accessed 17 March 2021].
- Moldenhauer, J. S., 2020. Postpartum Depression – Gynecology and Obstetrics – MSD Manual Professional Edition. [online] MSD Manual Professional Edition. Available at: <https://www.merckmanuals.com/en-pr/professional/gynecology-and-obstetrics/postpartum-care-and-associated-disorders/postpartum-depression> [Accessed 18 March 2021].
- Saju, J., MD, MS; Editor: Issacs, C., MD. Updated: Oct 11, 2019. Postpartum Depression: Overview, Risk Factors for Postpartum Mood Disorders, Screening for Postpartum Mood Disorders. [online] Reference.medscape.com. Available at: <https://reference.medscape.com/article/271662> [Accessed 18 March 2021].
- Kendell, R., Chalmers, J. and Platz, C., 1987. Epidemiology of Puerperal Psychoses.
- Beck, C., 2006. Postpartum Depression: It isn’t just the blues: . : AJN The American Journal of Nursing. [online] LWW. Available at: <https://journals.lww.com/ajnonline/Abstract/2006/05000/Postpartum_Depression__It_isn_t_just_the_blues___.20.aspx> [Accessed 20 March 2021].
- Wisner, K., Perel, J., Peindl, K., Fiendling, R. and Rapport, D., 2001. Prevention of Postpartum Depression. [online] MGH Center for Women’s Mental Health. Available at: <https://womensmentalhealth.org/posts/prevention-of-postpartum-depression/> [Accessed 20 March 2021].
- Sit, DK., Wisner KL. Identification of postpartum depression. Clin Obstet Gynecol. 2009 Sep. 52(3): 456-68. [Medline] [Full Text]
- Di Scalea, T. and Wisner, K., 2009. Pharmacotherapy of postpartum depression. Expert Opinion Phramacotherapy. [Medline] Reference.medscape.com. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2929691/ [Accessed 18 March 2021].
- Appleby, L., Warner, R., Whitton, A. and Faragher, B., 1997. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. Biological Psychiatry, [online] 42(1), pp.129S-130S. Available at: https://pubmed.ncbi.nlm.nih.gov/9099116/ [Accessed 19 March 2021].
- American Pregnancy Association. 2019. The Baby Blues | American Pregnancy Association. [online] Available at: <https://americanpregnancy.org/healthy-pregnancy/first-year-of-life/baby-blues-71032/> [Accessed 19 March 2021].
- Obstetrics & Gynecology, 2008. ACOG Practice Bulletin No. 92: Use of Psychiatric Medications During Pregnancy and Lactation. 111(4), pp.1001-1020.
- nhs.uk. 2018. Side effects – Selective serotonin reuptake inhibitors (SSRIs). [online] Available at: <https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/ssri-antidepressants/side-effects/> [Accessed 23 March 2021].
- Heron, J., McGuinness, M., Blackmore, E., Craddock, N. and Jones, I., 2008. Early postpartum symptoms in puerperal psychosis. [Accessed 19 March 2021]
- Obstetrics & Gynecology, 2006. ACOG Committee Opinion No. 343: Psychosocial Risk Factors: Perinatal Screening and Intervention. 108(2), pp.469-77. [Medline]
- Earls, M., 2010. Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice. PEDIATRICS, 126(5), pp.1032-1039.
- MURRAY, L. and COOPER, P., 1997. EDITORIAL: Postpartum depression and child development. Psychological Medicine, 27(2), pp.253-260. [Medline]
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