The postpartum period involves extraordinary physio- logic, psychological, and sociocultural changes in the life of a woman and her family. It is an exhilarating time for most women, but for others it may not be what they had expected. Women have varied reactions to their child- bearing experiences, exhibiting a wide range of emo- tions. Typically, the delivery of a newborn is associated with positive feelings such as happiness, joy, and grati- tude for the birth of a healthy infant. However, women may also feel weepy, overwhelmed, or unsure of what is happening to them. They may experience fear about loss of control; they may feel scared, alone, or guilty, or as if they have somehow failed.
Postpartum affective disorders have been docu- mented for years, but only recently have they received medical attention. Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy including sepsis. Information should include the impor-
tance of good hand and perineal hygiene and of the need to seek immediate medical care if feeling unwell.
Client teaching is a priority due to today’s short lengths of stay after childbirth. Some infections may not manifest until after discharge. Review the signs and symptoms of infection, emphasizing the danger signs that need to be reported to the health care provider. Most importantly, stress proper handwashing, especially after perineal care and before and after breast-feeding. Also reinforce mea- sures to promote breast-feeding, including proper breast care (see Chapter 16). Teaching Guidelines 22.2 high- lights the major teaching points for a woman with a post- partum infection.
Teaching Guidelines 22.2
TEACHING FOR THE WOMAN WITH A POSTPARTUM INFECTION
• Continue your antibiotic therapy as prescribed.
• Take the medication exactly as ordered and con- tinue with the medication until it is finished.
• Do not stop taking the medication even when you are feeling better.
• Check your temperature every day and call your health care provider if it is above 100.4° F (38° C).
• Watch for other signs and symptoms of infection, such as chills, increased abdominal pain, change in the color or odor of your lochia, or increased redness, warmth, swelling, or drainage from a wound site such as your cesarean incision or episiotomy. Report any of these to your health care provider immediately.
• Practice good infection prevention:
• Always wash your hands thoroughly before and after eating, using the bathroom, touching your perineal area, or providing care for your newborn.
• Wipe from front to back after using the bathroom.
• Remove your perineal pad using a front-to-back motion. Fold the pad in half so that the inner NURSING CARE PLAN 22.1
• Contact family members to participate in care of the newborn to allow mother to rest and recover from infection.
• Encourage mother to care for herself first and then the newborn to ensure adequate en- ergy for newborn’s care.
• Arrange for assistance and support after discharge from hospital to provide necessary backup.
• Refer to community health nurse for follow-up care of mother and newborn at home to foster continued development of maternal–infant relationship.
Overview of the Woman with a Postpartum Complication
(continued)sides of the pad that were touching your body are against each other. Wrap in toilet tissue or place in a plastic bag and discard.
• Wash your hands before applying a new pad.
• Apply a new perineal pad using a front-to-back motion. Handle the pad by the edges (top and bot- tom or sides) and avoid touching the inner aspect of the pad that will be against your body.
• When performing perineal care with a peribottle, angle the spray of water to that it flows from front to back.
• Drink plenty of fluids each day and eat a variety of foods that are high in vitamins, iron, and protein.
• Be sure to get adequate rest at night and periodi- cally throughout the day.
788 U N I T 7 Childbearing at Risk
The new mother may also:
• Cry a lot
• Exhibit a lack of energy and motivation
• Be unable to make decisions or focus
• Lose her memory
• Experience a lack of pleasure
• Have changes in appetite, sleep, or weight
• Show a lack of concern for herself
• Withdraw from friends and family
• Have pains in her body that do not subside
• Feel negatively toward her baby
• Lack interest in her baby
• Worry about hurting the baby
• Act detached toward others and infant
• Have recurrent thoughts of suicide and death (Miles, 2011)
Postpartum depression affects not only the woman but also the entire family. Identifying depression early can substantially improve the client and family out- comes. PPD usually has a gradual onset and becomes evident within the first 6 weeks postpartum.
The cause of PPD is not known, but research sug- gests that it is multifactorial. According to ACOG (2011),
“postpartum depression is likely to result from body, mind, and lifestyle factors combined.” The levels of es- trogen, progesterone, serotonin, and thyroid hormone decrease sharply and return to normal during the imme- diate postpartum period, which can trigger depression and can change a woman’s mood and behavior. Other aspects that can lead to PPD include:
• Unresolved feelings about the pregnancy
• Fatigue after delivery from lack of sleep or broken sleep
• Feelings of being less attractive
• Inadequate assistance from partner
• Lack of social support network
• Doubts about the ability to be a good mother
• Stress from changes in work and home routines
• Loss of freedom and old identity (Zubaran & Foresti, 2011)
Postpartum depression may lend itself to prophy- lactic intervention because its onset is predictable, the risk period for illness is well defined, and women at high risk potentially could be identified using a screen- ing tool. This is not the case for all women, however (see Evidence-Based Practice 22.1). Prophylaxis starts with a prenatal risk assessment and education. Based on the woman’s history of prior depression, prophylactic antidepressant therapy may be needed during the third trimester or immediately after giving birth. Management mirrors that of any major depression: a combination of antidepressant medication, antianxiety medication, and psychotherapy in an outpatient or inpatient setting (Wylie, Hollins, Marland, Martin, & Rankin, 2011). Marital counseling may be necessary if marital problems are contributing to the woman’s depressive symptoms.
and postpartum, the greater the chance for developing a mood disorder (Edler & Venis, 2012).
Many types of affective disorders occur in the postpar- tum period. Although their description and classification may be controversial, the disorders are commonly classi- fied on the basis of their severity as postpartum or baby blues, postpartum depression, and postpartum psychosis.
Postpartum or Baby Blues
Many postpartum women (approximately 50% to 90%) experience the “baby blues” (ACOG, 2011). The woman exhibits mild depressive symptoms of anxiety, irritabil- ity, mood swings, tearfulness, increased sensitivity, feel- ings of being overwhelmed, and fatigue (Edler & Venis, 2012). The “blues” typically peak on postpartum days 4 and 5 and usually resolve by postpartum day 10. Al- though the woman’s symptoms may be distressing, they do not reflect psychopathology and usually do not affect the mother’s ability to function and care for her infant.
Baby blues are usually self-limiting and require no formal treatment other than reassurance and validation of the woman’s experience, as well as assistance in car- ing for herself and the newborn. However, follow-up of women with postpartum blues is important, because up to 20% go on to develop postpartum depression (Buttner, O’Hara, & Watson, 2012).
Postpartum Depression
Depression is more prevalent in women than in men, which may be related to biological, hormonal, and psychosocial factors. Postpartum depression (PPD) is a form of clini- cal depression that can affect women, and less frequently men, after childbirth. It affects as many as 20% of all moth- ers in the United States, and as many as 60% of adolescent mothers (ACOG, 2011; Caple & Uribe 2012; Centers for Disease Control and Prevention, 2012; Joy, Contag & Tem- pleton 2012). Unlike the postpartum blues, women with postpartum depression feel worse over time, and changes in mood and behavior do not go away on their own.
Different from the baby blues, the symptoms of PPD last longer, are more severe, and require treatment.
Some signs and symptoms of PPD include feeling the following:
• Restless
• Worthless
• Guilty
• Hopeless
• Moody
• Sad
• Overwhelmed
• Loss of enjoyment
• Low energy level
• Loss of libido
C h a p t e r 2 2 Nursing Management of the Postpartum Woman at Risk 789 EVIDENCE-BASED PRACTICE 22.1
STUDY
Postpartum depression can be a devastating condition for women and their families. There is a lack of knowledge about its cause, and women receive limited education about the possibility of depres- sion after birth. Research has shown the effectiveness of treatment strategies that integrate psycho- social and psychological variables. The question then arises that if management addressing these variables were effective, would psychosocial interventions provided during pregnancy and the early postpartum period be effective in preventing postpartum depression?
Two reviewers searched multiple databases and contacted experts in the field. They also scanned secondary references and contacted several trial researchers for additional information. Both review- ers were involved in evaluating the methodology of the study and in extracting data. Information was gathered from all published and unpublished randomized controlled trials that compared psychosocial or psychological interventions with typical care during the antepartal, intrapartal, and postpartal periods. The researchers used relative risk for categorical data and weighted mean differ- ence for continuous data. The study included 15 trials involving over 7,600 women.
Findings
Women who received some type of psychosocial intervention had the same risk for developing post- partum depression as the women who received routine care; thus, the psychosocial intervention was not effective in preventing postpartum depression. However, statistical analysis found that intensive psychosocial support from public health nurses or midwives in the postpartum period was benefi- cial. The use of psychosocial interventions primarily during the postpartum period also was more effective than when these interventions were also used in the prenatal period. Interventions focusing on women at risk appear to be more effective than those geared to the overall maternal population.
Individualized interventions were found to be more effective than those designed for groups. How- ever, the risk for developing postpartum depression for either group did not differ significantly.
Nursing Implications
Although the study failed to identify effective measures for preventing postpartum depression, it did provide some useful information for nurses to incorporate when providing care to pregnant women throughout the perinatal period. Overall psychosocial interventions did not reduce the numbers of women who develop postpartum depression. However, a promising intervention is the provision of intensive, professionally based postpartum support. Nurses need to remain alert for risk factors as- sociated with postpartum depression so they can initiate appropriate interventions for these at-risk women. Nurses can implement psychosocial interventions during the prenatal period, keeping in mind that these interventions need to be continued throughout the postpartum period. They can also advocate for their clients upon discharge to ensure appropriate follow-up and support in the community.
Adapted from Dennis, C. L., & Creedy, D. (2010). Psychosocial and psychological interventions for preventing postpar- tum depression. Cochrane Database of Systematic Reviews, 2010(10). doi:10.1002/14651858.CD001134.pub2.
PSYCHOSOCIAL AND PSYCHOLOGICAL INTERVENTIONS FOR PREVENTING POSTPARTUM DEPRESSION
The father’s emotional health should not be over- looked during his partner’s pregnancy and throughout the first postpartum year. Postpartum depression, once expected only in new mothers, occurs in new fathers as well. Up to 50% of men whose partners suffer from PPD also have depressive symptoms, and little is known about the impact of maternal PPD on fathers. Depressive symp- toms are likely to decrease fathers’ ability to provide ma- ternal support. Paternal postpartum depression can be difficult to identify. New fathers may seem more angry and anxious than sad, yet depression is present. When left untreated, paternal postpartum depression limits men’s capacity to provide emotional support to their partners and children. The highest rates of depression among fa- thers have been reported between 3 and 6 months post- partum. Factors that increase the risk of paternal PPD
include a personal history of depression and/or anxi- ety, a low level of marital satisfaction, excessive finan- cial stressors, a lack of paternal parental leave, and the feeling that there is a great discrepancy between one’s expectations of parenthood and its realities (Strayer &
Cabrera, 2011).
Assessing paternal postpartum depression is not easy. Nevertheless, it is important for all nurses who have contact with new fathers to remain open to the notion that new fathers are predisposed to postpartum depres- sion, particularly if their partner is afflicted. Delving deeper into understanding behaviors of withdrawing, in- decisiveness, cynicism, avoiding, drinking, using drugs, fighting, partner violence, extramarital affairs, and feel- ings of heightened irritation will reveal important in- sights. Asking new fathers candidly if they are feeling
790 U N I T 7 Childbearing at Risk
outcomes for the mother and infant, as well as for decreasing mortality and morbidity. This is why it is crucial for nurses to understand and know about the risk factors, signs and symptoms, prevention, and use and interpretation of screening tools and to make ap- propriate referrals for treatment. Mass screening for PPD using a validated screening tool has been proven to improve the rates of detection and treatment of PPD and should be implemented in obstetricians’ and pe- diatricians’ offices and in primary care settings. The Edinburgh tool is shown in Figure 22.5.
Postpartum Psychosis
At the severe end of the continuum of postpartum emotional disorders is postpartum psychosis, which occurs in 1 in 500 births (Edler & Venis, 2012). Post- partum psychosis, an emergency psychiatric condition, can result in a significant increased risk for suicide and infanticide. Symptoms of postpartum psychosis, such as mood lability, delusional beliefs, hallucinations, and disorganized thinking, can be frightening for the women who are affected and for their families. It gen- erally surfaces within 3 months of giving birth and is manifested by sleep disturbances, fatigue, depression, and hypomania. The mother will be tearful, confused, and preoccupied with feelings of guilt and worthless- ness. Early symptoms resemble those of depression, but they may escalate to delirium, hallucinations, ex- treme disorganization of thought, anger toward herself and her infant, bizarre behavior, delusions, manifesta- tions of mania, and thoughts of hurting herself and the infant. The mother frequently loses touch with real- ity and experiences a severe regressive breakdown, associated with a high risk of suicide or infanticide (Waters, 2011).
Women with postpartum psychosis should not be left alone with their infants. Most women with postpar- tum psychosis are hospitalized for up to several months.
Psychotropic drugs are almost always part of treatment, along with individual psychotherapy and support group therapy.
Take Note!
The greatest hazard of postpartum psychosis is suicide. Infanticide and child abuse are also risks if the woman is left alone with her infant. Early recognition and prompt treatment of this disorder are imperative.
Nursing Assessment
Postpartum affective disorders are often overlooked and go unrecognized despite the large percentage of women who experience them. The postpartum period depressed, anxious, or angry can open the door to fur-
ther exploration of these emotions (Davies, 2011).
Although paternal depression is only now begin- ning to be defined and measured, sufficient evidence exists to warrant nurses’ attention and concern. Nurses may be most able to help a new father devastated by postpartum depression when they plant seeds of aware- ness that the disorder exists, that he is not alone, and that help is available.
Despite the negative outcomes associated with PPD, rates of diagnosis and treatment are low mainly because of lack of recognition by the health care provider. In addition, PPD is the most misinterpreted, frequently dis- missed, and most undiagnosed postpartum complica- tion. Early recognition of PPD can eliminate the length of time that women have to suffer with this debilitating condition and can decrease the potentially harmful ef- fects on the infants involved.
Screening for symptoms of postpartum depression is an important preliminary step to diagnosis and treat- ment, but the effectiveness of depression screening is dependent on the reliability and validity of the screen- ing instruments in the population. Both the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Depression Predictor Scale (PDSS) have been used to screen mothers for PPD, but it is not clear which instru- ment best predicts a diagnosis of postpartum depression (Tandon, Cluxton-Keller, Leis, Le, & Perry, 2012).
The EPDS is a self-report, quick, and easy screen- ing tool for PPD that consists of 10 questions with four possible responses. The women fill out the tool accord- ing to their symptoms during the past 7 days, with each response given a score of 0 to 3 points, creating a maxi- mum score of 30. Using a cutoff score of 9 or 10, the sensitivity is 86%; the specificity, 78%; and positive pre- dictive value, 73% (Lee King, 2012).
The PDSS is a self-report, 35-item Likert-type response scale divided into seven conceptual domains:
1. Anxiety/insecurity 2. Sleep/eating disturbance 3. Emotional liability 4. Loss of self-esteem 5. Guilt/shame
6. Cognitive impairment 7. Suicidal thoughts
The scores range from 35 to 175. The scale has five symptoms for each domain, and the woman is asked to identify her degree of disagreement or agreement on the basis of her feelings over the past 2 weeks. The sensitiv- ity of the PDSS is 91%; the specificity is 72% for detecting PPD. The PDSS takes 5 to 10 minutes to administer and is used during the postpartum period (Le, Perry, & Oritz, 2010).
Early identification, screening, prevention, and treatment of PPD are crucial for improving overall
FIGURE 22.5 Adapted from Edinburgh Postnatal Depression Scale (EPDS). From Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786.