Progress Needed for Postpartum: Part I

Birth is a factory that is never going out of business. Being a labor and delivery nurse is a recession and pandemic proof job. A fact that I confirmed over the last two and a half years. Being that having a baby is a such a stable and recurring system, there are many websites, bloggers, Instagram pages, and educational classes dedicated to pregnancy and birth. It can be an exciting but also a stressful and vulnerable time in a growing family’s life, which leads to a desire for information. But what about after? Sure, there is plenty of information. Plenty about pregnancy and about parenting and children. But I mean what about the after for the parents? What about postpartum education on how to care for yourself as a person and parent while also caring for a brand new human? Do you need more information to prepare for possible postpartum depression?

Being a Mom is Hard… I am Here to Help

Not to diss dads, or whatever the non birthing parent identifies as, but any mom knows that their stress and pressure, adding in hormonal changes, are exceeding that of the other parent. We need more apparent information and a greater presence for postpartum challenges, and even beyond the postpartum period. Serious and dangerous challenges such as postpartum depression and/or anxiety and other more common frustrations like comparison to social media highlight reels, mom guilt, and exhaustion. All things that can also eventually lead to depression and anxiety. Being a mom in this day and age is really strenuous, painful, demanding, problematic, and just plain hard. 

Current Standards in Postpartum Care

How is it ok that the standard of care is to only have ONE scheduled follow up visit 6 weeks after childbirth?! First of all, there are so many physical changes and risks for health conditions after childbirth, especially cesarean delivery. Did you know in a c-section the surgeon goes through at least 6 layers of tissue and organ to get to your baby? This is a major surgery, and one of the only surgeries where you are expected to get right back to business, caring for a whole human that needs you for literally anything and everything. Also you might have to be back to work 2 months or less later if you are not lucky to be able to stay home or take more time off of work. Paid maternity leave could help, I am sure. But we don’t have any of that in this country.

Follow up Care is Essential

Between discharge from the hospital 2 to 3 days post-birth and a 6 week postpartum doctors visit can you even imagine all the possibilities, not only mental condition deterioration but physical also. There is still a risk for hypertension (high blood pressure) and pre-eclampsia which can be damaging to your kidneys and liver and even cause a seizure if left unchecked for days, let alone 6 weeks. C-section incisions and vaginal lacerations can become infected or not heal properly and breasts can become engorged or infected with mastitis. 

During the last trimester of pregnancy, scheduled prenatal visits increase in frequency. Having an appointment every week after 36 weeks gestation until birth is standard of care in the US. Instead of treating the post-natal care like we do the prenatal, lets just give the parents a few printed out discharge instructions that hopefully get read and understood while being sleep deprived and caring for a newborn. Seems legit.

Postpartum Depression Screening

 Along with those discharge instructions the birthing parent is sometimes screened with a piece of paper at the hospital before discharge for risks of postpartum depression. The same screening tool is used at the doctors office at that 6 week visit. This scale is called the Edinburgh  Postnatal Depression Scale. It has the style of questions that ask in the past week have you (insert whatever here), always, sometimes, rarely, or never. One of those kind of things. What percent of new moms who are severely suffering are really going to feel comfortable or possibly even realize that they are feeling those symptoms all of the time? 

1.  I have been able to laugh and see the funny side of things… as much as I always could? Not quite so much now? Definitely not so much now? Not at all?
2. I have looked forward with enjoyment to things… as much as I ever did? Rather less that I used to? Definitely less that I used to? Hardly at all?
3. I have blamed myself unnecessarily when things went wrong… No, never? Not very often? Yes, some of the time? Yes, most of the time?
4. I have been anxious or worried for no good reason… No, not at all? Hardly ever? Yes, sometimes? Yes, very often?
5. I have felt scared or panicky for no very good reason… No, not at all? No, not much? Yes, sometimes? Yes, very often?
6. Things have been getting on top of me… No, I have been coping as well as ever? No, most of the time I have coped well? Yes, sometimes and I haven’t been coping as well as usual? Yes, most of the time I haven’t been able to cope at all?
7. I have been so unhappy that I have had difficulty sleeping… Yes, most of the time? Yes, sometimes?Not very often? No, not at all?
8. I have felt sad or miserable… Yes, most of the time? Yes, quite often? Not very often? No, not at all?
9. I have been so unhappy that I have been crying…Yes, most of the time? Yes, quite often? Only occasionally? No, never?
10. The thought of harming myself has occurred to me… Yes, quite often? Sometimes? Hardly ever? No, never?

Postpartum Mood Disorders

According to the Cleveland Clinic, which is a leader in healthcare and healthcare research, there are three postpartum mood disorders: Baby blues, postpartum depression, and postpartum psychosis. Apparently, even the leaders in healthcare haven’t caught up to add postpartum anxiety.

For credit and reference: https://my.clevelandclinic.org/health/diseases/9312-postpartum-depression

Baby Blues

About 50%-70% of new moms experience the baby blues, which can be unexplained periods of crying or feeling sad or anxious for no specific reason. This usually starts soon after delivery and should only last approximately 5 days give or take. The recommended treatment is plenty of rest (cause that’s super easy to come by with a newborn amiright?) and reaching out for support from your friends and family. 

Postpartum Depression

PPD is more serious, prolonged, and dangerous than the common baby blues. Up to 15% of people are affected by this and can start soon after delivery but can also be delayed for even a year later. The symptoms of PPD include unexplained highs and lows, frequent crying, anxiety, irritability, and fatigue. Along with this can come inability to bond with or properly care for your baby or yourself. Other than the symptoms severity, the key difference between the baby blues and PPD is how long the symptoms last. The symptoms may come on gradually or rapid but always last at least 2 weeks, almost always much longer, especially until treatment is started. 

Postpartum Psychosis

Postpartum psychosis, the severest form of PPD, is luckily rare, occurring in 1 in 1,000 new moms. But she is a nasty & hateful bitch. The symptoms of PP psychosis are insomnia, mania, hallucinations, paranoia, confusion, shame, hopelessness, and thoughts or plans to harm yourself or your baby. This requires immediate and emergency medical attention. 

Is it Postpartum Depression? Relatable

I never asked for help, or really admitted it to myself, but I experienced more than the baby blues. With what I have experienced in the past few years, I probably had underlying and undiagnosed depression and anxiety already, so I don’t even know if I would call in PPD. And also with a lens of clarity and reflection, how could I not experience PPD entering motherhood with the trauma I had with my own mother, my infertility journey, and lack of motherly support and advice? I had a very hard time bonding with Kylie. I couldn’t even call her by her name for at least a few weeks. It sounded so foreign and weird. I called her “the baby”. We didn’t decide on a name until after she was born, so I always chalked it up to that, that I just wasn’t used to it yet. But I think it was more than that. I don’t think it could sink in that she was a real person and that she was somehow mine.

It did not help that I didn’t really see her for 2 days immediately post birth as she was in the special care nursery and I was still in labor & delivery on a magnesium sulfate drip that restricted me to the bed. And honestly, I was so sick I couldn’t have gotten out of the bed and really didn’t even want to. I didn’t have the desire to breast pump and start my milk supply like so many mothers worry about. For one, like I said, I was pretty down and out, but also I just didn’t really care that much.

Support, But It’s Not the Support you Want or Need

I won’t go into too many details, but Travis also took zero time off work and wasn’t at home to help me at all recover from surgery when Kylie was still in the hospital. And he wasn’t home to help me get used to caring for her when she did come home. In his defense, he was a bartender so no work = no pay. But I would have rather ate ramen and PB&J for a month than not have him there. The help he sent made me feel more uncomfortable in my own home. I already felt uncomfortable at baseline. You know, having major surgery, losing a lot of blood, have to go back to the hospital to get your incision opened and drained, you boobs are leaking, but not making enough milk for a pre-term baby, and you look like shit and feel dizzy in the shower. So the thought was nice, but did more damage than help for my mental health.

I can now realize that being an introvert and growing up as an only child, I seriously need alone time. And when you have an infant, that alone time to recharge is out the window and down the block

I’m curious on the statistics of rates of postpartum depression in women who suffered with infertility.

Postpartum Psychosis: Less Relatable

Probably the most infamous story of the consequences of PP psychosis is that of Andrea Yates, who drowned all 5 of her kids in her bathtub in 2001. I remember that story, being a bratty naive 14 year old who hadn’t developed much of a sense of empathy. I could never understand that mental illness could cause you to do something so severe and seemingly hateful and unforgivable. Now that I have suffered from pretty severe symptoms of a mental illness… or 3, I not only have sympathy for Andrea Yates and the other moms who have been victims of this sick disease, but I have empathy. I would hope my brain wires never got that crossed that I would hurt my child, who I love most in this world, but I can see how it happens.

Just like suicide. I cannot stand when people say suicide is selfish. But I know, that like I have been before, people who say and think that, just do not understand even a fraction of what someone must being going through in their body and mind to get that low. When you are in the throws of mental illness, you don’t feel selfish; it is not always about you and how you cannot deal anymore. Many times, the opposite of selfish, you believe so little of yourself that you truly come to believe the world and your family and friends are better off without you. 

In that same way, the mind can get so screwed up that you actually believe either your child was sent here to harm you and your family, or that this world is so bad and you are such a bad mother that this innocent baby would be in a better place to not be in this world anymore. Can you even imagine the pain someone must be feeling to believe those thoughts? 

The Story of Emily

I wanted to share a story of Emily from Utah that I found while doing research for this post. Emily’s story is so relatable and could happen to anyone. Emily and Eric were married for 21 years and had four children. Eric said life was wonderful, but getting into their late 30’s Emily told Eric she wanted just one more baby. In 2015 they had their 5th baby and soon after getting home from the hospital Eric could see that Emily had changed. Luckily having a supportive family, Emily was able to get diagnosed with postpartum depression and anxiety and started on medication. Things got better. But like so many do, Emily wanted to stop the medication. She felt better right? 

Any nurses know, patients do this all the time. They stop their blood pressure medication because their blood pressure is good. Well it was working! And that is why your blood pressure is now sky high. People have that same mentality with psychiatric medications. I feel better, now lets wean off these meds. And the added stigma that comes with psychiatric diagnosis and medications makes that urge extra strong. I myself have done this. And a mental breakdown later, I know I can’t think like that.

Round Two

Well of course, Emily’s symptoms returned and she had to be treated in an in-patient facility. Eric recalls after 11 nights in the treatment facility he saw his wife return. The kids saw their mother return home. Things were back; things were good… for two weeks. The symptoms again returned, so Emily took a break and spent some time with her parents.

When things seemed to feel better, Emily’s dad was driving her home. In the car, Emily suffered a severe panic attack. The panic attack was getting out of control, her dad pulled over to the side of the road and got her husband Eric on the phone. Eric heard the panicked Emily and her calm dad, trying to get control of the situation. Eric recalls, when he heard the phone drop he knew it was bad. Emily got out of the car and while panicked and spinning, she lost spatial awareness and balance and was hit by a semi-truck on the highway. 

Story Credit and Reference

We are in Urgent Need for Change

Even with the best support and treatment, as well as medications, tragedy strikes. So imagine, the women who lack resources and support. Those scared to reach out for help. Those, like Emily, that don’t want to be judged or different and don’t want to need the help. Also, knowing your resources and actually having the ability to use them are totally different things. When someone is sleep deprived, depressed, and exhausted from anxiety, do you think they have the executive functioning skills to find a psychiatric provider that might take their insurance who also is accepting new patients and actually call, schedule, then go to that appointment? Do you know the delay medications can take to fill when your insurance requires a prior authorization? These are all major roadblocks. And these roadblocks, as we can see, can be deadly. 

Our mental healthcare, well, actually healthcare period, is a sick joke in this country. USA, greatest country on Earth right? It is a disservice to its citizens. And we do an even deeper disservice to the care and expectations we give to new parents, mothers in particular. I could go on a rant about this topic for days. But I will stop myself, and explore a super popular buzzword and concept these days: self care. But is a bubble bath, at home with a baby you are worrying about and hoping won’t wake up before you get out of the bath, actually self care? And why do mothers have to care for themselves? They already care for everyone else. 

I know this stuff is heavy. Someone has to tackle the heavy and hard, because that is what so many are uncomfortable talking about and the lack of LOUDNESS on this stuff makes it easier for people and groups to ignore. 

Come Back. There’s More

In part 2, I will discuss more about treatment for these mental health disorders, caring for yourself or loved ones after having a baby, and more.

Ashley, RN

Mental Mommy Nurse