Postpartum Depression Critical Analysis

I selected postpartum depression (PPD) for my critical analysis paper because I wanted to increase my knowledge and awareness surrounding PPD. While I participated in the direct care of many individuals at high risk for PPD, the patient I selected for my critical analysis was a case that surprised me, as I felt she was not given the holistic care that she needed. My selected patient was a 38-year-old, G3P1111, who had a planned cesarean birth at 37 weeks 1-day gestation. Relevant medical history included a current diagnosis of major depression without treatment due to pregnancy, as well as a history of stillbirth in the third trimester and a traumatic past pregnancy due to preeclampsia and pelviectasis. The patient denied substance use during pregnancy, was currently employed as a teacher and had an intact support system. The patient had given birth at 0535 the day prior and was quite fatigued throughout the bedside report and morning assessment from lack of sleep. During bedside report, the night nurse for the newborn, the float pool nurse for the mother, the oncoming nurse, and I were all cramped inside the patient's room along with the spouse and the newborn. Each nurse exchanged pertinent information and the oncoming nurse asked the patient what concerns she had for the day.

The mother then discussed, in front of all us, her frustration with her lack of breastmilk production and hopelessness with the breastfeeding process. The nurse encouraged the mother to continue breastfeeding and suggested addressing the problem after the mother had some rest. After leaving the room, the nurses discussed how she was a difficult patient and was going to be trouble for the day. An hour later, the patient's physical health was assessed. The nurse again asked the mother again if she had any concerns or questions and the mother replied just as before, expressing frustration with the lack of progress amidst two prior lactation consults and bedside education from multiple nurses. She refused another lactation consult out of exasperation. The nurse did not assess psychology health at that time and instead encouraged self-care and suggested ways the spouse could help ease some stress. Later, the nurse mentioned she was worried about the mom due to her anxiety and lack of bonding with the newborn. This assessment surprised me, as the nurse had not seemed empathetic during conversations with the patient. As far as I observed, the nurse's concern was not documented or discussed with the treatment team. Later that day, the nurse had a conversation with the lactation consultant about mom giving up on breastfeeding, but I perceived the discussion to be one of complaint rather than concern.

The Edinburgh Postnatal Depression Scale (EPDS) was provided to the patient and completed. There was no discussion of the purpose of the EPDS or review of warning signs and symptoms of PPD. The only education provided concerned self-care, newborn care, and breast feeding. The nurse provided the patient with the postpartum discharge packet which included A New Beginning: Your Personal Guide to Postpartum Care. This packet contained a section on PPD, including warning signs and what necessitates the need for treatment. However, the packet did not include a printout for local psychosocial support options, although support resources for breast feeding were included. Literature Review The Association for Women's Health and Neonatal Nursing (AWHONN) released a position statement in 2015 that advises any health care facility serving women, mothers, and newborns to require policies surrounding patient education and screening for PPD. Due to the fact that health care providers, especially nurses, play a key role in PPD screening and intervention, AWHONN also suggests appropriate education, training, and referral resources are provided for staff. Not unlike general mental health disorders, PPD is diagnosed on a continuum, ranging from mild to severe.

Signs and symptoms of PPD include baby blues that are more severe and last for more than a week (sad, anxious, or overwhelmed feelings, crying spells, loss of appetite, difficulty sleeping) and thoughts of causing harm to self or baby or lack of interest in the baby (Alderman, 2016, p. 749). Mild cases of PPD can be easily overlooked, as the symptoms can reflect what most individuals expect from parenthood. While severe cases of PPD can put the lives of both the mother and the baby at risk, even mild cases of PPD can have a lasting effect on the woman's health, her ability to connect with her child, her relationship with her partner, and her child's long-term health and development (AWHONN, 2015, p. 687). Symptoms of PPD may present for up to ten years after diagnosis, placing the women at increased risk for infanticide and non-compliance with future pediatric care. Potential adverse effects for children of those affected with moderate to severe PPD include increased risk for behavioural problems by age 3-5 years, and lower mathematics grades and depression during adolescence (Meltzer-Brody et al., 2018, p.1068).

The long-lasting adverse impact that PPD can have both mother and child highlight the imperative need for early intervention and rapid-acting treatment. Furthermore, nurses are a vital part of the intervention process, as they able to help encourage, assess, screen, educate, and provide resources throughout the spectrum of pregnancy. AWHONN recommends that nurses should encourage an open environment for patients to verbalize their fears and concerns surrounding pregnancy (2015). By providing a judgment-free zone, and taking care not to dismiss or misattribute symptoms, women are more likely to open up and gain more from the intervention (Hadfield & Wittkowski, 2017, p. 733). At this time, it is important to focus on the woman rather than the infant to avoid the perception that their needs have been overlooked (Hadfield & Wittkowski, 2017). Secondly, nurses should acquire a detailed patient history upon admission and provide a thorough assessment for PPD during each stage of the pregnancy. In order to provide an accurate assessment, nurses must first be aware of risk factors for PPD as well as presenting signs and symptoms (AWHONN, 2015).

Common risk factors include prenatal depression, prenatal anxiety, child care pressure, infant temperament, life stress, lack of social support, single marital status, marital dissatisfaction, history of depression, postpartum blues, low self-esteem, low socioeconomic status, unwanted and pregnancy (Kim & Dee, 2018, p. 23) It is important to assess for potential post-traumatic stress due to traumatic childbirth, reviewing high levels of medical intervention during labor, long and painful labors, or a perceived lack of support" (AWHONN, 2015, p.687). Symptoms of PPD. One of the most concrete nursing interventions for PPD is screening throughout, pre, intra, and postnatal visits. The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used tool in the prediction of PPD. Other tools used alongside the EPDS include the Postpartum Depression Predictors Inventory-Revised (PDPI-R) which quantify PPD risk factors (McCarter-Spaulding & Shea, 2016, p. 3).

A deficit in knowledge concerning PPD limits mothers and their support system from recognizing symptoms, decreasing stigma, and accessing treatment. To help overcome this barrier, nurses should include education for patients and families on self-monitoring for symptoms of PPD at various stages (Hadfield & Wittkowski, 2017). McCarter-Spaulding and Shea suggest that education is most effective when initiated and highlighted during the prenatal period, briefly addressed before discharge after delivery, and revisited during postnatal care visits. Post-delivery is a time full of many distractions for a new mother, as she is recovering and focused on care her newborn, as a result, education about PPD during the busy hospitalization might not be an effective use of nursing time, and may reduce attention to important priorities such as infant feeding and maternal care as well as rest (2016, p. 6). Finally, nurses should be aware of local resources for the treatment of PPD and have materials ready should their patient need them (AWHONN, 2015; Alderman, 2016).

Offering printed resources may be a more effective intervention as this helps empower the individual, allowing more opportunities for control in their plan of care. Hadfield and Wittkowski found that women who felt as though decisions were made by health care professionals rather than themselves experienced greater distress than women who had voluntarily sought a referral (2017, p. 732). Recommendations for treatment of PPD are determined by the severity of the diagnosis, with both therapy and antidepressants as effective treatment options. Mild to moderate cases of PPD typically involve peer support, counseling, or psychotherapy. While moderate to severe cases may indicate both psychotherapy and antidepressant treatment (AWHONN, 2015). The current standard for PPD pharmaceutical treatment consists of selective serotonin-reuptake inhibitors (SSRIs) which are approved for use with breastfeeding, however, some argue that the ability of SSRIs to prevent post-partum depression is also unclear (Alderman, 2016; Meltzer-Brody, S. et al., 2018, p.1060).

There are new trials for PPD specific medications, with promising drugs such as Brexanolone, a rapid onset intramuscular injection, on the forefront. However, pharmaceutical treatment for PPD is not without its own barriers, as some women felt ashamed for not being able to cope on their own and stigmatized for taking medication (Hadfield & Wittkowski, 2017, p. 732). Additional barriers to generalized treatment of PPD range from transportation and for care to fear of judgment from family and healthcare providers. Furthermore, preservation of self-image can prevent some women from seeking help, as they internalized the stigma surrounding PPD. Some mothers associated PPD with poor parenting, a label that was perceived to be worse than the label of 'depressed' (Hadfield & Wittkowski, 2017, p. 732).

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