The Regulation of the Minister of Health of 16.08.2018—THE ORGANIZATIONAL STANDARD OF HEALTH CARE IN ENTITIES PROVIDING PERINATAL CARE—draws particular attention to the need for assessing the risk and severity of depression symptoms by the person caring for a woman during pregnancy or the puerperium. It proposes screening for the risk of depression first in the first trimester, again one month before delivery, and one month after delivery during a postnatal home visit.
In clinical settings, identifying pregnant women with risk factors allows early intervention and prevention of postpartum depression episodes. Early screening during pregnancy enables recognition not only of women at risk who have no symptoms but also of those with subclinical symptoms.
Thomas Holmes and colleagues developed the Social Readjustment Rating Scale (SRRS), which measures stress level. Pregnancy scored as high as 40 out of 100 possible points, and the arrival of a new family member—39. Both were considered only slightly less stressful than, for example, “change in the health of a family member” (44 points), “retirement” (45 points), and “reorganization of a business” (39). Childbirth, unlike many other stressors, is an exceptional event in every woman’s life—one never forgotten. Even many years later, mothers recall that moment on various occasions, such as another pregnancy in the family or among friends.
How a woman feels in the puerperium, how she finds herself in the role of a mother, and adapts to motherhood depends, among other things, on the course of her labor—whether she remembers it as a meaningful, positive experience or as a traumatic event. Birth conditions, related medical procedures, and the actions or omissions of medical staff significantly influence adaptation to motherhood.
Numerous procedures during labor, often incomprehensible to the woman, immobilization and exposure, and changing staff mean that, in addition to excitement and joy at becoming a mother, a woman often feels fear, helplessness and total dependence, humiliation, and even shame. Treating the patient as a person, respecting her autonomy, and supporting her during labor help avoid unnecessary tension and improve cooperation with medical staff. It is also important whether labor is vaginal or by cesarean section. A mother may perceive a cesarean section as a failure: “I couldn’t give birth; they did it for me…” or as a luxury: “It didn’t hurt.” Likewise, a vaginal birth may be traumatic: “I couldn’t secure a C-section…,” or a reason for satisfaction: “I managed…”.
Another source of stress for a mother of a small child is the confrontation of expectations with reality—the feeling that “this isn’t how it was supposed to be…”. Compared to the idealized, media image of happy motherhood—run by beautiful models who don’t interrupt their runway shows, with the baby and nanny backstage—or women of success who, after building their businesses, now “excel” as mothers—the average woman may conclude that she is “no good because she neither looks nor feels that way.” Therefore, it is necessary to verify one’s expectations and ideas about motherhood and the fears associated with it, and to accept that it is not only a succession of positive experiences. Sometimes, a woman fearful of motherhood is relieved to find that she is coping and that it is not as bad as she feared.
A specific and quite common problem in this period is the postpartum blues (baby blues). It occurs in about 50–80% of women, usually around the onset of lactogenesis II, peaks on days 5–6 after delivery, and lasts about 10 days to 2 weeks, sometimes up to a month. Clinically, it falls within subdepression. These symptoms generally do not seriously impair the young mother’s ability to function, but they worsen her quality of life. Motherhood does not bring the expected and natural gratifications—such as pleasure from being with the baby or breastfeeding. Mothers feel incompetent, lost, “bad,” and guilty for not fully feeling love for the infant. This condition does not require pharmacotherapy—family support is sufficient and symptoms usually resolve spontaneously. For this reason, it has not been a focus of professionals and clinicians and is often downplayed by physicians, midwives, mothers, and their families. An attitude change is needed toward this disorder, among other things because, for reasons not fully understood, a portion of women with baby blues develop full-blown depression, and early therapeutic intervention may be preventive for postpartum depression; the mother’s mental state affects the early mother–infant relationship, which is very important for later child development.
Help consists mainly of education for the patient and her family and providing support. The task of the doctor or midwife is to provide comprehensive information to the patient and her relatives about the nature of these disorders and to reassure them. Advice is usually needed on how to prevent symptom escalation and contact information for organizations dealing with this issue. The patient’s relatives should be encouraged to relieve her of duties, allow rest when the baby sleeps, and reassure her that she is a good mother. It is also worth supporting parents—especially first-time parents—in learning infant care and ensuring the help of a lactation consultant if breastfeeding problems occur. Self-help and support groups, hotlines, and online forums also play an educational and supportive role. A woman using this form of help experiences a sense of connection with other mothers, does not feel lonely or misunderstood, finds a reference group, and sometimes receives concrete advice. Sometimes a consultation with a psychotherapist—for the patient individually, the parents as a couple, or the whole family—is indicated. Postpartum blues should not be trivialized, because in some women it increases the risk of postpartum depression.
Depression is a disease that occurs more often than other mental disorders but has a clear course and symptoms and requires pharmacotherapy and psychotherapy. Depressive and anxiety symptoms can appear in various mental states, including those related to coping with a new, difficult situation such as pregnancy, childbirth, or early motherhood, and their presence does not necessarily mean depression. There is evidence of genetic predisposition in pregnant women who are first-degree relatives of women who have had postpartum disorders. Based on the assumption that psychological changes occur at the same time as hormonal changes associated with pregnancy and childbirth, many studies have attempted to demonstrate a causal link between hormonal fluctuations and mental disorders. Researchers have considered changes in gonadal hormones, prolactin, thyroid hormones, and adrenal hormones (cortisol), but results are inconclusive. Work continues on the relationship between the serotonergic system and gonadal hormones during pregnancy and after childbirth. It is suggested that the postpartum decline in gonadal hormones may cause changes in the serotonergic system in particularly sensitive or genetically predisposed patients, leading to mood disorders.
Postpartum depression occurs in 10–20% of mothers of young children and appears around the turn of the first and second months of the child’s life. It is classified as a depressive disorder with a somatic basis, emphasizing the importance of reactive, genetic, and psychosocial factors. However, postpartum depression can also affect women who previously coped well and had no major emotional problems—that is, women outside any risk group. Conversely, not all mothers in risk groups will develop depression.
A specific cluster of symptoms is observed that is directly related to motherhood and the relationship with the newborn: a sense of worthlessness in the maternal role. In all women suffering from postpartum depression, a thorough medical history and physical examination are necessary. Thyroid function must be assessed, as both hypo- and hyperthyroidism significantly affect mood.
Postpartum psychosis occurs in 0.1–0.2% of women. Onset is usually within the first two weeks after delivery. The psychopathological picture is mixed and may be acute. Contributing factors include primiparity and a history (personal or family) of mental illness. This condition usually requires hospitalization because it poses a risk to the life and health of both mother and child. In extreme situations, there is a high risk of suicide, infanticide, or extended suicide. Admission to a closed psychiatric ward (even involuntarily) may be necessary.
PTSD is an anxiety disorder occurring after a psychologically exhausting and traumatic event such as a natural disaster, accident, war, rape, or childbirth. In psychiatric diagnosis, the term is used when symptoms last at least one month; if shorter, it is called an acute stress reaction. A hallmark of PTSD is the long-term persistence of reactions after a period of symptom incubation, so PTSD symptoms may last a long time—even several years after childbirth. This diagnosis applies to women who, at the sight of a white or green medical coat, have a panic attack; cannot pass near the hospital where they gave birth; are afraid to visit a gynecologist for a check-up; overreact to situations similar to labor (e.g., in the dentist’s chair); constantly recall the birth and cannot stop talking about it; promise themselves “never again” and plan a cesarean section even before becoming pregnant. Studies clearly indicate that experienced stress may cause mental disorders. Reports indicate PTSD as a result of traumatic childbirth, where significant contributing factors were: • pain experienced during labor; • loss of the sense of control; • lack of family support (partner, parents); • lack of support from medical staff