By Kathleen A. Montesi, MSN, CPNP, PCE
As pediatricians and pediatric nurse practitioners, we owe it to the child to not only be responsible for the physical and emotional health of the child but also of the emotional health of the parents as well. For example, we shouldn’t hesitate to ask a mother about her mood during her infant’s well child visits. I wish someone had asked me after my first daughter, Rachel, was born because it would have made a world of difference. My feelings during the postpartum period would have been validated and my illness would have been given a name.
This is the story of my family’s painful experience with Postpartum Depression (PPD).
Mike and I have been happily married for 11 years and have two daughters. Rachel is nine years old and Hannah is seven years old. My pregnancy with Rachel was an exciting time for us. I was 31 years old and I felt great during the entire pregnancy and was even able to continue running until I was about 32 weeks.
I was 3 days past my due date when Rachel arrived. The labor and delivery was normal without any complications. I had been holding Rachel for twenty minutes when I suddenly felt as if I was going to faint. I handed Rachel to Mike and he immediately called the nurse. I was hemorrhaging, but I didn’t realize it because I had been given an epidural. My blood pressure dropped to 80/50. There was a lot of tension in the room, but the doctor was finally able to get the bleeding under control. The doctor concluded the bleeding was because Rachel was a big baby. She was 8 lb, 4 oz. I needed a transfusion two days later.
The first two weeks at home I didn’t feel well. I went back to the doctor who delivered Rachel, because I was having painful cramping and the bleeding was not decreasing. I was told my symptoms were normal. I was also crying a lot. My mom and sisters, three of my sisters have children, told me it was the “baby blues” and how hard it was to take care of a newborn.
I continued with the cramping and bleeding for another three weeks and was also beginning to feel depressed. The next time I called, I spoke to my regular OB/GYN. He ordered an ultrasound which showed a large piece of retained placenta. When I had my pre-op physical for a D&C, I mentioned to my OB that I had been feeling depressed, I was 5 weeks postpartum, and he said, “Of course you’re depressed, you haven’t been feeling well.” He didn’t mention anything about PPD and I wasn’t familiar with the illness. After the D&C, I felt like a new person. The pain and bleeding subsided and my mood had improved. I finally felt good!
But within a week or two, I started feeling depressed again and found myself crying a lot. I kept telling myself it was the baby blues and it would go away soon. After several weeks, I went back to work full time as a pediatric nurse practitioner, at a primary care clinic where I had worked for several years. Rachel was only ten weeks old, and thankfully had been sleeping through the night for a few weeks. Mike and I had decided to take Rachel to a daycare where one of our friends worked.
It was so hard for me to leave Rachel at the daycare. I cried each time I dropped her off, on my way to work, and put on a smile once I arrived. I had wanted to stay at home part-time with Rachel, but Mike thought we couldn’t afford to do that. My mood improved after a few weeks, but it was still so hard leaving Rachel everyday. I couldn’t wait to go home and see her.
I was still breastfeeding when I returned to work and pumped a few times a day. It was a very busy clinic, and between the patients and trying to find time to pump, I was feeling very stressed. I stopped breastfeeding when Rachel was four months old, which was a very tough decision. I felt like I was letting her down.
Even before I had stopped breastfeeding, I was starting to feel depressed again. I was not crying as much, but I had an underlying feeling of sadness. Mike was also beginning a new job around this time, which added to sense of stress. Mike and I have a great relationship and we’ve always been able to share our thoughts and feeling with each other. I let Mike know how I was feeling and he said it was probably the stress of the job and missing Rachel. I also talked to my mom and sisters quite often and they were also supportive (my mom and sisters had not suffered with PPD).
My depression was becoming progressively worse, and I was also experiencing mild anxiety. I had gone through a brief period of depression in college, but this was much more intense. I began to doubt my competence as a mother. My sister-in-law also had her first baby two weeks before I did. We would often get together on the weekend with her and my brother. I kept comparing myself to her. I started feeling so inadequate as a mother.
It sounds strange, but I felt as though I didn’t know how to entertain Rachel and I couldn’t figure out why I wasn’t having more fun. Mike loved playing with Rachel on the floor and making her laugh. I used to watch them and wonder why I wasn’t able to do the same thing. I felt so guilty for feeling this way and didn’t share this with my husband, because I didn’t want him to think I was a bad mother, even though I was beginning to feel like a failure as a mother. Rachel loved her baths and she would squeal and splash as I washed her. I would watch her but I wasn’t happy and I couldn’t laugh with her. I kept trying to figure out what was wrong with me and I found myself getting more depressed and more anxious.
By the time Rachel was five months old, I was feeling so alone. I kept wondering what was happening to me. Mike kept asking me what was wrong and I kept saying I didn’t know. He didn’t know how alone I felt. He was starting to get frustrated with me and he told me I would ‘snap out of it soon’. Around this time, I called my OB/GYN again and told him about my worsening depression. He didn’t ask too many questions and suggested I try St. John’s Wort. I was hoping for some relief from these feelings, but no relief was found.
The feelings of anxiety were getting worse and were more painful than the depression. I felt as if my heart was racing and I had absolutely no appetite. I had to force myself to eat and when I did, I only wanted to eat peanut butter and jelly sandwiches or cereal. I began weight. I started running again, hoping to increase my endorphins to feel better, but couldn’t run too far because my energy level was so low. I began to have difficulty sleeping.
I didn’t have trouble falling asleep, but I couldn’t stay asleep. After a while I was only able to sleep 1 ½ hrs a night! It was awful. My mind was constantly racing. I couldn’t wait to go to bed at night to escape these awful feelings. I remember going to bed, looking at the clock, and knowing in 1 ½ hrs I would be awake again, alone with my racing thoughts.
If you had met me at that time, you probably wouldn’t have thought anything was wrong. Physically, I looked fine, except for the dark circles under my eyes, but my emotional health was rapidly declining. My personality had changed drastically. Tension was increasing between Mike and me. He was used to me being a happy, positive, fun person. I’ll never forget one day when he was especially frustrated with me and he said,” I just want my wife back!” I wanted her back, too.
I longed to feel happy again. I almost forgot what that felt like. Rachel was thriving, but I still felt like a failure. At each WCC visit, Rachel’s first pediatrician was pleased with her weight gain and development. She never once asked me about my mood. I kept trying to feel those maternal feelings I was told I would have but they weren’t there and I kept saying to myself,” What is wrong with me?” I would look at pictures from my baby shower and try to remember how I excited I was as Mike and I awaited Rachel’s arrival.
In the last few weeks before I got help, I was having trouble concentrating or making decisions. I love to read and I would try to read to get my mind to stop racing, but I kept reading the same paragraph over and over again. Grocery shopping became a painful experience- I remember walking down the aisles and not being able to decide which cereal or salad dressing to choose. I thought other people were watching me and thinking I was odd, because that is how I felt. I was falling further into this awful anxiety and depression.
I was so empty inside. I felt as if I were in a hole that continued growing deeper and deeper and I couldn’t get out. I didn’t know how to escape my feelings and I didn’t know how to ask for help. I was afraid others would think I was crazy if I told them what was happening to me. I wanted someone to tell me what was wrong with me. I was so frightened and I wanted someone to take all this pain away so I could get back to my old self. I mourned my old self. I had lost interest in everything. Nothing made me happy.
The most frightening part of this illness was what actually helped me finally get the help I needed. Suicidal thoughts became part of my racing thoughts. These thoughts paralyzed me with such anxiety. I couldn’t believe I was having them. I felt like I was in a very bad dream and I couldn’t wake up from it. I carried these terrifying thoughts alone with me for about two weeks before I broke down and finally told my co-worker.
Admitting I had those thoughts was almost as scary as the thoughts themselves. I knew I had to tell Mike. He actually didn’t believe me at first. I now know he was also afraid. He finally realized I wasn’t going to “snap out of this”.
I found a psychiatrist and started on meds, and I was able to sleep again. The meds and doses had to be changed several times. It took a while, but along with the meds, exercise, prayer and lots of talking, I began to feel good again. By the time Rachel was eight months old, I began to feel like my self again. Mike, Rachel and I were finally able to enjoy being a family.
I truly believe providers are “afraid to touch” postpartum depression. There is such a short time frame for each appointment, and by asking about a mother’s mood you think you don’t have enough time. You do not have to treat the mother. However, I cannot emphasize enough how important it is to let this mom know she may have a very common and treatable postpartum illness. Consider inviting her to return for a follow-up visit or call her the next day, and refer to the appropriate resources. (Pediatricians should know that such return visits by the pediatrician for the mother can often be a reimbursable activity for most insurers. Consider checking out the following article, Role of Reimbursement. It can also be found elsewhere on this website.)
Do not deprive that mom and her infant the maternal bond, which won’t happen if she is depressed. I was deprived of those wonderful maternal feelings for six months after Rachel was born. I wouldn’t want any mother to experience the pain I went through. There is no reason any mother should have to, if we as providers educate ourselves and our patients about this condition.
Mike and I were thrilled when I was expecting again, however, my second pregnancy was very stressful. I was diagnosed with complete placenta previa and placenta accreta at 20 weeks gestation. I was placed on strict bed rest at home when I was 22 weeks, and our oldest daughter was only 21 months old. I was admitted to the hospital when I was 24 weeks after a bleeding episode and was told I would remain in the hospital until the delivery.
Our second daughter, Hannah, was born at 29 weeks, six days via an emergency C section because I was hemorrhaging. I also had a hysterectomy. She was 3 lbs, 13 oz. and was in the ICU for four weeks. She was amazingly healthy – so many prayers were offered for me and Hannah. I “should” have had a more severe case of PPD after our second daughter was born, however, my husband and I, my OB, and the girls’ second pediatrician were prepared for the possibility and probability of having PPD again. Consequently, I received treatment much earlier in the illness.
That is why I feel so strongly about the early screening and treatment of PPD. Even though my physical health was much worse during and after my second pregnancy, my second episode of PPD, albeit still difficult to go through, had about one tenth of the emotional impact on me and our family. Our increased knowledge of PPD allowed me and my husband to handle the mental stresses after the birth of our younger daughter.
Postpartum depression can occur in as many as 10 – 20% of all pregnancies. As a health professional, I can appreciate how burdened most of us feel with the tasks we already have without adding still another responsibility to our daily lives. But if you get in the habit of routinely inquiring, “How are you doing?”, you’ll be amazed how skillful you can become in picking up these problems without spending much time doing so. A few questions you might consider might include, “Are you able to sleep when the baby is sleeping?”; “Are you feeling overwhelmed?”, and, “Do you feel more sad or irritable than usual?”
The Edinburgh Postnatal Depression Scale (EPDS) is a wonderful screening tool. It consists of ten statements regarding the mother’s mood and can be completed in less than five minutes. The EPDS was developed in order to help health care professionals identify women with postnatal depression.
If we don’t pick up these problems early, our feelings of depression, no matter how disguised they may be, can last for a long time. I can recall when I gave a talk about this condition to a group of colleagues I still felt a degree of sadness even though this event had occurred for me nine years before.
For those who want to appreciate what this experience can be like for a woman so afflicted, consider getting a DVS of the film, “The Hours, “with Julianne Moore. You can purchase it for less than five to ten dollars from Amazon.com and you will understand how painful such an experience can be.
For pediatricians or nurses who want more information about PPD and the increasing opportunities for recognizing this condition, see the following books:
This isn’t What I Expected: Overcoming Postpartum Depression
By Karen Kleiman, MSW and Valerie Davis Raskin, MD
Postpartum Mood and Anxiety Disorders: A Clinician’s Guide
By Cheryl Tatano Beck and Jeanne Watson Driscoll
Postpartum Depression and Child Development
By Lynne Murray and Peter J. Cooper (Eds)
Article updated January 2009
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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center, and the families of my medical practice.
I hope you find this site useful and encourage any comments.
- Dr. Howard King, M.D.