Depression II
This time, It’s Postnatal

WARNING:  The information contained herein is not for those of nervous disposition

“IT’S BACK. And this time it’s nastier than ever...

Within every pregnancy, there is something that could strike out and serve as a chilling reminder that there is no excuse for complacency. “

For most, pregnancy and its consequences are fantastic. But it’s a fact that women suffer more mental illness and mood disturbances both before and after birth. The reasons are many: social, environmental and biological – they all have something to contribute. Some of the biggest changes in a woman’s life happen after childbirth, and adjusting to the change can be traumatic.

“Postpartum blues”
“Postpartum blues” are a form of temporary mild depression and can affect up to 80% of women between 2 and 5 days after the birth. Losing sleep, extra demands from the baby and getting all the hormone levels back to normal all play a role. One theory is that there’s simply not enough -endorphin (which produces analgesia and euphoria) around after birth. The placenta produces loads of -endorphin during pregnancy and suddenly removing it may well be similar to the withdrawal symptoms experienced by heroin addicts. The hypothalamic-pituitary-adrenal axis also has to readjust and there may be some sort of relationship with all this (yet to be discovered).

Postnatal Depression
This is bad, and can strike 1 in 10 mothers. Postnatal depression isn’t temporary and this time you can’t blame unstable hormones. According to experts, a woman may experience the most significant – and stressful – changes in her life in her first pregnancy and childbirth. Studies have shown that the women that are most likely to be affected are those that put off having kids until they’d developed their careers, and who haven’t had much contact with other mums or support from their families. Before, they were competent, reliable, independent, and emotionally stable – the opposite to the depressed stereotype. They now fall into the trap of believing that everything is their responsibility. One factor may be social conditioning of ‘female role’ responsibilities. What does this mean? Well, picture a baby (let’s call him John) who isn’t very happy and cries quite a bit. John’s mum is probably thinking ‘what am I doing wrong, what can I do differently?’ John’s dad, on the other hand, externalises the problem and says, ‘what’s wrong with the baby. What can we do to settle the baby down?’

Alcohol, smoking, nutrition and other stresses also have some part in this and depressed mums are urged to ask for help from their partner, family and friends.

Postnatal psychosis
What? There’s more? Yep, a tiny proportion of mums get severely mentally ill after childbirth – affecting an estimated 1 in 1000 deliveries. Old Hippocrates back in 400 BC even wrote it down (probably hoping it would become a best seller). Firstly, it’s idiopathic and can lead to violence like suicide, child neglect and abuse – the mum usually needs to be put into hospital to protect both herself and the child.

[For those of you who are really into this sort of thing, there are two types. The first one, occurring 3-10 days after birth, the mum suffers an agitated, confused state, often being delirious or even schizophrenic. The second type begins after the 3rd week and consists of depression, confusion and somatic complaints.]

What happens to these poor people? 70% get better after a very difficult time. Which leaves the 30% who stay at whatever level they happen to go to or go downhill to chronic schizophrenia or even dementia. For those who do get better there’s a 0.1% of relapse – but this increases to 25% if they get pregnant again. The cause is usually unknown, but may indicate a brain lesion, infection, metabolic derangement or AIDS…

“Strange… but true?”

OI, Apgar! NO!

RIGHT, time for something less depressing! The Apgar system (named after Virginia Apgar, who invented the thing) is a method used to assess the general state of baby immediately after birth. When baby is born, we look at colour and respiratory effort to check he/she has been through the respiratory and circulatory changes without problems.  If all is well, we assess the muscle tone and reflex responses. This is done one minute after birth and then again at five minutes.

A typical Apgar score sheet is shown in Fig 1.

Score	What it means	
7-10	 Well baby 	
4-6	 May need medical help 	
0-3	 Needs urgent resuscitation 	

Most babies score 8 or more after 1 minute. The causes of a low Apgar score are mostly respiratory, and oxygen must be given immediately because baby can die or suffer irreversible brain damage.  Baby can suffer hypoxia in utero due to compression, poor function or premature separation of the placenta. Drugs taken by mama during labour can also depress respiration..

Fig. 1 	An Apgar Score sheet
	Score character		
Sign	0	1	2	Score rating	
Heart rate	Absent	Slow (below 100)	Over 100		
Respiratory effort	Absent	Slow, irregular	Good crying		
Muscle tone	Limp	Some flexion of extremities	Active motion		
Reflex irritability
 (response to slapping soles of feet)	No response	Some motion	Cry		
Colour	Pale, blue	Body pink, extremities blue	Completely pink		
Scored at …	Min after birth		TOTAL:	…	

Note: The bit on postnatal depression isn’t a social pack (and neither is the Apgar scale, for that matter!)

 

“I was like a pond – the surface was calm and the water clear. At the time, my life was going smoothly and nothing was going to stop me. And then it happened - like someone throwing in a rock. For a long time, the ripples spread out across the surface of my pond, affecting everything in my life. It turned everything upside-down.”
“But the ripples settled down eventually and disappeared, right? You’re calm again – and back to normal.”
“Yes, the ripples did fade away and my pond is peaceful again. But it’s changed… I’ve changed. My pond now has a rock in it.”