Disorders related to puerperium.pptx

THOMAS OWONDO
BWINDI COMMUNITY HOSPITAL
DISORDERS RELATED
TO PUERPERIUM
© 2017 Thomas Owondo. All rights reserved.

CASE SCENARIO 1.
• Loretta is a 25 year old first time mother. Her baby,
Sarah, is just four days old. Loretta was very excited
when she found out she was pregnant. She had always
wanted a baby. She and her husband, Bill, had planned
the pregnancy. Now that Sarah is here though, Loretta is
feeling down and will begin to cry when little things
happen, like the other day when she burned the cake she
was trying to make for Bill’s birthday. It feels as though
she just cannot shake the blues.

CASE SCENARIO 1 conti….
• She tries to sleep, but can’t seem to sleep when Sarah is
sleeping. She is trying to breastfeed but she is having a
difficult time with this and feels discouraged. Bill has tried
to be supportive, but Loretta thinks he doesn’t really
understand. She just feels exhausted all the time and has
become increasingly nervous and fears that she will have
to stop breastfeeding. She wonders if this is normal.

CASE SCENARIO 2.
• Francine is a 17 year old single parent who lives with her mother
and step-father. Dominique, her son, is 3 weeks old and cries a
lot. Francine’s labor was long and hard. Finally after nearly 20
hours of labor, the doctor decided to do a C-section. Francine
doesn’t remember much about Dominique during the first two
days of his life because she had an allergic reaction to the
medication she had been given. She came home when
Dominique was about 5 days old. Her mother had said to her,
“You made your bed…” Francine has never gotten along with her
step-father and has described him to her friends as abusive. She
thought she was in love with Terrell, but when she told him she
was pregnant, he left.

CASE SCENARIO 2 conti…
• She hasn’t seen him since she was about 3 months
pregnant. She is finding it difficult to get up to feed Dominique; it
seems as though she has no energy and wants to sleep all the
time. She would like to go out, but she can’t seem to motivate
herself. She doesn’t feel as though she is a very good mother
because she can’t seem to stop Dominique from crying. She has
had fleeting thoughts of suicide. She remembers when she was
15 and took a handful of Tylenol following an argument with her
step-father. At that time, she had been hospitalized for
depression. She is beginning to feel depressed like that
again. She feels all alone.

CASE SCENARIO 3.
• Mary is a 35 year old who is the mother of a four week old baby,
Peter. In the past few days, Mary’s boyfriend, Davis, has noticed
that she is behaving strangely. For example, one day when she
was playing cards with Peter, she suddenly stopped and began to
look around as if she was hearing something. Then she said that
the devil was telling her to cut her arm with a knife. One night a
week ago, Davis awoke to the sounds of Peter crying. At first he
couldn’t find Mary. Then he found her on the porch steps with
Peter in her arms singing a gospel song to herself. It was about 3
AM, it was quite cold outside, and Mary didn’t even have a
sweater on or a blanket for Peter.

CASE SCENARIO 3 conti….
• It seemed as though she didn’t even know Peter was crying or
that she was outside in the cold night air with him. Mary has also
stopped eating and she can’t seem to stay asleep at night.
• Davis has only known Mary for about a year. When they met, she
was a very happy, friendly person who worked hard. The
pregnancy had not been planned, but when they found out Mary
was pregnant, they decided to make the best out of it. Mary’s
family told Davis that as an adolescent, Mary was diagnosed with
Bipolar Disorder, although he has seen no symptoms of this and
Mary has never been on any medication to his knowledge.

• Note the above cases
• Lets begin

DEFINITION
• Perinatal- the period of time covering pregnancy and up
to roughly a year after giving birth. It's made up of two
parts:
• peri meaning 'around’
• natal meaning 'birth'
• You might have also heard terms used to describe the
time specifically before or after giving birth, such as:
• postnatal or postpartum meaning 'after birth'
• antenatal or prenatal meaning 'before birth'

INTRODUCTION
• Puerperium: is defined as the time from the delivery of
the placenta through the first few weeks after the delivery.
• This period usually is considered to be 6 weeks in
duration.
• By 6 weeks after delivery, most of the changes of
pregnancy, labor, and delivery have resolved and the
body has reverted to the non pregnant state.

INTRODUCTION
• Having a baby is a big life event, and it's natural to
experience a range of emotions and reactions during and
after your pregnancy. But if they start to have a big impact
on how you live your life, you might be experiencing a
mental health problem.
• Around one in five women will experience a mental health
problem during pregnancy or in the year after giving birth.
This might be a new mental health problem or another
episode of a mental health problem you've experienced
before. These are known as perinatal mental health
problems. © 2017 Thomas Owondo. All rights reserved.

INTRODUCTION
• During the postpartum period, about 85% of women experience
some type of mood disturbance. For most the symptoms are mild
and short-lived; however, 10 to 15% of women develop more
significant symptoms of depression or anxiety.
• Postpartum psychiatric illness is typically divided into three
categories: (1) postpartum blues (2) postpartum depression and
(3) postpartum psychosis.

CAUSES OF PERINATAL MENTAL
DISORDERS
• There are different theories about why one might develop
a mental health problem, and particularly why one might
develop it during or after pregnancy, but no-one knows for
sure.
• Some mental health problems like postpartum psychosis
or postnatal depression have clearer causes, but for many
people it may be a combination of risk factors that mean
you develop a mental health problem. These include the
following:

Risk factors
• Previous experience of mental
health problems.
• Previous postnatal illness.
• Family history of affective
illness.
• Caesarian section.
• Marital conflict.
• Mixed feelings about the baby.
• Inadequate psychosocial
support.
• Young age.
• Primigravida.
• Difficult childhood experiences
like physical, sexual or
emotional abuse.
• Low self-esteem; If your self-esteem
is low, you may doubt your ability to cope
as a new mother. When your baby cries,
for example, you may think it is because of
something you have done wrong, or
because of something you haven’t
• done. The way you think about yourself
can put you at risk of developing

Postnatal blues or maternity blues
• Also called "baby blues“ or postpartum blues is a transient
condition that 75-80% of mothers could experience shortly
after childbirth.
• Many women experience mild mood changes after having
a baby. It is common to feel many different emotions.
• Baby blues are feelings of sadness a woman may have
in the first few days after having a baby.

Baby Blues
 Not a psychiatric disorder
 Considered normal experience of childbirth
 Peaks 3-5 days after delivery.
 Symptoms may distress but typically resolve within two
weeks (lasts up to 10-14 days).
 Symptoms lasting longer than two weeks are a sign of a
more serious type of depression
 Usually don’t affect mother’s ability to function and care
for child

Causes
• The exact cause of the baby blues is unknown.
• It is thought to be related to the hormone changes that occur
during pregnancy and again after a baby is born. E.g.
oestrogen, progesterone. These hormonal changes may
produce chemical changes in the brain that result
in depression.
• The amount of adjustment that comes after the birth of a
baby, along with sleep disturbance, disruption of routine, and
emotions from the childbirth experience itself can all
contribute to the disorder.

Signs and symptoms
• Mood lability/swings.
• Tearfulness.
• Anxiety or irritability.
• Feeling separate and distant from the baby
• Insomnia
• Poor concentration
NOTE: Function is not impaired.

Signs and symptoms
• These symptoms typically peak on the fourth or fifth day after delivery
and may last for a few hours or a few days, remitting spontaneously
within two weeks of delivery
• While these symptoms are unpredictable and often unsettling, they do
not interfere with a woman’s ability to function.
• No specific treatment is required; however, it should be noted that
sometimes the blues show the development of a more significant mood
disorder, particularly in women who have a history of depression.
• If symptoms of depression persist for longer than two weeks, the
patient should be evaluated to rule out a more serious mood disorder.

Postnatal depression
• Postpartum depression may be mistaken for baby blues at first
but the signs and symptoms are more intense and last longer,
eventually interfering with one’s ability to care for the baby and
handle other daily tasks.
• Symptoms usually develop within the first few weeks after giving
birth, but may begin later (typically emerges over the first two to
three postpartum months but may occur at any point after
delivery). In some cases, symptoms may develop in the months
before childbirth.
• Postpartum depression is clinically indistinguishable from
depression occurring at other times during a woman’s life.

Postpartum Depression: Effects
Depression negatively affects:
• Mother’s ability to mother
• Mother—infant relationship
• Emotional and cognitive development of the child

Signs and symptoms
• Depressed or sad mood
• Tearfulness
• Loss of interest in usual
activities
• Change in appetite
• Poor concentration
• Suicidal thoughts
• Sleep disturbance
• Fatigue
• Feelings of guilt
• Feelings of worthlessness or
incompetence
• Significant anxiety symptoms
may also occur.

Mild Severe symptoms
Severe Symptoms:
– Thoughts of dying
– Thoughts of suicide
– Wanting to flee or get away
– Being unable to feel love for the baby
– Thoughts of harming the baby
– Thoughts of not being able to protect the infant
– Hopelessness

Causes of PPD
• Cause unclear
• Rapid decline in reproductive hormones
• Several factors increase risk

Risk factors
Risk factors for depression during
pregnancy include
• Being a very young and/or single
mother.
• Planned or unplanned pregnancy
• Having a history of mental illness or
substance abuse.
• Experiencing financial or marital
difficulties or other stressful life
events.
• Having a previous history of
pregnancy, birth, or postpartum
difficulties.
After the birth risk factors include
• Complications during labor or birth.
• Low confidence as a parent.
• Problems with the baby’s health.
• A major life change at same time as
birth of baby.
• Mixed feeling about the baby.

Treatment
• Combination of medications (antidepressants),
psychotherapy and marital therapy.

Postnatal psychosis
• Also known as puerperal psychosis.
• It is a rare event that occurs in approximately 1 to 2 per
1000 women after childbirth.
• Its presentation is often dramatic, with onset of symptoms
as early as the first 48 to 72 hours after delivery.
• The majority of women with puerperal psychosis develop
symptoms within the first two postpartum weeks.

Signs and symptoms
• Postpartum psychosis is different from postnatal
depression. It is a more severe illness.
• There are many different ways the illness can start.
• Women often have symptoms of depression or mania or a
mixture of these (bipolar).
• Symptoms can change very quickly from hour to hour and
from one day to the next.
• Risk for infanticide, as well as suicide, is significant in this
population.

Signs and symptoms in summary
• Restlessness
• Irritability.
• Insomnia.
• Rapidly mood swing
• Disorientation or confusion.
• Disorganized behavior.
• Delusional beliefs and often center on the infant.
• Auditory hallucinations that instruct the mother to harm
herself or her infant.

Causes and risk factors
• The exact causes of postpartum psychosis aren’t known.
• All women in the postpartum period experience fluctuating
hormone levels. However, some seem to be more sensitive to
the mental health effects of changes in hormones like estrogen,
progesterone, and/or thyroid hormones.
• Many other aspects of health can influence causes of
postpartum psychosis, including genetics, culture, and
environmental and biologic factors. Sleep deprivation may also
play a role.

Causes and risk factors
• While some women can have postpartum psychosis with no risk
factors, there are some factors known to increase a woman’s risk
for the condition. They include:
 History of bipolar disorder.
 history of postpartum psychosis in a previous pregnancy.
 history of schizoaffective disorder or schizophrenia
 family history of postpartum psychosis or bipolar disorder
 first pregnancy.
 discontinuation of psychiatric medications for pregnancy

Treatment
1. Admission to hospital:
Since it is an emergency, admission is priority.
2. Medication:
– Lithium started on the first postpartum day may prevent the onset of
postpartum affective psychosis
– Low doses of neuroleptics (chlorpromazine or haloperidol) are
relatively safe if breastfeeding
– Trials of transdermal oestrogen in the prevention of recurrent
postpartum
3. Psychotherapy:
– Marital therapy is frequently needed

Choice of treatment depends on:
• Type of syndrome found
• Tolerance to medication
• Breast feeding preference
• Patients previous response to treatment

Treatment
NOTE:
1. Antipsychotics (typical and atypical)
 If psychotic symptoms are present (Delusions, Hallucinations,
Agitated behaviour)
2. Mood stabilizers
 Manic symptoms (especially with a previous manic-depressive
episodes)
3. Anti depressants
 If depressive symptoms are prominent often in combination with
anti psychotics or mood stabilisers

Nursing care plan
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