The psychiatry of the postpartum period The normal puerperium

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For many or most mothers, giving birth is one of the supreme moments of their lives, and euphoria or elation is common. Some may be too excited to sleep. These feelings of peace, fulfilment, and accomplishment help to sustain mothers during the weeks of strain that follow. Prolonged euphoric reactions, lasting a week or more, are probably mild puerperal mania, and are often followed by depression.

Newly delivered mothers have to face a number of challenges, including the following.

• Physical exhaustion This can be coupled with the painful sequelae of pelvic trauma.

Breast feeding Although this has many advantages, it is often difficult to establish.

Insomnia Sleep deprivation is a cause of irritability, and should be borne in mind when mothers present 'at the end of their tether'.

• Recovery of normal figure and attractiveness This may be threatened by weight gain and stretch marks.

• Loss of libido Episiotomy and vaginal trauma often cause dyspareunia; nevertheless sexual relations are usually resumed within 1 to 3 months, though reduced in frequency, and with a delayed return of orgasm. For this and other reasons (e.g. jealousy) the marriage may come under strain.

• Social privation The loss of employment, income, and leisure, as well as confinement to the house and boredom, are all contributory factors.

With this background of rapid biological, social, and emotional transition, it is not surprising that a wide variety of psychiatric disorders occur; indeed the psychiatric complications of childbirth are more numerous and complex than in any other human situation.

The maternity 'blues' is so common as to be almost normal. About half of all mothers experience a brief period of dysphoria, usually lasting for a few hours and occurring between the third and fifth days. These mothers become sensitive to minor rebuffs, and are surprised and puzzled by their uncharacteristic weeping; thus its essence is not depression, but a sudden, fleeting, and unexpected mood change. The literature was reviewed by Kennerley and Gath, (42,43> who also devised a scale. Maternity blues has been observed in different countries and races, including Tanzania, (44) Jamaica/45 and China; however, it is less common in Japan.(46> It is statistically associated with neuroticism, trait anxiety, and depression in late pregnancy. There have been a considerable number of laboratory studies, but without a general consensus on the findings. Although a greater fall in progesterone was found in one study, (47) perhaps the most consistent finding is a reduction of noradrenaline (norepinephrine) levels in the urine or the serum. In the great majority of mothers this reaction passes off within a few hours, or a day or two. There is some evidence for an association between this brief dysphoric reaction and later more prolonged postpartum depression.

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