The postpartum period has been defined as “a bringing forth of the period following childbirth” (Webster, 1988, p. 1055) or “occurring after childbirth or after delivery, with reference to the mother” (Doriand, 1988, p. 1343). In nursing or medical textbooks, the postpartum period is defined as “the 6-week interval between the birth of the newborn and the return of the reproductive organs to their normal non-pregnant state” (Wong & Perry, 1998, p. 480).
However, Tulman and Fawcett’s (1991) found that the recovery of postpartum women’s functional status from childbirth takes at least 3 to 6 months. Webster’s Dictionary defines stress concretely as a “physical, mental, or emotional strain that disturbs one’s normal bodily functions” (Webster, 1997, p. 735). Stress is produced by stressors. Wheaton (1996) defines stressors as “conditions of threat, demands, or structural constraints that, by the very fact of their occurrence or existence, call into question the operating integrity of the organism” (p. 2). In addition, four characteristics of stressors are described: (1) threats, demands, or structural constraints; (2) a force challenging the integrity of the organism; (3) a “problem” that requires resolution; and, (4) “identity relevant” in threats in which the pressure exerted by the stressor, in part, derives its power from its potential to threaten or alter identities.
Further, awareness of the damage potential of a stressor is not a necessary condition for that stressor having negative consequences; and a stressor can be defined bidirectional ly with respect to demand characteristics. That is, it is possible for both over-demand and under-demand to be stress problems (Wheaton, 1996). Accordingly, based on the above definitions of the postpartum period, stress, and stressors, postpartum stress is defined as a constraining force produced by postpartum stressors.
Postpartum stressors are defined as conditions of change, demand, or structural constraint that, by the very fact of their occurrence or existence within six weeks after delivery, call into question the operating integrity of body changes, maternal role attainment, and social support. Due to its many adjustments, the postpartum period has been conceptualized as a time of vulnerability to stress for childbearing women (Too, 1997). Postpartum Period
The postpartum period has been conceptualized by a variety of cultures as a time of vulnerability to stress for women (Hung and Chung, 2001). It is characterized by dramatic changes and requires mandatory adjustments that involve many difficulties and concerns, possibly leading to new demands, or structural constraints and, therefore, stress. All mothers face the multiple demands of adjusting to changes in the body, learning about the new infant, and getting support from significant others.
For women going through this transition, it may be a uniquely stressful life experience. Several stressors specific to the puerperium as it exists in the literature have been identified. Those pertaining to body changes include: pain/discomfort, rest/sleep disturbances, diet, nutrition, physical restrictions, weight gain, return to prepregnancy physical shape, care of wounds, contraception, resuming sexual intercourse, discomfort of stitches, breast care, breast soreness, hemorrhoids, flabby subcutaneous tissue, and striae.
Stressors pertaining to maternal role attainment include: concerns about infant crying, health, development, bathing, clothing, handling, diapering, night-time feeding, breastfeeding, conflicting expert advice, keeping the baby in an environment with a comfortable temperature, bottle feeding, appearance, safety, elimination, body weight, skin, baby’s sex, breathing, spitting up, sleeping, and cord care (Moran et al. , 1997; Too, 1997).
Finally, those stressors pertaining to social support include: running the household, finances, perception of received emotional support, giving up work, finding time for personal interests and hobbies, father’s role with the baby, relationship with the husband, restriction of social life, relationship with children, and coordinating the demands of husband, housework, and children (Moran et al. , 1997). In addition, Hung and Chung (2001) shows that after childbirth women will encounter another type of stress during the postpartum period, which is characterized by dramatic changes and requires adjustment.
Conditions of change, demand, or structural constraint may occur during these dramatic changes, creating many difficulties or concerns. Therefore, in addition to general stress, postpartum stress is induced after delivery during the postpartum period. Postpartum Stress Disorder Postpartum Stress Disorder (PSD) is the most serious, least common, and most highly publicized of the postpartum mood disorders: mothers with PSD have killed their infants and themselves.
It is on the extreme end of the postpartum continuum of mood disorders (Nonacs, 2005) and attention to symptoms is vital for any postpartum support program. The treatment issues will not be fully discussed here because of their specialty and complexity. However, it remains a primary function of the service delivery to recognize symptoms and refer appropriately for specialized psychiatric care and management.
A sensitive, direct question such as, “Some women who have a new baby have thoughts such as wishing the baby were dead or about harming the baby; has this happened to you? (Wisner, et al. , 2003, p. 44), is an essential element of postpartum evaluation and Wisner and colleagues (2003) have suggested that this question be asked of all postpartum women. PSD is a rare, severe disorder with a prevalence of one to two cases per one thousand births (Seyfried & Marcus, 2003). Symptoms are abrupt and often occur within 48 hours of delivery but can be delayed as long as two years (Rosenberg, et al, 2003). Typically, however, symptoms occur within the first three weeks, and two thirds appear within the first two weeks postpartum (Chaudron & Pies, 2003).
Symptoms include mood lability, distractibility, insomnia, abnormal or obsessive thoughts, impairment in functioning, delusions, hallucinations, feelings of guilt, bizarre behavior, feelings of persecution, jealousy, grandiosity, suicidal and homicidal ideation, self-neglect, and cognitive disorganization (Wisner et al. , 2003). Women with PSD who harbor thoughts of harming their infant are more likely to act on those thoughts (Wisner et al. , 2003).
Because of the severity of the illness and significant concern for the safety of both the infant and the mother, PSD is considered a psychiatric emergency and hospitalization is necessary. Etiology of PSD There has been some debate about the etiology of PSD. As noted previously, the incidence is approximately one or two women per one thousand births. This rate has remained unchanged for that last 150 years (Wisner et al. , 2003). In cross-cultural studies the rates for PSD are similar to those reported in the United States and the United Kingdom.
These findings suggest a primary etiologic relationship between PSD and childbirth, rather than psychosocial factors (Wisner et al. , 2003). O’Hara (1997) has noted that women are 20 to 30 times more likely to be hospitalized for PSD within thirty days after childbirth than at any other time during the life span, leading him to speculate, with little doubt, that for women there is a specific association between childbirth and PSD. There are subgroups of women who may be more likely to develop stressful symptoms after delivery.
Primaparas appear to have a higher risk for c than multiparous women (Wisner et al. , 2003). This may be the result of an undiagnosed bipolar disorder. Women with a history of bipolar disorder or PSD have a 1 in 5 risk of hospitalization following childbirth (Seyfried & Marcus, 2003). The overall pattern of symptoms described as PSD suggests the illness is on a continuum of bipolar mood disorders (Wisner et al. , 2003). The clinical presentation of PSD is often very similar to a manic episode (Seyfried & Marcus, 2003).
Affective disturbances may be depressive, manic, or mixed (Chaudron & Pies, 2003). While there is no typical presentation, women often display delusions, hallucinations, and/or disorganized behavior. Delusional behavior often revolves around infants and children, and these women must be carefully assessed because thoughts of harming their children are sometimes acted upon (Chaudron & Pies, 2003). The predominant affective symptom in those postpartum women who commit infanticide, filicide, or suicide is depression rather than mania (Chaudron & Pies, 2003).
In reviewing the connection between bipolarity and PSD several studies have shown evidence for a link in four areas: symptom presentation, diagnostic outcomes, family history, and recurrences in women with bipolar disorder (Chaudron & Pies, 2003). The relationship to bipolar disorder is considered quite persuasive and it has been suggested that acute onset PPP be considered bipolar disorder until proven otherwise (Wisner et al. , 2003). However bipolarity does not account for all cases of PSD and a meticulous differential diagnosis is mandatory for those women with presenting stress symptoms.
A careful checking of the patient’s history for previous manic or hypomanic episodes as well as any family history of bipolar disorder is important in order to rule out bipolar disorder. Organic causes contributing to first onset PSD need to be examined and ruled out. These include: tumors, sequelae to head injury, central nervous system infections, cerebral embolism, psychomotor seizures, hepatic disturbance, electrolyte imbalances, diabetic conditions, anoxia, and toxic exposures (Seyfried & Marcus, 2003).
Of special consideration in postpartum women is thyroiditis. This is relatively common in postpartum women and usually begins with a hyperthyroid phase progressing to hypothyroidism. In either phase PSD can occur (Wisner et al. , 2003). Obtaining serum calcium levels is important to rule out hypercalcemia for patients displaying PSD symptoms (Wisner et al. , 2003). Sleep loss resulting from the interaction of various causes may be a pathway to the development of PSD in susceptible women (Wisner et al. , 2003).
The later stages of pregnancy and the early postpartum period are associated with high levels of sleep disturbance. This seems to be more prevalent in primiparous women than in multiparae. Historical and contemporary studies have noted that insomnia and sleep loss are significant and early symptoms of PSD. The rapid and abrupt changes of gonadal steroids after delivery and the evidence that estrogen has an effect on mood and the sleep-wake cycle (Wisner et al. , 2003) suggest an interaction between hormonal fluctuations, sleep loss, and the onset of PSD. Treatment of PSD
PSD is a severe illness and should be considered a psychiatric emergency requiring hospitalization (Rosenberg et al. , 2003). The stigma attached to mental illness and especially to mothers who may harm their infants and themselves, often prevents women and their families from seeking help. PSD is often marked with periods of lucidity that can fool those close to the mother and health care professionals. Because of the complexity of the diagnosis and treatment, referral to a psychiatric specialist is required and formal treatment is beyond the scope of this program.
However, it will be necessary to recognize symptoms and be cognizant of risk factors, such as history of bipolar disorder or previous PSD. Such awareness is essential, as is the readiness to offer support until adequate services can be implemented (Wisner et al. , 2003). Prevention of PSD is unclear, but early identification of a history of bipolar disorder and/or previous PSD would be an element of a comprehensive postpartum program. Prenatal education describing symptoms is an important aspect of a proactive approach to postpartum care.
Part of the prenatal and postpartum educational effort will include urging women to share any bizarre thoughts and fears with their health care professionals and families. New mothers experiencing insomnia will be encouraged to seek assistance from their physicians and to engage other family members to care for the infant during nighttime feedings (Wisner et al. , 2003). As noted earlier, specific treatment is beyond the scope of this program, but a proactive approach to early identification and recognition of unusual thoughts, feelings, and experiences may help to initiate treatment and avoidance of tragic results.
Conclusion During the postpartum period, women are immersed in the realities of parenting and coping with balancing their multiple roles (e. g. , wife, mother, and career woman). However, women frequently report difficulty in adjusting to the needs of the baby and other children, difficulty with housework and routines, concerns over support to cope with family needs, and concerns over weight gain and body changes. Accordingly, postpartum stress has an important role in a woman’s life and influences her health status, both physical and mental.