Obstetric Fistula

A major depressive episode with onset during pregnancy or within the first year postpartum (most commonly within the first 6 weeks), distinct from the much more common and self-limiting "baby blues" (transient low mood, tearfulness, and anxiety peaking around day 3 to 5 postpartum and resolving within 2 weeks without treatment) and from postpartum psychosis (a rare, severe, rapid-onset psychiatric emergency with psychotic features, typically within the first 2 weeks postpartum, requiring urgent psychiatric admission).

Risk factors include a previous history of depression or other mental illness, a difficult or traumatic birth experience, poor social support, intimate partner violence, and significant psychosocial stressors.

Persistent low mood, anhedonia, excessive guilt (often specifically focused on perceived inadequacy as a mother), sleep disturbance beyond that expected from normal newborn care demands, appetite change, poor concentration, and, importantly, intrusive, distressing thoughts, which should be distinguished from the far more common and generally benign intrusive thoughts of harm coming to the baby that many new parents without depression also experience.

Difficulty bonding with the infant may be reported.

Any suicidal ideation, or, critically, thoughts of harming the infant, requires immediate, urgent assessment given the serious risk this represents.

• Edinburgh Postnatal Depression Scale (EPDS), a validated 10-item screening tool, is widely used in routine postnatal care; a score of 13 or above generally indicates likely depression warranting further clinical assessment (thresholds vary slightly by validation population)
• Clinical assessment for the diagnostic features of a major depressive episode per standard criteria (see general psychiatric diagnostic principles), specifically distinguishing from baby blues (by duration, beyond 2 weeks) and screening for any features suggestive of psychosis (which mandates emergency referral, see below)
• Screening for suicidal ideation and, specifically, any thoughts of harm toward the infant, should be undertaken directly and non-judgmentally as a routine part of assessment, given how important open disclosure is to safe management

• Mild to moderate depression: psychological therapy (CBT or interpersonal therapy, adapted for the postpartum context) is first-line, alongside practical support, peer support groups, and involvement of partner/family in care where possible
• Moderate to severe depression, or where psychological therapy alone is insufficient: antidepressant medication, with sertraline generally preferred as first-line in the postpartum period, including for breastfeeding women, given its favorable safety profile and comparatively low transfer into breast milk relative to some other agents, started at 50 mg PO od and titrated as per standard depression management; paroxetine is also considered relatively favorable for breastfeeding compatibility, though generally less preferred than sertraline as a true first choice
• Choice of antidepressant during pregnancy specifically requires balancing maternal benefit against fetal exposure risk, individualized with specialist perinatal mental health input, particularly given specific associations (e.g. a small increase in persistent pulmonary hypertension of the newborn with SSRI use very late in pregnancy, and neonatal adaptation syndrome with late pregnancy exposure) that require informed discussion rather than blanket avoidance, since untreated maternal depression itself carries significant risks to both mother and infant
• Postpartum psychosis is a psychiatric emergency: features include rapid-onset confusion, delusions, hallucinations, or severe mood disturbance with psychotic features, typically within the first 2 weeks postpartum; requires immediate psychiatric admission, ideally to a specialist mother and baby unit where available, allowing joint admission and supporting bonding while ensuring safety
• Any expressed suicidal ideation or thoughts of harming the infant require immediate, same-day psychiatric assessment and a specific, individualized safety plan, given the seriousness of these features
• Ongoing multidisciplinary follow-up involving obstetric, health visiting/community midwifery, and mental health services, given the importance of continuity of care through this vulnerable period

Referral: perinatal mental health services for all confirmed or suspected postpartum depression; emergency psychiatric assessment for any suicidal ideation, thoughts of infant harm, or features suggestive of postpartum psychosis.