Postpartum Blues

Postpartum blues are a common, transient, self-limiting mood disturbance in the first 2 weeks after childbirth, affecting 50 to 80 percent of new mothers (often described as the baby blues).

• Onset typically between day 2 and day 5 after delivery, peaking around day 5, resolving within 10 to 14 days without treatment.
• Pathophysiology is thought to relate to the abrupt fall in oestrogen and progesterone after delivery, sleep deprivation, physical recovery, role change and hormonal sensitivity.
• Risk factors: history of premenstrual dysphoric disorder, previous depression, family history of mood disorder, anxiety in pregnancy, a difficult labour or caesarean section, low social support. A severe course or longer duration signals postnatal depression.
• Distinguish from:
  • Postnatal (postpartum) depression: affects about 10 to 15 percent, persists beyond 2 weeks, with pervasive low mood, anhedonia, fatigue, sleep disturbance beyond infant care, guilt, poor concentration, and appetite change.
  • Postpartum psychosis: occurs in 1 to 2 per 1000 births, onset within 2 weeks usually in the first days, with mood elevation or depression, confusion, hallucinations, delusions, insomnia, and risk of harm to herself and the infant; a psychiatric emergency.
  • Postpartum anxiety, obsessive compulsive disorder, thyroid dysfunction (postpartum thyroiditis), anaemia, sleep deprivation.

• Tearfulness, mood lability, irritability, anxiety, sadness, feeling overwhelmed, difficulty sleeping beyond the infant's demands, poor concentration, fatigue, oversensitivity; usually able to care for the baby and enjoy moments with the infant.
• No persistent functional impairment, no psychotic features, no suicidal intent.
• Examination: mental state, vital signs, wound and lochia, breast and feeding, thyroid, pallor.
• Red flags: low mood or anxiety lasting longer than 2 weeks, thoughts of harming herself or the infant, hopelessness, severe insomnia not due to infant care, confusion, hallucinations, delusions, extreme agitation, inability to care for self or baby, rapid mood swings with elation, previous postpartum psychosis or bipolar disorder, substance misuse, suspected abuse.

• Clinical assessment with direct questions about mood, sleep, anxiety, bonding and thoughts of self-harm or harm to the baby; Edinburgh Postnatal Depression Scale (score of 10 or more suggests possible depression; 13 or more probable; item 10 asks about self-harm and a positive response needs same day assessment).
• Bloods only if indicated: thyroid function (postpartum thyroiditis), full blood count and ferritin, glucose, vitamin B12.
• Screen again at 2 weeks and 6 to 8 weeks postnatally.

• Reassurance and explanation that these symptoms are common and temporary, with no stigma.
• Practical support: rest and sleep protection (partner or family share night feeds, sleeping when the baby sleeps, one 4 to 5 hour sleep block), nutrition, hydration, gentle exercise (walking), visitors limited, sunlight, help with household tasks, peer support groups, breastfeeding support.
• Follow up by midwife, health visitor or doctor at about 2 weeks.
• No drug treatment is needed for blues alone.
• If symptoms persist beyond 2 weeks or meet depression criteria: psychological therapy (cognitive behavioural therapy, interpersonal therapy) for mild to moderate cases; sertraline 25 mg orally daily for 1 week, increasing to 50 mg daily, and titrating to 50 to 200 mg according to response after 2 to 4 weeks (preferred antidepressant in breastfeeding because of low infant exposure); review at 2 weeks and then monthly; continue for at least 6 to 12 months after remission. Paroxetine 10 to 20 mg daily is an alternative with low infant exposure. Avoid fluoxetine and citalopram where possible when breastfeeding because of longer half life and higher infant levels. Screen for bipolar disorder before starting an antidepressant.
• Severe depression, psychosis, or suicidal ideation: same day psychiatric assessment; admission to a mother and baby unit if available; antipsychotics and mood stabilisers (specialist), electroconvulsive therapy for severe cases; never leave the mother alone with the infant if there is risk.
• Women with a previous history of postpartum psychosis or bipolar disorder: preventive plan before delivery, close postnatal monitoring.
• Safety advice: seek help urgently if she has thoughts of harming herself or the baby; emergency numbers and helplines; involve partner and family.
• Review at 2 weeks, 6 to 8 weeks, and 6 months.