Postpartum depression interview

You, the Baby, and Everything After

John Sussman, MD and Ann Douglas (08/26/03)
By Ann Douglas
John Sussman, MD
WebMD Live Events Transcript

John Sussman, MD, and Ann Douglas looked at how you might be feeling physically and emotionally as you ease into your mother role, including information on postpartum depression and dealing with recovery, weight loss, and resuming sex.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD University: "4 Weeks to a Healthy Pregnancy." Our instructors today are Ann Douglas and John Sussman, MD. Today we are talking about how you might be feeling physically and emotionally as you ease into your mother role.

Member question: How long will I be in the hospital after giving birth?

Sussman: The answer may vary depending on state law as it relates to mandatory insurance coverage for minimum length of stay. In Connecticut, where I practice, typically women spend two nights after giving birth vaginally and four nights after C-section. Some women feel well enough to home sooner and that's usually OK.
Sometimes the pediatrician wants the baby to stay a day beyond when the mother would otherwise be ready to go, and it may be possible in some cases to extend the mother's stay by one day for that reason, depending on insurance coverage.

Member question: How long does it take to recover from a C-section?

Sussman: The recovery after any major surgery is a lot longer than just the hospital stay. However, it never ceases to amaze me how quickly most women bounce back after a C-section. By the time they leave the hospital, they are taking minimal doses of pain medicine, are walking up and down the hallways at a good clip, and are able to attend to the baby's needs, though feeling somewhat more fatigued than the woman who has delivered vaginally.
The incision in the skin takes four to six weeks to heal, at which time the abdominal wall muscles will feel back to about 90% of their normal comfort level. The last 10% may take another month or two.

Member question: I heard that usually the doctor gives you an episiotomy to prevent ripping. Is this true? How long does it take for the cut to heal?

Sussman: Episiotomy, which is the name for the surgical cut that enlarges the vaginal opening prior to delivery of the baby's head, is done if the caregiver feels that a large tear will result if one isn't done. They used to be done more routinely, but today more and more doctors and midwives are avoiding them unless they feel the baby's delivery needs to be expedited because of excessive fetal stress or they believe that the woman is at an unacceptably high risk for a severe tear because of lack of room at the vaginal opening.
Most of the time this is a judgment call that is made while the baby's head is crowning against the perineum moments before it is delivered. I personally have decreased my use of episiotomy substantially in the last 10 years, and feel that my patients have benefited from less post-delivery discomfort and interruption of normal bowel and bladder function.
When I do an episiotomy or repair vaginal tears, I find that healing is generally rapid in terms of closure of the skin and underlying tissue layers, but the perineum may not be totally comfortable for activities such as intercourse for four to eight weeks and maybe longer.

Douglas: I just thought I would chime in with a bit of personal experience here, as someone who's been on the receiving end of one of those "delightful" episiotomies.
I ended up having an episiotomy with my first birth because my daughter was delivered with forceps. I can still remember how gingerly I had to sit for weeks after the fact. I perfected the art of sitting at a 45-degree angle on one bum cheek because it was too painful to sit in my regular position. So I just want mums to know that if they do end up having an episiotomy, they may wish to have a hemorrhoid cushion or extra pillows on hand to help assist with a comfortable sitting position.
With all of my other deliveries I only ended up having a tear as opposed to an episiotomy, and even though the idea of tearing kind of freaked me out, the healing process, as Dr. Sussman indicated, was a breeze, as compared to the healing after an episiotomy. I just thought I'd share my experience on this front.

Member question: Ann, how long does it take to get back on your feet after giving birth? Does it get easier or harder with subsequent births?

Douglas: That is an excellent question, and it's something that I remember wondering when I was pregnant for the first time. Of course, I'm now going to give you one of those lovely wishy-washy answers that people always dread receiving: "It depends."
If your pregnancy and your birth were relatively uncomplicated you may recover relatively quickly, but if you spent a good portion of your pregnancy on bed rest and/or had an extremely difficult birth, it may be some time before you start feeling like your old self again.
You're wise to raise the issue of the number of other children that you need to care for. At one point I had a 3-year-old, a 1-and-a-half-year-old and a newborn. Obviously, I learned to care for these three children, I just have no memory of doing so. I was up a lot in the night with the baby and busy during the day with the toddler and preschooler. The word exhaustion doesn't begin to capture it. And then you're on to other exciting stages with your kids!
When we're talking about getting back on your feet, we're obviously talking about two separate issues: physical recovery and emotional adjustment. In my experience the physical recovery is the easy part. It's the emotional transition to the challenges of motherhood that takes longer. Even though having a baby is one of life's greatest joys, it changes your life in ways you could never have anticipated ahead of time. You need time to wrap your head around the ways your life has changed.

Member question: Does postpartum depression run in families? What are your chances of experiencing and if so how long does it generally last?

Douglas: Yes, postpartum depression does run in families. In fact it might be helpful to talk about the risk factors for postpartum. In addition of having a family history of postpartum depression you have a higher than average chance of developing postpartum if you have:

• Experienced major depression in the past.
• A history of hormonal problems such as PMS.
• Difficulty conceiving or repeated pregnancy losses (something that can cause your expectations of parenthood extremely high).
• You delivered your baby prematurely or C-section.
• You have given birth to more than one baby.
• You had either a very big or small gap between pregnancies.
• You're experiencing a lot of stress in your personal life (relationship or financial problems).
• You're feeling isolated or lonely at home.
• You feel you are lacking family support.
• You've experienced the death of a parent during childhood or adolescence.

Sussman: You were asking how common postpartum depression is. According to a recent study from Sweden, postpartum depression affected 10%-20% of all mothers, and there was a 30%-50% risk of relapse in a future pregnancy.
My own experience is that the 10%-20% figure seems high, although I will confess that this condition may go underdiagnosed unless the caregiver gently draws out the patient about how she's feeling and offers enough time to pick up the pieces when she breaks down in tears.

Douglas: I think we have just one last part of your question to answer, and that is how long postpartum depression lasts. There's some good news on this front. Approximately 95% of women can expect to experience an improvement in symptoms within three months of starting treatment, and 65% will recover within a year.
The key is to pick up on the warning signs early on so that you can seek treatment, so perhaps we should run through those warning signs so that everyone knows what to look out for after the birth. I would also suggest that you share this list of warning signs with your partner and/or another family member, as they may be more tuned in to the symptoms of postpartum depression in you than you may be yourself.
Here's what to look out for:

• Difficulty making decisions.
• Feeling inadequate.
• Feeling afraid of being left alone.
• Feeling afraid of some sort of impending disaster.
• Feeling you don't want the baby.
• Feeling you want to run away.
• Experiencing panic attacks or extreme anxiety.
• Feeling your life is out of control.
• No longer enjoying activities you've always enjoyed.
• Sleep problems.
• Eating disturbances.
• Feeling helpless or suicidal.

Again, if you are feeling some of these problems, you should seek out your doctor.

Sussman: There is a very helpful tool for the recognition of those women who are at highest risk for postpartum depression. It is called the Edinburgh Postnatal Depression Scale and you can find it by typing those four words into the search window of your browser or search engine. It consists of 10 simple statements to which you answer in degrees of agreement or disagreement, and your score is tabulated.
A recent study in Minnesota showed that 11%-19% of women, based on their scores, were at risk for postpartum depression, which is in agreement with the Swedish study I mentioned before. I think you will find the self-administered test very helpful to you and your caregiver.

Member question: If you are at risk for postpartum depression, should you begin therapy before the baby is born?

Sussman: If you are depressed during your pregnancy, then you should, of course, talk to your caregiver about your therapeutic options. There are a number of antidepressants that are used safely during pregnancy, including the first trimester.
If your question is that you think that you are at higher risk for postpartum depression and are wondering if you should preemptively treat it, my advice would be to discuss this with your caregiver of course, but to avoid medication during pregnancy if you are not actually symptomatic from your depression.
Since many antidepressants take several weeks to work at their optimal level, it's possible that you and your caregiver will agree to start one of them shortly after you give birth.

Douglas: In the past few years there has actually been some new research to indicate that depression during pregnancy may be more common than postpartum depression. Unfortunately, there's a huge taboo around admitting to being depressed during pregnancy. After all, aren't you supposed to be blissfully happy about having a baby on the way?
It's really important to reach out and ask for that help if you need it, both for the sake of your own health and the health of your baby-to-be, because mums who are depressed during pregnancy face a much higher risk of postpartum depression than other mums.
The adjustment to motherhood is tough enough without starting when you're dealing with postpartum depression, so anything you can do to decrease your odds of facing such a struggle will bode well for you and your baby.

Member question: How soon after delivery can I start exercising? I don't want to have a belly.

Sussman: As far as exercise, you are generally going to be able to resume exercise sooner after a vaginal birth than after a C-section birth or if you had a difficult delivery or other complications. Some women can resume their routine within days of giving birth while others may need considerably more time.
I recommend starting with walking that you can do more briskly as your body allows. Doing this several times a week will get you ready for more strenuous exercise. There are often postpartum exercise classes at your local hospital or health club that you might consider joining. If nothing else, it's a great way to meet others who are going through what you are.

Member question: How long does it take to get rid of the weight after the baby comes?

Sussman: How much weight you lose before you even leave the hospital has a lot to do with how much weight you gained during the pregnancy. It's obvious that delivery of the baby and placenta along with the loss of amniotic fluid and extra blood volume you were carrying at the end of your pregnancy is going to lead to quite a few pounds shed before you go home.
The additional weight that you are carrying is largely the result of water retention, increased breast size, and to varying degrees, additional body fat. The water weight will probably be shed within a week or two and this will be supplemented by the continued shrinkage of your uterus. Your breast weight will probably not change dramatically until you stop nursing. The great unknown that remains is whatever body fat you may have put on during your pregnancy. This can range from literally nothing to 20 or more pounds and may take months or longer to lose, in spite of being active and eating sensibly. Some women never seem to be able to lose this added body mass.

Douglas: I'm going to take that as my opportunity to jump in because sadly I am one of those mums who still has a few pregnancy-related souvenirs from each of her pregnancies. Anyway, I just wanted to point out that there are all kinds of really great mom-and-baby fitness classes available these days. Some of them even take place outside in the park. I know there's one such group in my sister's neighborhood that involves a huge group of mums who all pop their babies in strollers and go running or jogging together. I just wanted to draw your attention to the mum-and-baby type activities because these types of activities deliver an added bonus: They allow you to make contact with other mums in your neighborhood who have new babies and have fun at the same time.
One other thing I wanted to say on this issue is that it's easy to put a huge amount of pressure on yourself to lose your pregnancy weight overnight. It took nine months to gain that weight, so you should plan to give yourself at least that amount of time to lose it again in a healthy way. In the meantime, if you can't quite fit in your prepregnancy clothes, I have some fun-fashion-after-baby tip sheets on my web site. It's called Postpartum Diva, and you can go and download a copy from my website at www.having-a-baby.com.

Member question: How long should you wait to begin having sex again? My husband really wants to know.

Sussman: You may be able to have sex within three to four weeks after you deliver when your episiotomy or other stitches have healed and you feel comfortable. It can take a little longer or possibly a little less, if you have few or no stitches. You may need a lubricant, especially if you are nursing. Of course, you'll also need to be thinking about contraception, even if you're nursing, if you don't want to get pregnant again too soon.

Moderator: We are almost out of time. Before we wrap up for today, do you have any final comments for us?

Sussman: Once again, it has been my pleasure to participate in this WebMD University with my friend and co-author Ann Douglas, and our moderator. I look forward to being online again with WebMD and invite you to check out some of the helpful links at my practice web site www.newmilfordobgyn.com.

Douglas: I know you're not supposed to play favorites, but I have to say that out of all the different online events I do, the ones I do at WebMD always seem to go the most smoothly and to attract the most interesting questions. It has been a privilege to spend the last four weeks with you, as well as the highly professional staff of WebMD and John Sussman, my highly respected co-author. I hope to have the opportunity to be invited back at some point in the future. In the meantime, I would like to wish you all the best with pregnancy, birth, and motherhood.

Moderator: We are out of time. Our thanks to Ann Douglas and John Sussman, MD, for being our instructors today, and thank you class for joining us! For more information, please read The Unofficial Guide to Having a Baby by Ann Douglas and John Sussman, MD.