What L&D Nurses Need to Know About Perinatal Mental Illness

Perinatal mental illness represents a serious concern for labor and delivery (L&D) nurses, a condition they must screen for on admission, watch for symptoms that might indicate a mental health problem and involve the entire interprofessional team.

“Nurses – with their emphasis on patient care and education – can provide an opportunity for pregnant and postpartum patients to talk about their emotional and mental health,” said Adrienne Griffen, executive director of the Maternal Mental Health Leadership Alliance in Arlington, Virginia.

“Simply slowing down and asking a new mother or father about their birth experience or how they are feeling after giving birth can open the door for real and meaningful conversation,” Griffen continued. “Nurses can provide a ‘verbal hug’ to let patients know that they are not alone, that many new parents feel overwhelmed and exhausted, and that help is available.”

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Mental illness a common complication of childbirth

Griffen was the lead author of a 2021 article in Health Affairs, which indicated mental health conditions are the most common pregnancy and childbirth complication, with 20 percent of childbearing people experiencing it, or about 800,000 people annually in the United States. Those diagnoses include “depression and bipolar disorder (with or without psychosis), anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, and substance use disorders.”

The article goes on to mention that parents facing racial or economic inequities disproportionately suffer from perinatal mental health conditions, and are less likely to be screened for these conditions or receive care.

Katrina C. Little, MSN-Ed, BSN, RN, LNC, LE, a faculty member at Metropolitan State University of Denver, reported greater awareness about perinatal mental illness now than in the past. She said that patients with severe and persistent mental illness, whether it developed before or during pregnancy, are at 50 percent greater risk of developing a major depressive disorder in the postpartum period.

In a position statement about perinatal mental health, Mental Health America reported that as many as 80 percent of new mothers suffer from some negative feelings or mood swings during the first few postpartum days, as hormonal changes occur. But these women do not require treatment. And as many as 20 percent of women experience depression while pregnant, according to the statement.

“People from all walks of life and lived experiences may choose to become pregnant, or because of circumstances, they find themselves in that situation,” Little said. “If they had a history of anxiety, schizophrenia or depression, that will be factored into the care of the woman.”

Awareness about perinatal mental health

“Nurses are both privileged and tasked by being the first line for assessment,” Little said.

Most facilities in the United States require L&D nurses to screen for perinatal mental illness upon admission of a patient or during triage. If the nurse finds a concern, the nurse would contact the provider, either the physician or certified nurse midwife, for an order for a consult with a mental health professional, Little said.

If the patient is not staying in the hospital, the provider and mental health professional would complete a threat assessment to determine if the woman is safe to leave the hospital or needs to remain for care.

The nurse will usually ask about thoughts of self-harm or of hurting others. If the patient answers “Yes,” the nurse would notify the primary provider and ask for a mental health consultation.

“Nurses should prepare themselves for the ‘Yes,’ Little advised, and that includes knowing the hospital protocol for what to do next.

Little indicated that during the COVID-19 pandemic many more women have said “Yes, I am not OK.” The pandemic led to a “threefold increase in symptoms of perinatal anxiety and depression,” according to Griffen’s Health Affairs article.

Griffen added that L&D and postpartum nurses often can tell some new parents are going to struggle. Signs that might indicate a more serious problem include:

• Lack of support, especially from the partner;
• Parents being upset if the birthing process is not going according to the birth plan;
• Traumatic birth, which is in the eye of the birthing person, not the medical staff; and
• The baby needing to go to the NICU.

L&D nurses and postpartum nurses also will observe how the mother is interacting with the infant after delivery, Little said. For instance, how is the mother bonding with baby, and is her affect appropriate? Does she have persistent sadness, anxiety or show a lack of interest in the newborn? Any of these issues could trigger a report to the primary provider and a mental health consult.

Management of perinatal mental illness

If the woman is already on medication, that prescriber should discuss the drug’s use during pregnancy and breastfeeding, Little said.

In the hospital, providers will weigh the risks and benefits of medication management, so it is beneficial to the mother and will pose the lowest risk of fetal harm, such as cognitive damage or being born co-dependent on the medication, said Little, adding, “It’s a fine balance.”

Resources are available to help the woman. Griffen called Postpartum Support International (PSI) the best resource. The organization provides support to new mothers and families, information about local resources and training for mental health professionals. PSI also offers the only Perinatal Mental Health Certification. Nurses can develop an expertise based on lived experience, Griffen said.

“But the most important resource is care and compassion, letting new parents know that mental health conditions are very common, that they are treatable, and that new families can recover and live normal lives,” Griffen said. “Mental health needs to be normalized and discussed, not shuffled under the rug.”

Postpartum nurses can educate the families or caregivers of new mothers about what to watch for, such as the new mother not engaging in the care the infant, avoidance behaviors, persistent sadness or anxiety, or a sense of ambivalence, which could indicate postpartum depression or postpartum psychosis. Then the caregiver can alert the provider.

Once discharged, a home healthcare nurse offers one of the best ways to identify a new mother with mental illness symptoms, said Little, who makes such visits.

Otherwise, the problems of postpartum depression or postpartum psychosis could go unidentified until the woman returns for her first post-op visit.

“Patients tend to fall between the cracks from discharge to that six-week to eight-week appointment,” Little said.

Griffen’s Health Affairs article pointed out that perinatal mental illness left untreated can lead to suicide and overdose, and is the “leading cause of death for women in the first year after pregnancy.” In addition to the human cost, untreated perinatal mental health illnesses cost the United States $14.2 billion in 2017.

Nurses can make a difference in these poor outcomes.

“Anyone can help new parents – just ask how they are doing, how the birth experience was, what they are worried about, etc.,” Griffen concluded. “It's important that everyone who interacts with pregnant and postpartum patients and their partners be sensitive to how they are doing both emotionally and physically.”

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