associates1I found thyroid di. 11% of 238 post-partum wor yet my survey found none. O0 the 16 women in the study b) and colleagues had typical sy and seven ...
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Ellen Wiebe, MD, CCFP
Post-partum Misery: A Family Physician's Perspective RESUME
SUMMARY
On a procede a un audit des dossiers de 106 femmes A chart audit of 106 women after delivery accouchees consecutivement dans le but de decouvrir was undertaken consecutively to discover le type de problemes et leur extension vecus par les the extent and type of problems they femmes au cours des six premiers mois apres un encountered during the first six months after accouchement. Trente-quatre pourcent de ces childbirth. In 34% of the charts, no dossiers ne contenaient aucune plainte. Les complaints were noted. The most common problemes les plus frequemment notes furent les infections non obstetricales, la fatigue et la lombalgie, problems were non-obstetrical infections, alors qu'on a note moins frequemment les fatigue, and back pain, while hemorrhoids, hemorrhoides, la dyspareunie et la depression. dyspareunia, and depression were noted less often. (Can Fam Physician 1990; 36:1285-1287.) Key words: family medicine, obstetrics, post-partum depression, parenting, psychiatry
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Dr. Wiebe, a Fellow of the College, is a Clinical Instructor in the Department of Family Practice, University of British Columbia, Vancouver. Requests for reprints to: Dr. Ellen Wiebe, Clinical Instructor, Department of Family Practice, University of British Columbia, 1305-750 W. Broadway, Vancouver, B.C. V5Z 1J3
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haps to learn how to help my patients more.
Method
The practice is an urban solo family practice in the centre of Vancouver. The computer printout from the provincial medical insurance plan for 1985 to 1987 showed that 58% of the patients were women between 15 and 44 and that 8% were infants younger than one year. A retrospective chart audit was perHAVE BEEN IMPRESSED over formed of all 106 women delivered bethe years with the sheer quantity of tween December 1, 1984, and Decemmisery I see in the new mothers in my ber 31, 1987. The usual pattern of folpractice. This contrasts sharply with my low up was office visits at 10 days, three personal experience as a mother of weeks, six weeks, two months, four three, and it seemed to me that these months, and six months. At these visits women should have been experiencing both the infant's and the mother's charts joy, not misery. I also felt inadequate as were in the examination room. Other a physician because they did not enjoy than the six-week Pap test, no formal their healthy new babies as much as I screening of the mothers was perthought they should. formed. General questions were used, I decided to do a chart audit of my such as, "How are you managing?" or practice to see of what exactly these "Are you feeling back to normal yet?" women complained and then to review Complaints were noted and diagnoses the literature to compare my findings of, for example, depression or bronchiwith those of others. I hoped to under- tis were made on clinical grounds. Hosstand this phenomenon better and per- pital charts were not reviewed. CAN. FAM. PHYSICIAN Vol. 36: JULY 1990
Results The study population was a relatively stable group. Only two women had data unavailable, and four had less than six months' data. All of these patients had left the practice (Table 1). There were a total of 24 obstetrical (Table 2) and 72 non-obstetrical problems (table 3) in the 70 women for whom any problems were noted. The most common complaints were related to non-obstetrical infections, fatigue,
and back pain. Table 1 Demographics of Women Studied
Characteristics Average age Range of ages Para 1 Para 2 Para 3 Para 4 Data for < 6 months
No. (N = 106) 28 15-39 60 33 11 2 6 1285
Discussion A retrospective chart audit has the advantage of showing what problems actually prompted patients' visits to a family physician in the office but misses all the conditions that patients do not complain about or that the physician does not chart. This may emphasize the problems that most concern the patients themselves. I could find no comparable study in the literature. Each research paper on post-partum care looked at only one narrow area. My obstetrical infection rate appears low, but it reflects only infections that were still a problem after discharge from hospital. Most studies of post-partum infections looked at hospitalized patients. Pelle and associatesl found a 6.6% wound infection rate after Caesarean section. Mastitis is seen in approximately 2.5% of mothers who breast-feed their in-
only information available on all types of post-partum infection wass that of Passmore and colleagues,7 wIho found that 16% of hospitalized pos t-partum women received antibiotics. Fatigue Fatigue has not been studiied separately. Much of it could be c aused by sleep deprivation. Studies slt-now tnat short-term sleep deprivation actually improves depression,8 but dlecreases performance.9 A study of first--year residents indicated that they had dlecreased short-term memory and increaised hostility after a call night.10 Fatigue could also be relat4 ed to depression, anemia, or hypothyrcaidism. I did not diagnose any post-parvtum thyroiditis during this period. Nilkolai and associates1I found thyroid diisease in 11% of 238 post-partum wornen, and yet my survey found none. O0 nly 10 of the 16 women in the study b)y Nikolai and colleagues had typical syrmptoms, and seven of those 10 belie)ved their symptoms to be normal for recovery from pregnancy. It is possible that this condition is of little clinical significance. It is also possible tha,t women who could benefit from therap)y are being missed because they vvere not screened for the condition. 4 Certainly post-partum fatigue is both common and debilitating. Back Pain Back pain is common duiring and after pregnancy. A prospective study of
862 pregnant women found that half of them complained of back pain. Nine per cent had severe disabling back pain, and in 65% (two of three) of these the pain persisted for a mean offour months after delivery.'2 My finding of 8% with back pain fits with this information.
Depression Most of the studies on post-partum depression have much higher incidences than mine. Cox and associates 13 found severe post-partum depression in 13% and mild post-partum depression in another 17% using Goldberg's Standardised Psychiatric Interview. Paykel and collegues14 found mild symptoms in 20% using the Raskin Three-Area Depression Scale. Is my clinical judgement not adequate in finding the depression; are they overdiagnosing; or are my patients less depressed? The populations studied by Cox and associates'3 and Paykel and colleagues14 were hospital clinical patients. Because lack of fants.2'3 social support, 14,17 increased stress,18 Hemorrhoids, episiotomy pain, and and previous psychiatric diagnosis'9 indyspareunia are obviously related to the crease the incidence of depression, it is physical trauma of childbirth, and I had possible that my patient population may stopped doing routine episiotomies4 bebe less at risk and have less depression. fore the study period. The standarized depression screens inPatients did not complain of declude items that could be irrelevant in creased sexual desire or coital infrepost-partum women, such as sleep disquency. It could be that I did not ask the turbance and somatic symptoms. On the right questions or that it was not perother hand, women diagnosed by stanceived as a problem. Decreased libido dard screens have significant morbidity, may have been part of the issue for the with halfofthem recovering within only 5% who reported relationship probadverse one with the year,18 consequent lems. affects on their marital relationship13 and their children.20 Non-obstetrical Infections There are simple screens for The high rate of non-obstetrical Table 3 N Problems oted Non-obstetrical post-partum depression,13'21 and perinfections in this survey is interesting; it should start giving doctors haps family could be related to the high stress level (N = 106) No. Problems ( at the six-week them to women the during post-partum period. Many After Delivery check-up visit to increase the detection studies describe the possible effects of rate. 36 stress on the immune system.5'6 The No problems noted infections (n = 21) Conclusion 7 Vaginal or cervical Table 2 My general impression of the misery Furuncle or absess Obstetrical Problems Noted in my post-partum patients was borne Bronchitis out by the comments in my charts. My No. (N = 106) Problems Sinusitis review of the literature revealed reports After Delivery Gastrointestinal of significant morbidity in the post-par36 No problems noted Other tum period, but with apparently signifi4 Mastitis cant differences from a primary care 20 F-atigue Wound infections population. I do not believe family 9 Back pain 2 after Caesarean section physicians need to start screening for Headache 6 Dyspareunia post-partum thyroiditis (except in paDepression tients with prolonged fatigue) because I 6 Hemorrhoids discord 4 Relationship am not convinced that transient thyroiEpisiotomy pain ditis is symptomatic. Routine questionOther abdominal (including 1 Breast pain pain, rashes, constipation, ing about sexual dysfunction at six 1 diabetes mellitus Urinary retention weeks might be useful. 1 286
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I do believe that the discrepancy in the numbers of patients I diagnosed with depression and the number found on screening tests is significant, and I recommend that family physicians do screen for post-partum depression at the six-week check-up visit. The literature on post-partum illness is limited, and further prospective studies in primary U care settings would be useful.
Acknowledgements I thank the Family Practice Research Support Group of the Department of Family Practice at the University of British Columbia and, in particular, Dr. Robin Percival-Smith.
13. Cox JL, Connor Y, Kendell RE. Pro- post-partum depression. Child Dev 1986; spective study of psychiatric disorders of 57:1507-18. childbirth. Br J Psychiatry 1982; 18. O'Hara MW, Rehm LP, Campbell SB. 140:111-7. Predicting depressive symptomatology: 14. Paykel ES, Emms EM, Fletcher J, et al. cognitive-behavioral models and postparLife events and social support in puerperal tum depression. J Abnorm Psychol 1982; Br J Psychiatry 1980; 91(6):457-61. depression. 136:339-6. 19. Cox JL, Holden JM, Sagawsky R. De15. O'Hara MW, Rehm LP, Campbell SP. tection of postnatal depression. Br J PsyPostpartum depression: a role for social net- chiatry 1987; 150:782-6. work and life stress variables. J Nerv Ment 20. Wrate RM, Rooney AC, Thomas PF, Dis 1983; 171(6):336-41. Cox JL. Postnatal depression and child de16. Cmic KA, Greenberg MT, Ragozin AS, velopment: a three year followup study. BrJ Robinson NM, Basham RB. Effects of stress Psychiatry 1985; 146:622-7. and social support on mothers and prema- 21. Ancill R, Hilton S, Carr T, Tooley M, ture and full-term infants. Child Dev 1983; McKenzie A. Screening for antenatal and 54:209-17. postnatal depressive symptoms in general 17. Cutrona CE, Troutman BR. Social sup- practice using a microcomputer-delivered port, infant temperment and parenting questionaire. J R Coll Gen Pract 1986; self-efficacy: a mediational model of 36:276-9.
References 1. Pelle H, Jepsen OB, Larsen SO, et al. Wound infection after Cesarean section. Infect Control 1986; 7(9):456-1. 2. Marshall BR, Hepper JK, Zirbel CC. Sporadic puerperal mastitis: an infection that need not interupt lactation. JAMA 1975; 233:1377-9. 3. Helville MC, Neifert MR, ed. Lactation: physiology, nutrition, and breastfeeding. New York: Plenum Press, 1983:334. 4. Reamy KJ, White SE. Sexuality in the puerperium: a review. Arch Sex Behav 1987; 16(2):165-86. 5. Jemmott JB, Locke SF. Psychosocial factors, immunologic mediation, and human suseptibility to infectious diseases: how much do we know? Psychol Bull 1984;
95(1):78-108. 6. Risenberg DE. Can mind affect body defences against disease? Nascent speciality offers a host of tantalizing clues. JAMA 1986; 256(3):313. 7. Passmore CM, McElnay JC, D'Arcy PF. Drugs taken by women in the puerperium: inpatient survey in Northern Ireland. Br Med J [Clin Res] 1984; 289:1593-6. 8. Holsboer-Trachsler E, Ermst L. Sustained antidepressive effect of repeated partial sleep deprivation. Psychopathology 1986; 19(suppl 2):172-6. 9. Downey R, Bonnet MH. Performance during frequent sleep disruption. Sleep 1987; 10(4):354-63. 10. Hart RP, Buchsbaum DG, Wade JB, et al. Effect of sleep deprivation on first-year residents' response times, memory, and mood. J Med Educ 1987; 62:940-2. 11. Nikolai TF, Tumey SL, Roberts RC. Postpartum lymphocytic thyroiditis: prevalence, clinical course, and long term follow-up. Arch Intern Med 1987; 147:221-4. 12. Berg G, Hammar M, Moeller-Nielsen J, Linden U, Torbald J. Low back pain during pregnancy. Obstet Gynecol 1988; 71(1):71-5. CAN. FAM. PHYSICIAN Vol. 36: JULY 1990
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