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Psychiatric Consultation to the Postpartum Mother

Psychiatric Consultation to the Postpartum Mother

Reasons for consultation to psychiatry by percentage of total consultationsTABLE. Reasons for consultation to psychiatry by percentage of total c...
The consultant’s approachThe consultant’s approach

Increased psychological vulnerability, maternal capacity, and the choice of psychiatric treatment during breastfeeding are concerns specific to mothers during the postpartum period. Because caring for a newborn requires a substantial level of psychological functioning, the psychiatric assessment of a new mother includes observation of her behavior with the infant. The consultant generally has one visit in which to address all questions from the primary team.

Here, we examine the potential areas of concern underlying the most common reasons for consultation. We also provide a practical approach to differential diagnosis and treatment.

Reasons for consultation

Six retrospective chart reviews list the most common reasons for inpatient psychiatric consultation to postpartum patients.1-6 Because these studies used different terminology, we provide consolidated groupings of the reasons for consultation in the Table.

In one retrospective chart review (N = 96), the most frequent reason for referral was a report of past psychiatric illness without current symptoms, specifically “because they were deemed to be at risk of postpartum depression.”3 That study is supported by results reported in an abstract (N = 165) that showed 42% of all psychiatric consultations from the obstetric service were for past psychiatric illness alone, without current psychiatric symptoms.7 There is currently no consensus on whether consultation in the absence of symptoms is useful for health preservation or is a non-productive use of resources.

Past psychiatric history and maternal capacity. Underlying many psychiatric consultations for postpartum mothers is the question of maternal capacity (ie, the ability of the new mother to care for her newborn). The generally accepted standard is minimal capacity, not optimal parenting.8

The most useful information comes from observation of the mother’s behavior with the child, by both the consultant and the nursery staff. For example, a schizophrenic patient may be organized and appropriately attentive to her newborn and may have maternal capacity. However, the mother’s attitude is also important. A disengaged or hostile attitude toward the infant, especially in the setting of previous abuse or the removal of other children by child welfare authorities, signals a higher risk of a poor outcome.8

We recommend the following steps:

• Observe the mother with her infant

• Ask her and her partner about her attitude toward the pregnancy

• Evaluate stressors and supports

• Assess the family, especially for members who could monitor the mother and/or take over primary caretaking of the infant if necessary

• Ascertain the mother’s level of insight into her psychiatric illness, as low insight signals the need for more intervention

A determination of lack of maternal capacity should prompt the involvement of child welfare services.

Current depression symptoms. In evaluating current depression symptoms, the consultant must differentiate between maternity blues, which occurs in up to 80% of mothers, and postpartum depression.9 While a case of the blues is self-limited, untreated perinatal depression can have devastating sequelae, such as adverse birth outcomes; impairments in the child’s growth, attachment, and cognitive and emotional development; and elevated risk of maternal suicide.10-12


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