8. Postpartum depression with Juli Briglio



Hello and welcome to ubiquitous evolution on your host Roberta he'll. I'm very excited to welcome Julie Briglio to this episode. Juli has a long NP career in a variety of settings, but mostly focusing on women's health. In this role, she's addressed mental health of women who are pregnant, and in their postpartum period. So, we're going to discuss this issue today. Welcome, Juli, would you begin by telling us about yourself.


I graduated with a certificate in family practice in 1999. The second graduating class after the inception of the nurse practitioner program and Ontario. At that time NP jobs in family practice were almost non-existent. My first job was in women's health. I did a five year stint a female family practice, but the OB GYN needs were so great that I was told I could only do OB GYN. So, I stayed in that position until September of 2021 when I retired.


In 2016 when I was doing some upgrading, I was asked to work with a visiting dermatologist in a dermatology clinic in Sault Saint Marie, and I still continued to work with him today. Post retirement, in the last eight months I've been working at a Nurse Practitioner-Led Clinic in Sault Saint Marie doing family practice and looking after their OB/GYN needs at the clinic.


You've been very busy, but among all the skills that you have. We're here to talk today about postpartum depression particular, but actually more broadly the mental health of women during pregnancy and postpartum period. To start, how did you become aware of mental health needs of women during this time?


Okay, if I could back up just a little bit. I thought it would be prudent to sort of talk about what the definitions are and sort those out a little bit. So, major depression, or postpartum depression, it's a shoot off of major depression and it begins about four weeks after the delivery. And it happens for a lot of reasons but mostly for the chemical social and psychological changes that happened after the birth of the baby.


Baby blues happens days after the birth sudden mood swings feeling very happy feeling very sad crying don't really know why they're crying feels impatient cranky restless anxious lonely sad. This should only last for a few hours, or up to one to two weeks post delivery. If this last longer than that, then they need some assistance so at that time they're not functioning normally they can't cope with everyday situations they have thought to harming themselves or their baby, they feel extremely anxious scared and panicked, most of the days.


So those range of emotions happen in both of those situations, but it's a persistent lasting effects that cause it to be more of a concern, and then roll into that postpartum depression stream, if you will.


So the mental health stuff. I'm not really talking about women that already have mental health issues. This is more focused on women that sort of develop these issues during pregnancy or in the postpartum period. However in saying that, women that present with depression or anxiety pre pregnancy, they are really at a high risk for postpartum depression, and should be screened, and if they already are on SSRI or SSNRIs, we really need to leave them on those medications. Okay, so for this podcast though we're talking about your average young women, you know, 18 to 35. And they have no really pre-existing disease, prior to the pregnancy.

And like many things in medicine, you won't know unless you ask, and when I took the job I thought okay I need to sort of look back and see the things I need to focus on with these women. I had to dig hard in my brain because my kids were little bit on the older side, so I thought I'd take an inventory of all my friends. There was a couple of trends when I was talking to them about their pregnancy and their birth. These were the ones that popped out to me:


· sleep or lack of

· health during the pregnancy

· partner support, or lack of

· family support, or lack of

· expectations perceived by them, by self, and by the partner: realistic versus unrealistic.

· The delivery. Was it perceived as traumatic?

· And how long it took to settle into this new life change.


And although obvious now, it really comes to light like poor sleep, lack of partner support, lack of family support unrealistic expectations of the pregnancy in the postpartum period and difficulty coping, in the pregnancy and the postpartum period were huge standouts for women

that would later develop postpartum depression or depression during the pregnancy.


And I should add anxiety as well because oftentimes anxiety is masked as depression.


So, yeah, so I found if the delivery was perceived as traumatic or invasive that postpartum period was very difficult for women to cope with. So once I started asking, I was shocked by the number of women who felt unsupported by either their partner or their family or their OB or their midwives. It was, it was very interesting and the expectations that I believe are placed on women now, especially with social media being blown up,…they had to look good they had to fake it till they made it, you know they have to post these pictures on social media I look at my bump. Here's my shower. Look at my gender reveal… like so much stress.


It's overwhelming and I found a little bit maybe two years pre COVID, I noticed a huge trend upward in mental health issues.


Oh my goodness! You say that and not only the pregnancy. You know you're sort of meant, you're the expectation is that they will have the perfect pregnancy, and be happy the entire time. And by the way, not throw up 24 hours a day for, you know, nine months, but once the baby's born it's like how fast are you going to get back into your bikini? And it becomes really, totally unrealistic. Well, I remember back in the day, adds to all the, the stress. You know, the feelings of inadequacy, the anxiety, the lack of sleep is just really, really difficult. Really difficult time for some women so then knowing all this, then what would you say are some of the key issues that NPs should be aware of when they're caring for pregnant women and women who've had children, just recently?


Yeah, I mean, postpartum depression can happen in any pregnancy. So just because you didn't have it maybe in your first pregnancy doesn't mean that you're excluded from future pregnancies of developing this. So, I took an approach where I use that Edinburgh Scale, it was my tool of choice, with every pregnancy. I would do an Edinburgh, or at least try to do an Edinburgh on every woman at their first visit. If I saw red flags throughout the pregnancy, I would introduce it at that time, and all women in the postpartum period, I would do the Edinburgh scale on. I found that to be a really good indicator, especially when you repeated it.

Because women would say ‘Well I don't think I’m doing better” but then when you would show them the score. It would be like, Oh, I guess I, I am better or, I would say “I don't think you're, you're doing better I you know I feel that we've taken a little bit of a downward spiral here, and they would say no, no I'm good and good” and then I would show them their score and it would be like, “Oh, okay”. So I found that as a, as a good benchmark.


When I saw that the woman, I always wanted to make sure the partner was with them, you know, during COVID that was impossible but, but pre COVID having the couple present at that initial appointment was huge, because we had a really good talk about relationships and changes and relationships and expectations of one another. You know, and I would say, men aren't mind readers. If you don't tell them what you need, they're never going to figure it out. You'll always be disappointed. They'll be walking on eggshells, and the relationship is going to suffer and that's not the time for a relationship to suffer this is a time when you need to support one another. So I always would want the partner to be there if they could.


And then when you're there, you could talk to the men, which I loved. The dads and you'd say you know you're an important part of this process. You're there to support her. By looking after her, you're looking after Baby. You know, and it's not just what can I do for you today it's what can I do for you throughout this pregnancy and throughout this postpartum period. And I found that the men that attended those appointments in the postpartum period.


I was always thanked by the couple, because they would say, My God, you brought to light a lot of things that needed to be done during the pregnancy and the flip to the postpartum period was simple. “I was already doing those things. I was already looking after her. I was already cooking extra meals. I was already cleaning. My job wasn't just to take a garbage.” You know, so it was, it was very rewarding in that way, as an NP, knowing that those small little conversations that I had made a huge impact on the postpartum period.


So, I really encourage all NPs to talk to the couple, as, as the couple and the family because it really, really does provide them with some insight about what's going to hit them later on, you know, as they're nine months unfold.


The other thing is to make sure that they sleep. I mean, and that was another piece when the when the partners were in the room. It was basically you know if she's tired, tell her to go to sleep. Give her permission and say, “Go sleep for 20 minutes” “Go sleep for a half an hour” You know by you sort of giving them permission to sleep, they'll do it, versus just saying I'm so tired I need to lie down because, then, for us women, we always feel guilty. Why look after ourselves? We're going to feel guilty about that right? But I always found if they get permission, especially from the person they love the most, it just goes over much better, and then the woman feel very supported and the partner feels like he's helping in some way,


Exercise, I really encourage exercise, all the way through. Even if it's 10 minutes, three times a day, I found that to be very helpful. A lot of women can't do 30 minutes or 40 minutes, you know, at 36 weeks, but small little spurts of exercise…very, very helpful not only just for physical well-being, also mental health


Prenatal classes. Your first baby, you got to do them. Encourage women to do them just so that they have an idea about what's coming at them.


Scrap the birth plan. I always found is that, and I this is from my labor and delivery days, whenever a woman had a birth plan, It never happened. So, you can have all these wonderful expectations about what you would like, or what you would like to see, but 90% of the time it just didn't happen that way. Then you just set yourself up because you feel like you failed. Meanwhile, you didn't fail. Baby tells us how they want to be born we don't have any control of that, you know? At the end of the day, all birth attendants want: midwives, OB/GYN, your labor nurse, is to have a happy, healthy mom and baby, and it's going to take whatever it takes to get there. I think that's one of the things that women need to at least have parked in their brain, you know, it's maybe I might have to have an epidural, maybe it might be a C section, maybe, maybe, maybe right.


Don't be afraid to start our prenatal patients on antidepressants if they need them. You know a lot of people are afraid to do that. Don't be. I mean, I found around 32 to 36 weeks, that's when I would see the need increase and start. We know these things take four to six weeks to work.

The worst thing we can do is wait till 38 or 39 weeks because you know in the postpartum period, it hasn't kicked in yet, and that's the hardest part of the pregnancy, if you will.


That was actually one thing I was going to ask you about. There seems to be a concern or fear of starting women on anything but we do know that the evidence supports the use, that women can take these medications safely during pregnancy, and from what you've said you have this objective measure with the Edinburgh scale. And if you note, through that and obviously discussing the women's situation with her, how she's doing, it only makes sense to treat the problem before it becomes huge issue. So I really really appreciated that piece of it. When you spoke to me. Prior when you, when you presented my class at one point about this, it was really important for them to hear that.


Yeah, oh yeah the worst thing we can do is leave an untreated depression into the postpartum depression. I've seen that spiral nasty. I always like to bring my high- risk patients back about two to three weeks postpartum just to check in on them and see how they're doing.


Oh yeah. So that was my other question then. If you know a mother’s struggling a little bit what would be a reasonable monitoring of her? How often would she come back?


I was crazy. I mean I would bring the pack every couple of weeks, I really, I really did. I just found that if I left it longer if I left it a month, it was spiralling, it was out of control.

But I found a two week interval, it was enough that you know if things were starting, I caught it. If things are getting better, I caught it. so it was, I found the two-week benchmarking a good spot.


Okay, well that's really helpful. And you know I don't want to be an alarmist or anything but not only do you want every woman to have a really fulfilling transition to motherhood or postpartum time, but there were, I mean I can think of several news stories in my during my career where mothers, you know, were suicidal during this time and harmed themselves or the babies, or killed themselves. It was very, very tragic when it could have been avoided.

So I you know that's one of the reasons why I asked you to do this talking about. So, so, so important.


That postpartum depression, it can last it encompasses the whole year after the birth.

You know, and there have been cases where women have committed suicide and their baby has been a year of age. I've seen that one postpartum psychosis, which was just devastating to see, you know, it's an undiagnosed postpartum depression that just spiraled in and, again, so sad to have that happen to anybody. Then to just watch that happen, is unbearable really, it was very, very, very sad. It's so important from what you said to keep your eyes on the mother.

It's like a friend of mine who was having her first baby was frustrated because she said: “Everybody is wanting to do this for me, to do that…they're not leaving me.” I said “Oh don't worry once the baby's born, nobody will care about you at all.” I mean that's not really true, and I was, I was joking but the tendency…


Okay, you know what? I think you're right on spot about that, you know, I find a lot of women with postpartum depression, because that shift was from mum, all of a sudden now it's on baby and there's nothing about the mother. That really I think was a factor in the development of the postpartum depression.


So one of my things you know, they bring their babies in and I, I try not to goo ga over the baby. As much as I love babies. I really make a point of focusing on the mother.


“Oh look at look at how well you're doing. Look at how well you're coping. I see that you've you know, whatever “…whatever I'm seeing in front of me. But my focus is always on the mother. Always.


And I always tell the partner you know you make sure that you don't forget about one another.

You know there is you. There's the couple, and then there's the family, and you have to always make sure that each of those parts of the relationship are addressed. And I know you were going to get into that I'll leave that one for you to ask me the question.


Well okay, well then let's just dive in. I was going to then ask, is there anything else you'd like to add about the issue?


Yeah, you know you're pregnant for 10 months, it's going to take you longer than that, you know, to get back into shape, to get comfortable with your new motherhood role, you know, don't be so hard on yourself if by six months you're not fitting into your jeans. I find women are so hard on themselves. It's crazy.


After my second child was born, she was about four or five, I looked in my closet and I had seven different sizes of clothing. Something's got to give here, true though.


I always say tell your patients to ask for help. That's the big one. You know, everyone wants to help you, but they don't know how to help you. So, unless you ask and tell them what you need, nobody's going to be doing anything except focusing on that baby. I'll hold the baby, I'll do this, but if you need help you have to speak up and say, Okay, I need some laundry done. I need some food prep. I need my dishes to be done. Can someone clean my house? You have to give permission for your family and friends to do those things no one's just going to walk into your house and start doing your dishes. So you know you give them permission and they're going to be all over it. Yeah they want to do things.


Another one is leave time for themselves and I started you know alluding to that.

Sleeping, showering and eating doesn't count. Those are those are baseline. See you know was so what did you do for yourself, you know, in the last week. “I had a shower.”


Oh my goodness.


Self care isn’t that. It’s not showering and eating and sleeping. It's, you know, do something fun do something that brings joy back to your life. You're an important part of this family and you have to take care of yourself and if you don't take care of yourself, the rest of the parts of the family are going to fall apart because you are, you know, sort of like the rock there, and your rocks going to crumble if you don't take care of you.


I always say, if you feel resentment, that means you're lacking self- care. And I always say look at your partner. They're a very good example of looking after themselves. You know we always want to you know give that the partner a kick and say well he still goes to hockey still, you know meets up with his buddies on Wednesdays. What's wrong with that? Yeah. What is wrong with that? We should be looking at that and saying, no, that's self-care why am I not doing that? And when I go out with my friends why do I feel guilty? No, there should be no guilt. That’s self-care. Do the things that bring you joy.


Loneliness when surrounded by family and friends is a huge red flag for depression. So you have all these people, all in your life, all wanting to help you and you feel lonely. Yikes. That is a huge red flag. Realistic expectations about yourself, the baby, your partner. You know you got to know there's going to be some good days and there's going to be some bad days. There's going to be days when you're in your pajyamas all day, and you're going to wonder what did I do today, and it's probably nothing.


Showers i think but oh my gosh. The other one is limiting your visitors, you know, you only want especially in the beginning for the first six weeks. If you don't want those people to ever see you un showered, your hair messy and you and your underwear, they should not be in your home.


Those are good benchmarks.


You’re going to feel a little better you will and you know you'll, you'll want to open up those doors and have, you know, more friends come and visit, but those first six weeks, Yowza, you’re healing physically, mentally, emotionally in a huge way. Bigger than what you even could imagine. Because until you experience it, you're not really going to understand it. It's like anything else right? Unless you experience, say for example, death, you don't know what grieving is, you know.


So it's kind of like that you're grieving your old life in a way. You really are, because it's such a huge change. So once you get past the physical healing, then there's that whole emotional piece that “I can't do what I used to do”. My life's a whole different way and it's in a way that you just couldn't even imagine until you're walking it.


The other thing is birthing is not a disease.

Yeah.


No, you're right.


it's just it's not a disease, and I mean the minute we stepped foot in that hospital we feel sick.

I don't know why, but we just feel sick. But we shouldn't be. I mean, we should, you know, bring our pajyamas and have our own stuff that's personal to us. When you pack your bag, make sure you pack all your stuff that you can throw away, disposable slippers, disposable toothbrush, the night gown that you thought was going to be beautiful and look nice and be useful and work, No. Get the kind where the breast can just fall out.


And again, people shouldn't be visiting unless you're okay with them seeing you naked so you know don't.




That's right.


Limit the visitors.


That's so true, and a huge, huge, huge caution about social media. There will always be somebody who posts out there three months old who sleeps through the night and eats and is potty trained. You know people are going to do that and it just may not make you feel better.

That's right. Yeah, and I mean there's so many good supports out there. Tap into those supports because, especially for your first baby… your second baby seems to be a little bit different, you've done this before you know you know what you need to do, etc. etc. That first baby, the pressure to be perfect is awful. It's just awful.


It is what it is I always say that “it just is what it is.” Every baby is different. Every personality is different. You'll have those and see through the night and then they'll have those that just don't. You're up every you know, two to three hours. It’s just what it is. Yeah, the newborn period is very challenging.


Oh my goodness. It certainly is. And I, that's why I so appreciated that you were interested in coming to have this little chat with me today because I think it's so important to be reminded of caring for the mother, and particularly her mental health and her, her transition into motherhood, or her transition to having multiple children. Either way every birth experience is different, every postpartum is different. So we can't lose track of the fact that the mother has to be the central focus of this little adventure because without her being strong and healthy it's not going to be a good thing for that family.


No, and it's been proven that you know, women that suffer from postpartum depression, those babies, the cry more. they're just more stressed. It has detrimental effects. So, we

really, really need to look after our mothers, you know I always say, back in the day, You know pre…I don't know, 1980s I would say, there was some more family support. You know, it wasn't uncommon for all the women to just be with that mother, all the time, and supporting her.


Something has to be said for that and we'd like that, you know, we have the women had have no family support you know the family is overseas or their families are cities away 8-10 hours away. And it's hard on those women that don't have you know their mothers. I always say you need your mother about that you just you need your mother. Whether that mother be your sister, your mother be the mother- in- law your mother be an aunt, whatever that mother figure is for you. You need her.


I tend to agree. I mean, it's all the art part of the art and science of being a nurse practitioner and. And I think you have that in spades. You have it all so thank you so, so much for this, this has been wonderful.


Oh, thank you for having me. I love talking about women's health. Anytime, Anytime.

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