Evidence-Based Postpartum Care

Postpartum depression (PPD) occurs in the first year after pregnancy, but oftentimes mothers do not recognize the symptoms and if they do, may feel uncomfortable talking about their feelings with a healthcare professional.

University of Louisville Hospital (ULH), Louisville, KY, wants to change this trend through a new evidence-based policy created by a team of direct care perinatal nurses.

Led by M. Cynthia Logsdon, PhD, APRN, FAAN, professor, University of Louisville School of Nursing, and associate chief of nursing research, ULH, and her team, the initiative offers guidelines for hospital-based perinatal nurses in caring for women with a risk of PPD.

Educating Caregivers

Many hospitals lack comprehensive perinatal patient PPD assessment, education and referral policies, according to Logsdon. Previously published guidelines do not focus on the first days after birth and so the ULH team worked to fill in the gaps.

Logsdon worked alongside Diane Eckert, BSN, RN, clinical manager, mother-baby unit, ULH, and Roselyn Tomasulo, MSN, RN, perinatal educator to develop the policy, “Identification of Mothers at Risk for Postpartum Depression by Hospital Based Perinatal Nurses,” published in The American Journal of Maternal Child Nursing.

Two international nursing experts on postpartum depression, Drs. Cheryl Beck (University of Connecticut) and Cindy Lee Dennis (University of Toronto) were co-authors of the manuscript.

“The guidelines provide perinatal nurses with the tools to teach new mothers how to self-monitor for PPD and what they should do if they experience symptoms,” said Logsdon. “Nurses must feel prepared and confident in their role as patient educators.”

Optimal patient care depends not only on a caregiver’s knowledge, but also his or her comfort level with communicating that information to the patient.

“We first conducted a research study in which we looked at how comfortable our nurses feel in teaching patients about PPD,” said Logsdon. “Most did not feel very comfortable due to a lack of recent and/or formal education.”

Following the study the ULH team began to build the policy’s foundation. “We embarked on a carefully laid out two year plan,” she said. “Direct care nurses met with us and reviewed literature on how patients should be screened, assessed, and registered. We compiled all the necessary information to develop evidence based practices.”

A computer based system was developed to teach the nurses. They received education online, which allows ULH to keep track of who has done the work and when. “It is vital perinatal nurses not only receive the necessary education, but also that it is renewed on a consistent basis,” said Logsdon.

Teaching Mothers

Based on the new guidelines, which were put into use at ULH on Dec. 1, 2011, perinatal nurses now assess mothers for PPD and suicide risk factors during the obstetric patient admission process.

Risk factors include, low-income status, lack of social support and previous history of depression. Nurses report any at risk patients to the obstetrical physician.

“The evening before discharge nurses give new mothers a questionnaire based on the Edinburgh Postnatal Depression Scale (EPDS),” said Eckert. “Mothers are asked a variety of questions, including whether they feel anxious or worried and/or sad.”

The EPDS is one of the most widely used instrument to assess for postpartum depressive symptoms, according to Logsdon.

The higher the score the greater the risk. “If a patient scores a 13 or above they are at risk for PPD,” said Tomasulo. “The physician, social services and oncoming shift nurse are all informed.”

“The results are discussed with the patient to determine the next steps and if a referral is needed,” she added. “Patients are provided support and advice on what to do if feelings of hopelessness increase.”

Staff makes sure new mothers are aware of the services available to them; they leave the hospital with a list of physician referrals and community resources. “We ask the mothers to retake the EPDS questionnaire about a week after discharge to see if they’re experiencing PPD symptoms,” said Eckert.

At ULH, where there is a high number of Spanish-speaking patients it can be challenging to provide the necessary education, but ULH and its staff are dedicated to preparing every new mother the best they can. Interpreter phones and other translation services are used to bridge the gap.

Successful Start

The program at ULH has found success due to hospital-wide support and high nursing staff engagement.

“We carefully planned every aspect of the program’s implementation,” stressed Logsdon. “We involved every level of staff in advance, which eased the process.”

“It is important nurses are involved in the whole process,” added Tomasulo. “Nurses are the caretakers and it is imperative that they are involved so they can take ownership.”

ULH gets feedback on a regular basis to ensure that the policy is working and generating the best care possible. Quarterly updates are provided and a bulletin board is on display for staff.

“We want nurses to be able to see the difference they are making,” said Eckert. “Nurses have embraced the policy from the beginning. They are passionate and dedicated to doing all they can to prepare mothers before they leave the hospital.”

Nurses are not the only ones who recognize the value of the policy. Mothers have responded well to the program, showing appreciation for the additional support and information available to them before they leave the hospital. “It is important they know they are not alone,” emphasized Tomasulo. “We want them to ask for help and not stay silent because they are afraid or don’t understand what they are feeling.”

“New mothers have to have a safe place to turn, especially during their darkest moments,” she added.

Professional Responsibility

The policy created and implemented at ULH has laid the framework for other facilities interested in improving the care and resources available to new mothers at risk for PPD.

Logsdon and her team developed these guidelines to fill a gap in the evidence based practices available for perinatal nursing care. It promotes the education of both caregiver and patient. “We are proud to set the bar for PPD care with this policy,” said Logsdon. “It is our job to prepare mothers for the world outside the hospital.”

New mothers must have a support system and it is the responsibility of the healthcare providers to arm them with the knowledge they will need once they leave the hospital.

“This is an ethical obligation,” stressed Logsdon. “It is not acceptable for us to send new mothers out in the world who are not prepared for what they may encounter.”

“PPD is one of the most common complications of child bearing,” she concluded. “And that is our biggest motivator, we feel it is our professional responsibility.”

Catlin Nalley is editorial assistant at ADVANCE.

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