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The influence of certain variables upon the development of postpartum blues Paull, Dorothy Bowden 1975

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THE INFLUENCE OF CERTAIN  VARIABLES  UPON THE DEVELOPMENT OF POSTPARTUM  BLUES  by DOROTHY BOWDEN PAULL B.ScN., U n i v e r s i t y  of Alberta,  1971  A THESIS SUBMITTED IN PARTIAL FULFUIiMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER  OF SCIENCE IN NURSING  i n the School of Nursing  We a c c e p t required  this  t h e s i s as conforming  t o the  standard  THE UNIVERSITY OF BRITISH COLUMBIA April,  1975  In p r e s e n t i n g  t h i s t h e s i s in p a r t i a l  f u l f i l m e n t o f the  requirements f o r  an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree the L i b r a r y s h a l l make i t f r e e l y  a v a i l a b l e f o r r e f e r e n c e and  I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e f o r s c h o l a r l y purposes may by h i s r e p r e s e n t a t i v e s .  thesis  Department or  I t i s understood that c o p y i n g or. p u b l i c a t i o n  of this thesis f o r financial written  study.  copying of t h i s  be g r a n t e d by the Head of my  that  gain  permission.  Depa rtment The U n i v e r s i t y o f B r i t i s h Columbia Vancouver 8, Canada  shall  not  be a l l o w e d w i t h o u t  my  ABSTRACT The purpose o f t h i s s t u d y was t o determine t h e i n f l u e n c e o f c e r t a i n v a r i a b l e s upon t h e development partum B l u e s .  Q u e s t i o n s asked were:  of Post-  Do f a c t o r s r e l a t e d  t o m a t e r n a l r o l e . c o n f l i c t i n f l u e n c e the' development  of .  .Postpartum B l u e s ? D o C s p e c i f i c I e n d o c r i n e . f a c t o r s r e l a t e d t o the m e n s t r u a l c y c l e i n f l u e n c e t h e development Blues?  o f Postpartum  Does a r e d u c t i o n i n t h e number o f s l e e p c y c l e s i n -  f l u e n c e t h e development  o f Postpartum B l u e s ?  Two s e m i - s t r u c t u r e d i n t e r v i e w s c h e d u l e s and a q u e s t i o n n a i r e were c o n s t r u c t e d f o l l o w i n g a r e v i e w o f t h e l i t e r a t u r e t o d e r i v e i n f o r m a t i o n p e r t i n e n t t o t h e r e s e a r c h problem.  The Beck D e p r e s s i o n I n v e n t o r y was a l s o a d m i n i s t e r e d .  The s t u d y p o p u l a t i o n c o n s i s t e d o f t w e n t y - n i n e women. The s t u d y p o p u l a t i o n was r e s t r i c t e d t o women who d e l i v e r e d  full-  term, a p p a r e n t l y h e a l t h y i n f a n t s i n one h o s p i t a l i n Vancouver. C e r t a i n o t h e r c r i t e r i a o f language, demography, h e a l t h , and o b s t e t r i c s were a p p l i e d .  A n a l y s i s o f t h e d a t a i n c l u d e d des-  c r i p t i v e a n a l y s i s , f r e q u e n c y t a b l e s , and t h e use o f t h e c h i square  test. The f i n d i n g s o f the s t u d y showed t h a t 70 p e r c e n t  of t h e women e x p e r i e n c e d Postpartum B l u e s .  The f a c t o r s r e -  l a t e d t o m a t e r n a l r o l e c o n f l i c t , e i t h e r i f s i n g l y o r i n comb i n a t i o n , d i d n o t s i g n i f i c a n t l y i n f l u e n c e t h e development of- Postpartum B l u e s .  Nor d i d t h e e n d o c r i n e f a c t o r s r e l a t e d iii  to the menstrual c y c l e i n f l u e n c e the development o f Postpartum B l u e s .  However, i t was found t h a t a r e d u c t i o n i n  s l e e p c y c l e s over a four-day p e r i n a t a l p e r i o d i n f l u e n c e d the development o f Postpartum  significantly  Blues.  en who experienced a s l e e p d e f i c i e n c y , 8 5 percent Postpartum  Of the womdeveloped  Blues. The study suggests t h a t more a t t e n t i o n be p a i d to  the s l e e p needs o f postpartum  women, both i n h o s p i t a l and  a t home i n the community.  110 pages  ACKNOWLEDGEMENTS I wish t o express my a p p r e c i a t i o n t o the twentynine postpartum women who p a r t i c i p a t e d i n t h i s study.  I  would a l s o l i k e t o thank the D i r e c t o r o f N u r s i n g and the nursing  s t a f f o f the h o s p i t a l i n which p a r t o f the study was  conducted.  Finally,  I wish t o thank  Assistant-Professors  Helen E l f e r t and S y l v i a Holmes f o r t h e i r advice and encouragement .  v  TABLE OF CONTENTS Page ACKNOWLEDGEMENTS  •  LIST OF TABLES  viii  CHAPTER I.  1  INTRODUCTION TO THE STUDY  • • 1  INTRODUCTION  II.  STATEMENT OF THE PROBLEM  3  SIGNIFICANCE OF THE PROBLEM  4  ASSUMPTIONS OF THE STUDY  5  DEFINITIONS OF TERMS USED  5  LIMITATIONS OF THE STUDY  8 , . 1 0  REVIEW OF THE LITERATURE  1 0  INTRODUCTION THE PUERPERIUM AS A DEVELOPMENTAL CRISIS  .  . . 1 0  THE CHANGES OCCURRING IN THE PUERPERIUM  III.  14  ROLE THEORY CONCEPTS  1 6  SLEEP NEEDS  2 0  THE POSTPARTUM BLUES  2 2  SUMMARY  2 6  RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY  28  SELECTION OF THE STUDY GROUP The S e t t i n g /  2 8 28  The cts I n i t Si ua b l j eContact with the Subjects . . .23 9 1  vi  CHAPTER  Pag INSTRUMENTATION  •  31  H o s p i t a l I n t e r v i e w Schedule  32  Home I n t e r v i e w Schedule  33  The Beck D e p r e s s i o n I n v e n t o r y . . . . .  34  The B l u e s Q u e s t i o n S i r r e . . PRE-TEST  36  THE INTERVIEWING PROCEDURE  37  I n t e r a c t i o n w i t h t h e Study Group  IV.  ...  STATISTICAL ANALYSIS  40  SUMMARY  41  ANALYSIS OP THE DATA  42  CHARACTERISTICS OF THE STUDY POPULATION  42  ASSESSMENT OF THE INCIDENCE OF POSTPARTUM BLUES  51  INCIDENCE OF STRESS ITEMS RELATED. TO MATERNAL ROLE CONFLICT  57  INCIDENCE OF SPECIFIC ENDOCRINE FACTORS RELATED TO THE MENSTRUAL CYCLE  75  INCIDENCE OF SLEEP DEFICIENCY' .. .. . . . SUMMARY V.  38  SUMMARY, CONCLUSIONS AND RECOMMENDATIONS SUMMARY  .77 80 . 81 '81  CONCLUSIONS .  -83  RECOMMENDATIONS  87  BIBLIOGRAPHY  (90  APPENDICES .  95  A.  Consent Form  96  B.  I n s t r u m e n t s Used i n t h e Study . . . . .  98  L I S T OF  TABLES  TABLE  Page 1.  Percentage  Distribution  o f Study-  P o p u l a t i o n by Age 2. 3.  4.  5. 6.  7.  8.  9.  10.  11.  . .  Percentage D i s t r i b u t i o n of P o p u l a t i o n by B i r t h p l a c e  43  Study 43  Percentage D i s t r i b u t i o n of Study P o p u l a t i o n by L e n g t h o f Time L i v e d With F a t h e r of the I n f a n t  44  Percentage D i s t r i b u t i o n o f the Study P o p u l a t i o n by H i g h e s t E d u c a t i o n a l Attainment  45  P a r i t y by I n c i d e n c e o f P o s t p a r t u m I n t h e S t u d y Sample  46  Blues  P r o x i m i t y o f C o n f i n e m e n t Date t o . E s t i m a t e d C o n f i n e m e n t Date by Incidence of Postpartum Blues i n the Study P o p u l a t i o n  r  D u r a t i o n o f L a b o u r f o r P r i m i p a r a s and M u l t i p a r a s by I n c i d e n c e o f P o s t partum Blues i n the Study P o p u l a t i o n .  4?  .  48  B i r t h W e i g h t o f I n f a n t s by I n c i d e n c e of Postpartum B l u e s i n the Study Population  ,51.  I n c i d e n c e o f S t r e s s Items R e l a t e d t o Maternal C o n f l i c t — I n a d e q u a t e Preparation f o r Maternal R o l e — B y Incidence of Postpartum Blues i n the Study P o p u l a t i o n ...... . . . .  6l  I n c i d e n c e o f S t r e s s Items R e l a t e d t o M a t e r n a l Role C o n f l i c t — A n x i e t y About Maternal R o l e — b y Incidence of Postpartum Blues i n the Study P o p u l a t i o n . .  66  I n c i d e n c e o f S t r e s s Items R e l a t e d t o Maternal Role C o n f l i c t — C o n f l i c t w i t h O t h e r R o l e s and D i s t r e s s i n g E v e n t s D u r i n g the P u e r p e r i u m — b y Incidence of Postpartum Blues i n the Study P o p u l a t i o n  70  viii  •  ix TABLE  Page 12.  13.  14.  15.  S i g n i f i c a n t Help During Labour by I n c i d e n c e o f P o s t p a r t u m Blues i n the Study P o p u l a t i o n . . . . .  71  S i g n i f i c a n t Help During Labour ; by I n c i d e n c e o f P o s t p a r t u m Blues i n the Study P o p u l a t i o n  72'  I n c i d e n c e o f S t r e s s Items R e l a t e d to Maternal Role C o n f l i c t — E m o t i o n a l and C o g n i t i v e C h a n g e s — By I n c i d e n c e o f P o s t p a r t u m Blues i n the Study P o p u l a t i o n . . . . . Incidence of Menstrual Cycle D i f f i c u l t i e s According to Incidence of Postpartum Blues i n the Study Population  ' 73 •  77  CHAPTER I . INTRODUCTION TO THE STUDY I.  INTRODUCTION  The r a p i d s o c i o - e c o n o m i c advances o f t h i s  century  have caused changes which i n c r e a s e t h e s t r e s s t h a t c h i l d b e a r i n g p l a c e s upon women.  Some o f t h e changes i n c l u d e  g r e a t e r u r b a n i z a t i o n , a s h i f t from t h e extended f a m i l y structure to that of the nuclear family, smaller f a m i l i e s , and  t h e c h a n g i n g s t a t u s o f women.  c r i b e d as a d e v e l o p m e n t a l c r i s i s ,  C h i l d b e a r i n g has been desa p e r i o d i n which " t h e r e i s  marked p h y s i c a l , p s y c h o l o g i c a l , and s o c i a l change t h a t i s c h a r a c t e r i z e d by common ' d i s t u r b a n c e s * Although medical  i n thought and f e e l i n g . "  s c i e n c e has g r e a t l y i n f l u e n c e d  the b i o l o g i c a l outcome o f c h i l d b e a r i n g , t h e e m o t i o n a l o u t 2 come o f c h i l d b e a r i n g has n o t shown such f a v o u r a b l e  progress.  Postpartum d e p r e s s i o n has been c o n s i d e r a b l y s t u d i e d i n p s y Howard J . Parad, " P a r t I I . Common M a t u r a t i o n a l and S i t u a t i o n a l C r i s e s , " C r i s i s I n t e r v e n t i o n t S e l e c t e d Readi n g s , ed. Howard J . Parad (New York: F a m i l y S e r v i c e A s s o c i a t i o n o f A m e r i c a , 1965), p. 73. 2 A.A. Baker, P s y c h i a t r i c D i s o r d e r s i n O b s t e t r i c s ( S a l i s b u r y : The S a l i s b u r y P r e s s L t d . , 1967), pp. 34-44: James A l e x a n d e r H a m i l t o n , Postpartum P s y c h i a t r i c Problems ( S a i n t L o u i s : The C.V. Mosby Company, 1962), pp. 107-111: F r e d e r i c k T. Melges, "Postpartum P s y c h i a t r i c Syndromes," Psychosomatic M e d i c i n e , X X X . V ( J a n u a r y - F e b r u a r y . 1968), 955 B r i c e P i t t , " ' A t y p i c a l ' Depression Following C h i l d b i r t h , " B r i t i s h J o u r n a l o f P s y c h i a t r y . CXIV (1968), 1325. x  1  1  2 chiatric hospitals.  However, the much m i l d e r form of p o s t -  partum d e p r e s s i o n , known as the Postpartum ved l i t t l e a t t e n t i o n i n the  Blues, has  recei-  literature.  While the i n c i d e n c e r a t e of Postpartum  Blues  has  been estimated as h i g h as e i g h t y percent, the syndrome i s 3  f r e q u e n t l y r e f e r r e d to as a normal sequel to c h i l d b i r t h . In ing.  f a c t , P i t t d e s c r i b e d the syndrome as t r i v i a l  and  fleet-  Yalom a l s o concurred with t h i s viewpoint, as d i d  Joseph and Peck.^  On the other hand, one study  suggests  t h a t more than h a l f of c h i l d b e a r i n g women showed s u b j e c t i v e evidence of a n x i e t y and or d e p r e s s i o n . ^ w r i t e r ' s experience as a midwife  t h a t the Postpartum  can be a very d i s t r e s s i n g e p i s o d e w h i c h :  by some women who  I t has been the  i s l o n g remembered  experience the syndrome.  t r a n s i t o r y nature of the Postpartum t h a t a h i s t o r y of Postpartum  Blues  In s p i t e of the  Blues, there i s evidence  Blues i s f r e q u e n t l y a f a c t o r i n  the more severe and l o n g e r - l a s t i n g postpartum  depression.^  "'Hamilton, l o c . c i t .  4 B r i c e P i t t , "Maternity B l u e s , " B r i t i s h J o u r n a l of P s y c h i a t r y , CXX (1973). 432-433. ^ I r v i n Yalom and Others, "'Postpartum B l u e s ' Syndrome," A r c h i v e s o f General P s y c h i a t r y . XVIII (January, 1968), 26« Sharon Serena Joseph and Rana Limbo Peck, "Postpartum Needs of the Family," M a t e r n i t y Nursing Today, ed. Joy P. Clausen (New Yorkt McGraw H i l l Book Company, 1973)# P« 557. ^ F r a n c i s J . Kane, J n r . and Others, "Emotional and C o g n i t i v e Disturbance i n the E a r l y Puerperium," B r i t i s h J o u r n a l of P s y c h i a t r y . CXIV (January, 1968), 101. ^Melges, op. c i t . , p. 98? P i t t , " ' A t y p i c a l ' Dep r e s s i o n F o l l o w i n g C h i l d b i r t h , " p. 1332; Yalom, l o c . c i t .  The c u r r e n t m e d i c a l and n u r s i n g l i t e r a t u r e  deal-  i n g w i t h Postpartum B l u e s i n d i c a t e s the importance o f a s s i s t ing  women t o meet t h e i r e m o t i o n a l needs.  A s t u d y by Gordon,  K a p o s t i n s , and Gordon r e v e a l e d t h a t a s s i s t a n c e from n u r s e s and d o c t o r s i n overcoming e m o t i o n a l d i f f i c u l t i e s  experienced  i n the puerperium had e x t r e m e l y b e n e f i c i a l r e s u l t s .  Like-  w i s e , Auerback urged t h a t n u r s e s and d o c t o r s l e n d e m o t i o n a l s u p p o r t t o postpartum women t o h e l p them cope w i t h the  new  and c h a n g i n g demands o f p a r e n t h o o d . ^ Yet,  t h e r e i s l i t t l e agreement i n the l i t e r a t u r e  as t o the cause o f these e m o t i o n a l d i f f i c u l t i e s .  Many d i f f -  e r e n t f a c t o r s have been a t t r i b u t e d t o Postpartum B l u e s , but 1 0  t h e r e i s n o . f i r m evidence p o i n t i n g t o common f a c t o r s .  It  was f e l t t h a t f u r t h e r s t u d y o f r e l a t e d f a c t o r s t o the develop ment o f Postpartum B l u e s c o u l d p r o v i d e s t r o n g e r g u i d e l i n e s f o r people i n v o l v e d i n the c a r e o f postpartum women. II.  STATEMENT OF THE PROBLEM  i.  The purpose o f t h i s d e s c r i p t i v e s t u d y was t o d e t e r s mine the i n f l u e n c e of c e r t a i n v a r i a b l e s upon the of  development  Postpartum B l u e s . The f o l l o w i n g . q u e s t i o n s p r o v i d e d the f o c u s o f the  " R i c h a r d E. Gordon, E l i E. K a p o s t i n s , and K a t h e r i n e K. Gordon, " F a c t o r s i n Postpartum Adjustment," O b s t e t r i c s and Gynecology, XXV ( F e b r u a r y , 1965), 158-166. ^ A l i n e G. Auerback, "Meeting the Needs o f New e r s , " C h i l d and F a m i l y , VI ( W i n t e r , 196?), 10-13. Pitt,  Moth-  *°Yalom, op. c i t . , pp. 16-2?; Gordon, l o c . c i t . ; " M a t e r n i t y B l u e s , " p. 431.  4 (1)  study:  influence specific  Do f a c t o r s r e l a t e d  t o maternal  the development o f Postpartum endocrine f a c t o r s r e l a t e d  influence  r e d u c t i o n i n t h e number o f s l e e p c y c l e s  ( 2 ) Do  Blues?  (3)  influence  cycle Does a  the develop-  Blues?  III.  SIGNIFICANCE OF THE PROBLEM  Postpartum scanty a t t e n t i o n  Blues?  conflict  to the menstrual  the development o f Postpartum  ment o f P o s t p a r t u m  role  Blues, according t o Riker,  "gets  from m e d i c a l r e s e a r c h e r s , so t h e e x a c t  remain  obscure."  I n Canada, a s e l s e w h e r e ,  volved  i n the care o f postpartum  1 1  out i n C a l g a r y , A l b e r t a ,  women.  causes  nurses arei n -  In a study  carried  J o r d a n r e p o r t e d t h a t more women i n  a f a m i l y - c e n t r e d m a t e r n i t y c a r e group  i nhospital  h e l p w i t h p s y c h o l o g i c a l problems from  the nurse  sought  than from the  12 doctor.  Moreover, h e r f i n d i n g s  home i n t h e community w i s h e d predesignated nurse Joseph of  child-bearing  that  f o r assurance  a n d Peck n o t e d  showed t h a t new m o t h e r s a t they c o u l d c a l l  upon a  and a d v i c e .  that  "provides a unique  the developmental  crisis  opportunity f o r the nurse  13 to  intervene."  as  "one w h o , e n t e r s t h e p r o b l e m  VI  A u d r e y R i k e r , "New P a r e n t B l u e s , " C h i l d ( S p r i n g , 1967), 14.  J  The c r i s i s  i n t e r v e n e r i s d e f i n e d by P a r a d s i t u a t i o n and h e l p s  those and Family,  12 D o r r e e n J o r d a n , An E v a l u a t i o n o f a F a m i l y - C e n t r e d M a t e r n i t y C a r e H o s p i t a l Program ( u n p u b l i s h e d r e s e a r c h p r o j e c t , C a l g a r y , 1971), p p . 264-66. 13 ^ J o s e p h a n d Peck, op. c i t . , p . 554.  5 involved mobilize the  crisis  able  their  or c r i s i s - l i k e  t o those  state  i n a manner w h i c h  i s accept-  involved."  Clearly, assist  s t r e n g t h s i n o r d e r t o move o u t o f  then, the nurse  p o s t p a r t u m women t o r e d u c e  i s i n an i d e a l p o s i t i o n t o the s t r e s s e s o f t h i s  The n u r s e a s i n t e r v e n e r , must u n d e r s t a n d t h e f a c t o r s cause  the d i s t r e s s  implicated of  o f postpartum  v a r i a b l e s would i n c r e a s e  the Postpartum  B l u e s syndrome.  be f u r t h e r a s s i s t e d or  to minimize  The Postpartum  Further study of  the nurse's understanding Thus p o s t p a r t u m  the e f f e c t  women may  o f t h e snydrome  degree  ASSUMPTIONS OF THE STUDY  s t u d y was b a s e d  B l u e s i s an e n t i t y  o t h e r forms  on t h e a s s u m p t i o n that  of severity,  (2) T h a t e a c h  that:  from  appropriate  from  and (b) i t s  a c c o r d i n g t o t h e Beck D e p r e s s i o n I n v e n -  subject  statements o f the respondents.  interviewed  i s s u f f i c i e n t l y cognizant  h e r own f e e l i n g s a n d i n t e r p e r s o n a l b e h a v i o u r t h a t  select  (1)  c a n be d i s t i n g u i s h e d  o f d e p r e s s i o n by ( a ) i t s d u r a t i o n ,  t o r y and t h e s e l f - d e c l a r e d  she c a n  the i n t e r v i e w q u e s t i o n n a i r e s the statement  most  t o h e r f e e l i n g s and b e h a v i o u r .  V. For are  which  t o m a x i m i z e t h e i r r e s o u r c e s t o cope w i t h i t .  IV.  of  blues.  period.  DEFINITIONS OF TERMS USED  the purpose  of this  defined.  Parad,  op. c i t . , p . 2.  study the f o l l o w i n g  terms  6 Apgar  Score This scoring  ical  evaluation  after  birth.  scored  0; 1,  cellent  s y s t e m was d e v i s e d t o e n a b l e a  clin-  t o be made o f a b a b y ' s c o n d i t i o n a t one m i n u t e  The f i v e o r 2,  vital  the t o t a l  signs,  shown i n T a b l e 1,  o f which  may be 1-10  a r e each  (poor t o ex-  status). Table I * 1  Apgar  Scoring.System  0  Sign  1  2  Heart rate  Not d e t e c t able  Slow 100)  Respiratory effort  Absent  Slow, ular  Muscle  Flaccid  Some f l e x i o n Active of e x t r e m i t i e s  tone  Reflex i r r i t a bility No 'response .1. response t o s l a p on s o l e of f o o t 2. response No r e s p o n s e to c a t h e t e r i n nostril (tested a f t e r o r o pharynx i s c l e a r )  Color  Blue, pale  (below  irreg-  Over-100  Good,  crying  motion  Grimace  Cry  Grimace  Cough o r sneeze  Body p i n k , extremities blue  Completely pink  '.i  15 Z i e g e l , E r n a a n d C a r o l y n C. Van B l a r c o m . Obstetr i c a l Nursing. New Y o r k : The M a c m i l l a n Company, 1972. p p . 392-93. ' v  F  F  7 Childbearing Process The period frpm conception u n t i l the reproductive organs have returned to normal. C o n f l i c t with Maternal Role The d i f f i c u l t y experienced i n the assumption of the new r e s p o n s i b i l i t i e s and feelings of motherhood and t h e i r integration with existing roles and i n t e r e s t s . Dysmenorrhoea Painful menstruation. Early Menarche Menarche refers to the appearance of the  first  menstrual period, usually occurring between the age of eleven and f i f t e e n years.  Early menarche i s considered to be under  the age of eleven years. Multipara A woman who has experienced two or more labours i n the bearing of viable  infants.  Postpartum Blues, Postpartum Blues Syndrome These terms are used interchangeably and are  often  referred to i n the l i t e r a t u r e as Postpartum ''Blues " or ^Postpartum Blues" syndrome. The terms refer to the transitory mild depression occurring within the postpartum period. Premenstrual Tension A state of depression or anxiety which may occur several days before menstruation.  8 Primipara A woman who ing  of a viable  Puerperium,  has  infant  or v i a b l e  Postpartum The  experienced  terms a r e used  Social  organs  to  i n t e r c h a n g e a b l y and  the c o n t e n t  only.  LIMITATIONS OF  (1) The  limitations  s m a l l sample  size  restricted  the f i n d i n g s  Because o f t h i s ,  other populations.  w h i c h may  (2)  gathering  have c a u s e d  instruments  a Depression the degree  mentation social  one-  in relation  the  desirability  study  and  foll-  hossample  be g e n e r a l i z e d  conducted  a. t i m e  t o be  one  to t h i s  cannot  of  during  festivity,  unrepresentative of (3)  study, with  were r e l a t i v e l y  established. biasing  from  o f the y e a r .  i n the  of v a l i d i t y  were n o t  s t u d y were a s  s t u d y was  sample  Inventory,  STUDY  selected  January,  used  THE  o f the p o p u l a t i o n r e s i d e n t  o f the  The  the p o p u l a t i o n a t o t h e r times  fore,  the  q u e s t i o n s about  o f the  the f i n d i n g s  t h e months o f December and  of  to  d u r i n g which  manner r a t h e r t h a n  t h e G r e a t e r V a n c o u v e r a r e a and  pital  refer  o f the q u e s t i o n .  Recognized  to  childbirth,  of answering  approved  VI.  in  infants.  Desirability  in a socially  ows:  bear-  r e t u r n to t h e i r pregravid state.  A s y s t e m a t i c way self  labour in-the  Period  the six-week p e r i o d f o l l o w i n g reproductive  one  The  the  data-  exception  untested.  reliability  o f the  Thereinstru-  A l s o , the p o s s i b i l i t y  the f i n d i n g s  o f the  study  of cannot  be r u l e d out because a t e s t not  administered.  for social desirability  was  CHAPTER I I . REVIEW OF THE LITERATURE I. Although  INTRODUCTION  r e f e r e n c e had been made t o Postpartum  B l u e s i n t h e n i n e t e e n t h c e n t u r y , i t was n o t u n t i l 1952 t h a t the syndrome aroused s u f f i c i e n t i n t e r e s t f o r s t u d y .  1  Yet,  the s t u d i e s t h a t have been done a r e meagre and l a c k d e f i n i t i v e answers t o t h e syndrome.  I n t h e l a s t twenty y e a r s a  number o f s m a l l s t u d i e s were r e p o r t e d i n t h e U n i t e d of America and i n Europe.  States  However, a p a r t from t h e s e , no  major s t u d i e s appeared i n t h e a c c e s s i b l e l i t e r a t u r e . The  l i t e r a t u r e reviewed  here d i s c u s s e s t h e o r y and  r e s e a r c h under t h e f i v e main headings o f t h e puerperium a s a d e v e l o p m e n t a l c r i s i s ; t h e changes o c c u r i n g i n the puerperium; some c o n c e p t s o f r o l e t h e o r y ; s l e e p needs; and t h e Postpartum Blue s" syndrome. II.  THE PUERPERIUM AS A DEVELOPMENTAL CRISIS •  The puerperium i s g e n e r a l l y a c c e p t e d  as t h e p e r i o d  between t h e t e r m i n a t i o n o f l a b o u r and t h e r e t u r n o f t h e r e p r o d u c t i v e organs t o t h e i r normal c o n d i t i o n , u s u a l l y dei  James A l e x a n d e r H a m i l t o n , Postpartum P s y c h i a t r i c Problems ( S a i n t L o u i s : The C.V. Mosby Company, 1962), p. 108. 10  fined  as f o r t y - t w o days.  y o u n g woman i s c a l l e d physical, the  which  t o enormous  as a developmental  bio-  Therefore,  stage, d u r i n g  i s much more s u s c e p t i b l e  to stress.  t h e woman a s more v u l n e r a b l e i n t h e p u e r p e r i u m ,  Highley noted that in  rapidly  i n which t h e  and e n v i r o n m e n t a l changes.  may be v i e w e d  time an i n d i v i d u a l  Regarding  i s a period  upon t o a d a p t  psychosocial,  puerperium  This  an e f f e c t i v e  adaptive process i s required  o r d e r t o meet t h e marked c h a n g e s i n t h e s t a t u s a n d l i f e -  2 style  c r e a t e d by c h i l d b e a r i n g . , Furthersto  a developmental 3  on a n d S c o t t . frequently are  1  crisis,  Kane r e g a r d e d t h e p u e r p e r i u m a s  a viewpoint also  P a r a d commented  seen a s "normal"  that  s u p p o r t e d by R o b i s c h -  developmental  c r i s e s because  common t o a l l p e o p l e i n t h a t p a r t i c u l a r er  ment.  During a developmental  must be e f f e c t i v e l y mental and  this,  accomplished  s t a g e may r e a l i z e  development.^  crisis  its full  crises are  the experiences stage o f develop-  there are tasks  i n order that potential  which  the next  for further  developgrowth  The t a s k s t o be a c h i e v e d i n t h e p u e r p e r i u m  ''Betty H i g h e l y , " M a t e r n a l R o l e I d e n t i t y , " D e f i n i n g C l i n i c a l Content, V o l . 1 (Boulders W e s t e r n I n t e r s t a t e Commi s s i o n f o r H i g h e r E d u c a t i o n , 196?), p . 32. - ^ F r a n c i s J . Kane, J n r . and O t h e r s , " E m o t i o n a l a n d C o g n i t i v e Disturbance i n the E a r l y Puerperium," B r i t i s h J o u r n a l o f P s y c h i a t r y , XCIV ( J a n u a r y , 1968), 99: P a u l e t t e R o b i s chon and Diane S c o t t , "Role Theory and i t s A p p l i c a t i o n i n F a m i l y N u r s i n g , " N u r s i n g O u t l o o k XXVII ( J u l y , 1969), 5^. h  Howard J . P a r a d , " P a r t I I . Common M a t u r a t i o n a l a n d Situational Crises," C r i s i s Intervention: S e l e c t e d Readings, ed. Howard J . P a r a d (New Y o r k : Family Service A s s o c i a t i o n o f A m e r i c a , 1965)1 p . 73. Ibid.  12 f a l l i n t o the b i o p h y s i c a l , p s y c h o s o c i a l , and e n v i r o n m e n t a l c a t e g o r i e s p r e v i o u s l y mentioned, and t o be d i s c u s s e d the changes o c c u r i n g i n the p u e r p e r i u m .  under  Should these tasks  n o t be a d e q u a t e l y a c h i e v e d , t h e n some degree of d i s t u r b a n c e ensues. S t a t i n g t h i s a n o t h e r way, c r i s i s may  Caplan s a i d t h a t a  o c c u r when a p e r s o n i s f a c e d w i t h a problem he  cannot s o l v e .  According to Caplan, a person's a b i l i t y to  w i t h s t a n d a c r i s i s depends on t h r e e f a c t o r s :  (1) the capa-  c i t y t o d e a l w i t h a n x i e t y and s t r e s s , and t o m a i n t a i n e q u i l i b r i u m , ( 2 ) t h e c a p a c i t y t o e f f e c t i v e l y s o l v e problems, based on r e a l i t y , and ( 3 ) the r e p e r t o i r e of e f f i c i e n t c o p i n g mechanisms which f a c i l i t a t e the maintenance o f e q u i l i b r i u m . Parad d e f i n e d a c r i s i s as f o l l o w s : a hazardous c i r c u m s t a n c e or s t r e s s which c o n s t i t u t e s a t h r e a t f o r i n d i v i d u a l s and f a m i l i e s because (a) the s t r e s s j e o p a r d i z e d i m p o r t a n t l i f e g o a l s such as health-, •;/security, and a f f e c t . i o n a l t i e s , and (b) -the problems posed cannot be i m m e d i a t e l y s o l v e d by the immediate r e s o u r c e s o f the ego, t h e r e b y g e n e r a t i n g a h i g h l e v e l o f u n c e r t a i n t y , a n x i e t y , and t e n s i o n . 8 A s t u d y by L e M a s t e r s , i n which f o r t y - s i x m i d d l e c l a s s c o u p l e s p a r t i c i p a t e d , found t h a t new  parenthood con-  s t i t u t e s a c r i s i s s i t u a t i o n f o r 8 3 p e r c e n t o f the sample.^ ^ G e r a l d C a p l a n , An Approach t o Community M e n t a l H e a l t h (New Y o r k : Grune & S t r a t t o n , I n c . , 1961), p. 18. 7  I b i d . , pp. 38-41.  8  Howard J . Parad, " P r e v e n t a t i v e Casework: Problems and I m p l i c a t i o n s , " C r i s i s I n t e r v e n t i o n : S e l e c t e d Readings, ed. Howard J . Parad (New York: F a m i l y S e r v i c e A s s o c i a t i o n of America, 1 9 6 5 ) , pp. 2 8 8 - 8 9 . Q  E.E. L e M a s t e r s , "Parenthood as a C r i s i s , " C r i s i s I n t e r v e n t i o n : S e l e c t e d Readings, ed. Howard J . Parad (New York: F a m i l y S e r v i c e A s s o c i a t i o n o f A m e r i c a , 1965), p. 111.  LeMasters pointed f a m i l y as a status and  and  ways t o be  that  that  quate.  social  1  the  life  t o be  f o r meeting needs.  experiences  in  redesignated, readjusted, Yoshioka  o f some women a r e  f o r coping  the  sugg-  limited  with c r i s e s are  inade-  0  o r new  state  stated,  upheaval occurring  s h i f t e d , values  found  the  stresses  R a p a p o r t assumed t h a t  the  the  s y s t e m , c a u s e s r o l e s t o he  t h e i r resources  If  vived  that  p o s i t i o n s t o be  new  ested  out  of a c r i s i s  old psychological  c o n f l i c t s may  appear,  of mental h e a l t h .  i f the  crisis  are  1 1  On  poorly  coped  c o n f l i c t s may  e i t h e r of which the  other  hand,  with, be  re-  reduce Rapaport  i s well-managed, then the i n d i v i d u a l  will  gain  i n m a t u r a t i o n or development.  that  individuals in crisis  I t was  s i t u a t i o n s are  also  noted  more amenable  to  12 therapeutic  counselling.  In s u p p o r t i n g ing  indivuduals  t h i s v i e w , Bloom r e l a t e d t h a t  when t h e y a r e  in crisis  s i t u a t i o n s can  assistsig-  13 nificantly  improve  t h e i r mental h e a l t h .  J  Ruth Y o s h i o k a , " M a t u r a t i o n C r i s i s M a t u r a t i o n a l C r i s i s o f C h i l d b e a r i n g . ed. Ann lulu! U n i v e r s i t y o f H a w a i i , 1971), p . 16.  of Pregnancy," C l a r k (Hono-  R h o n a R a p a p o r t , "Normal C r i s e s , F a m i l y S t r u c t u r e , and M e n t a l H e a l t h , " C r i s i s I n t e r v e n t i o n s S e l e c t e d Readings, ed. Howard J . P a r a d (New Y o r k : Family S e r v i c e A s s o c i a t i o n of A m e r i c a , 1965), P« 75 1 : L  1 2  Ibid.  -^Bernard L. Bloom, " D e f i n i t i o n a l A s p e c t s o f t h e C r i s i s Concept," C r i s i s Interventions S e l e c t e d Readings, e d . Howard J . P a r a d (New Y o r k : Family Service A s s o c i a t i o n o f A m e r i c a , 1965). P. 303. 1  14 III.  THE CHANGES THE  Biophysical  b i o p h y s i c a l changes ^  ium a r e enormous. release  With  theb i r t h  occurring  loss  woman i s a b o u t  twenty  organs, a s w e l l  By t h e end o f one  e x p e r i e n c e d by t h e p o s t p a r t u m  pounds.  i seliminated.  d u r i n g which state.  Within twenty-four hours  the weight  labour,  uterus a f t e r b i r t h ,  of del-  o f the u t e r u s , which  ary gland.  ounces by  t h e d i s c h a r g e from t h e  taking place  which  pregravid  i s two pounds  continues f o r ten to f i f t e e n  e n d o c r i n e changes.  days.  i n the puerperium a r e  Lactation  i sinitiated  i s p r o d u c e d by t h e a n t e r i o r  by t h e pituit-  The p r e g n a n c y hormones, t h e o e s t r o g e n s a n d p r o g e s -  terone, a r e produced by the p l a c e n t a i n g pregnancy.  Immediately  of oestrogens i s t e n - f o l d Reva R u b i n , (December,  1961),  prior  i n i n c r e a s i n g amounts d u r -  to childbirth,  the production  t h e maximal p r e - p r e g n a n c y  level,  " P u e r p e r a l Change," N u r s i n g O u t l o o k ,  753.  ^ M a r g a r e t P. M y l e s , A T e x t b o o k f o r M i d w i v e s , E . & S. L i v i n g s t o n e L t d . , 1 9 6 1 ) , p . 4 6 3 . 1  during  t h e time  organs r e t u r n t o t h e i r  Lochia,  J  Other changes  hormone p r o l a c t i n ,  i s also  i s r e d u c e d t o two a n d one h a l f 1  t h e end o f s i x weeks.  dramatic  The p u e r p e r i u m  the generative  Thus,  following  gurgh:  i s immed-  t h e a d d i t i o n a l ' . " 36 " p e r c e n t ^ b l o o d volume,, wfiieh j e y o l v e d  pregnancy,  IX  internal  o f t h e baby.  week t h e t o t a l w e i g h t l o s s  i n the puerper-  o f t h e baby t h e r e  o f p r e s s u r e on crowded  as t h e i n s t a n t weight  ivery,  PUERPERIUM  Changes  The  iate  OCCURRING IN  (Edin-  l6 while that of progesterone i s increased twenty-five times. With the e x p u l s i o n o f t h e p l a c e n t a t h e r e i s an a b r u p t f a l l i n the l e v e l s o f these hormones and t h e l e v e l s r e m a i n v e r y 17 low u n t i l t h e m e n s t r u a l c y c l e i s resumed. '  The e f f e c t o f  the sudden changes i n these hormone l e v e l s has o f t e n been a t t r i b u t e d , although  n o t p r o v e n , t o t h e l a b i l i t y " o f mood 18 observed i n postpartum women. P s y c h o s o c i a l and E n v i r o n m e n t a l Changes The  expressions  l a b i l i t y o f mood i s shown by sudden swings from  o f h a p p i n e s s t o those' o f sadness and by an over19  s e n s i t i v i t y t o t h e remarks and a c t i o n s o f o t h e r s .  As w e l l  as l a b i l i t y o f mood, a s t a t e o f m i l d c o n f u s i o n has o f t e n 20 been r e p o r t e d as f r e q u e n t l y o c c u r r i n g i n postpartum women. The  changes i n t h e r o l e s o f postpartum women a r e c o n s i d e r a b l e  and w i l l be d i s c u s s e d s e p e r a t e l y . a l s o marked.  E n v i r o n m e n t a l changes a r e  The l i t e r a t u r e commonly c i t e d d i s r u p t i o n i n  the a c t i v i t i e s o f d a i l y l i v i n g i n c u r r e d by the h o s p i t a l s t a y . The  changes r e q u i r e d i n a d j u s t i n g t o h o s p i t a l r o u t i n e s a r e • ^ H a m i l t o n , op. c i t . , pp. 112-13. 1 7  I b i d . , p. 113.  1R  A.A. Baker, P s y c h i a t r i c D i s o r d e r s i n O b s t e t r i c s ( S a l i s b u r y ! The S a l i s b u r y P r e s s L t d . , 1967), p. 39; Kane, op. c i t . , p. 101; A.A. Robin, "The P s y c h o l o g i c a l Changes o f Normal P a r t u r i t i o n , " P s y c h i a t r i c Q u a r t e r l y . XXXVI (January, 1962), 139; I r v i n Yalom and O t h e r s , "'Postpartum B l u e s ' Syndrome," A r c h i v e s o f G e n e r a l P s y c h i a t r y , X V I I I (January, 1968), 16. 19  ^Robin, l o c . c i t . 20 H a m i l t o n , op. c i t . , p. 109; Kane, op. c i t . , p. 101; Robin, op. c i t . , p. 147. ;  usually quite exacting. contend with sical  h o s p i t a l noises,  discomforts.  r e t u r n home w i t h changes.  I n a d d i t i o n , p o s t p a r t u m women must i n t e r r u p t i o n o f s l e e p , and phy-  Following  the h o s p i t a l stay  the mother's  a new f a m i l y member c o n s t i t u t e s f u r t h e r  F o r the mother w i t h  her f i r s t  baby t h e a r r i v a l  means t h a t s h e must now assume t h e r e s p o n s i b i l i t y  of meeting  the  b a b y ' s n e e d s when she may be u n c e r t a i n o f what  are  o r how t h e y  c a n be met.  a home i n w h i c h t h e r e not  only  care  offspring case,  those  needs  F o r t h e m o t h e r t a k i n g a baby t o  i s already  a child  o r c h i l d r e n , s h e must  f o r t h e new baby b u t meet t h e n e e d s o f t h e o l d e r  i n t h e i r adjustment  t h e m o t h e r must  of s l e e p and r e s t , volved  home  t o a new s i b l i n g .  be p r e p a r e d  In e i t h e r  t o reduce h e r usual  a s w e l l a s cope w i t h  any o t h e r  amount  changes i n -  i n a d d i n g a new member t o t h e f a m i l y u n i t .  IV. Role theory  ROLE THEORY CONCEPTS has been d e s c r i b e d  by W r i g h t s m a n as" a n 21  orientation  toward i n t e r p e r s o n a l behaviour.  agreed with  Sarbin  that role  theory  regards  Wrightsman human c o n d u c t a s 22  the role  product  of the i n t e r a c t i o n  o f s e l f and r o l e .  i s g e n e r a l l y d e f i n e d as "the s e t o f behaviours  tions appropriate  The t e r m or func-  f o ra person holding a p a r t i c u l a r p o s i t i o n  within a particular  social  context." -^ 2  Rubin concurred  with  Lawrence S. Wrightsman, S o c i a l P s y c h o l o g y i n t h e (Montereys B r o o k s / C o l e P u b l i s h i n g Company,  1972),  Seventies P.  23.  2 2  Ibid. Ibid.  L i n t o n i n d e f i n i n g a p o s i t i o n as "the achieved  or a s c r i b e d  s o c i a l s t a t u s r e s u l t i n g from the performed or a n t i c i p a t e d a c t i v i t i e s o f persons e n a c t i n g s p e c i f i c r o l e s , a c o g n i t i v e o r g a n i z a t i o n of r i g h t s and o b l i g a t i o n s i n a s o c i a l l y  defined  ok.  situation."  Thus, every person occupies a number o f p o s i -  t i o n s and enacts a number o f r o l e s .  Robischon and S c o t t  d e f i n e d a r o l e as a p a t t e r n o f needs and g o a l s ,  beliefs,  f e e l i n g s , v a l u e s , a t t i t u d e s , and a c t i o n s , expected by the community, which should be c h a r a c t e r i s t i c o f the occupant o f 25 a position.  J  A c c o r d i n g l y , r o l e behaviours  d i t i o n e d , and r e i n f o r c e d . l e a d to r o l e c o n f l i c t researchers.  are learned,  con-  That p o o r l y d e f i n e d r o l e s may  i s noted by Robischon and many other  Other f a c t o r s l e a d i n g t o r o l e c o n f l i c t a r e con-  f l i c t i n g pressures,  complexity  of r o l e s t o be l e a r n e d , and 2.f>  d i f f e r e n c e between r o l e and emotional phasized  needs.  Robischon em-  t h a t r o l e c o n f l i c t i s a p p r o p r i a t e a t times and t h a t  the a n x i e t y and t e n s i o n aroused may be used t o f a c i l i t a t e h e a l t h y .'adaptation.  27  The g o a l i n the process  of r o l e - t a k i n g i s i d e n t i t y .  Rubin, c o n c u r r i n g with E r i c k s o n , d e s c r i b e d an e s t a b l i s h e d i d e n t i t y as a sense of being i n a r o l e , a sense o f ease about ^ R e v a Rubin, "Attainment o f Maternal Role. P a r t 1, Processes," N u r s i n g Research, XVI (Summer, 1967). 237. 2  ^ R o b i s c h o n and S c o t t , op. c i t . , p. 52  2 6  2 7  I b i d . , p. 53. I b i d . , p. 54.  18 the p a s t and the f u t u r e . mine how  Rubin r e p o r t e d a study t o d e t e r 29  the m a t e r n a l r o l e i d e n t i t y i s a c h i e v e d .  / b u i l t 'upon Mead's concept and S a r b i n ' s concept  7  She  of " T a k i n g - i n - t h e - r o l e - o f - o t h e r "  o f " a d o p t i n g the ways o f o t h e r s " t o  d e s c r i b e the a t t a i n m e n t o f the m a t e r n a l  role.  A c c o r d i n g t o Rubin t h e r e a r e t h r e e dimensions  to  becoming a mother; the s e l f - c o n c e p t or s e l f system as o b j e c t , the p r o c e s s as>mode, and the model o r r e f e r r a n t as the subject.-*  0  The d a t a o b t a i n e d by the study o f the s e l f system  Vwere" c l a s s i f ie.d. i n t o - t h r e e c a t e g o r i e s as the i d e a l image, .the s e l f image, and the body image.  Rubin s t a t e d t h a t the t a k i n g  i n of the m a t e r n a l r o l e i s a c o n t i n u o u s p r o c e s s c a r r i e d  out  by a s e r i e s o f o p e r a t i o n s .  five  c a t e g o r i e s which ares  3 1  These o p e r a t i o n s f i t i n t o  mimicry,  role-play, fantasy, i n t r o -  j e c t i o n - p r o j e c t i o n - r e j e c t i o n , and g r i e f work.  The f i v e  a t i o n s o c c u r i n s e q u e n t i a l o r d e r and v a r y i n the time  oper-  taken  f o r each. Rubin c l a s s i f i e d the f i v e o p e r a t i o n s i n t o the f o l l o w i n g phases: i n " phase, and  (3)  (1) the " t a k i n g - o n " phase, (2) the " t a k i n g the " l e t t i n g - g o " phase.  The  taking-on  phase i n c l u d e s the o p e r a t i o n s o f m i m i c r y and r o l e p l a y .  Mimi-  c r y r e f e r s t o the a d a p t i n g of b e h a v i o u r s , such as d r e s s , t o 28 c e s s e s , " i b iRubin, d . , p. "Attainment 243.  29I b i d . , pp. 237-45. 2 9  30 3 1  I b i d . , p.  I b i d . , pp.  240. 240-45.  of Maternal Role.  P a r t 1.  Pro-  those which symbolize the s t a t u s the woman wishes to a t t a i n . Although s i m i l a r t o mimicry,  r o l e p l a y symbolizes and a c t s  ou,t the expected behaviour.  The t a k i n g - i n phase i n v o l v e s  the o p e r a t i o n of f a n t a s y and the o p e r a t i o n of i n t r o j e c t i o n projection-reject ion.  Fantasy d i f f e r s from r o l e p l a y i n  t h a t there i s no a c t i n g - o u t . dreams i n v o l v e the s e l f .  Wishes, f e a r s , day-dreams, and  The baby i s seen as "an.extension 32  of s e l f ,  the wished-for s e l f , and the dreaded-self."-^  The  f a n t a s y o p e r a t i o n promotes a c t i v i t y such as p l a n n i n g , e f f o r t s to be r e a l i s t i c , and e f f o r t s to g a i n more i n f o r m a t i o n by which to v e r i f y or negate the f a n t a s y m a t e r i a l .  The  intro-  j e c t i o n - p r o j e c t i o n - r e j e c t i o n o p e r a t i o n i s s i m i l a r to mimicry but the d i s t i n c t i o n i s that i t begins w i t h s e l f moves t o f i n d a r o l e model from without  (introjection),  ( p r o j e c t i o n ) , and com-  pares the behaviour of the r o l e model with the behaviour b e i n g experienced.  In the event that there i s poor  correspondence,  t h a t r o l e model i s r e j e c t e d and another sought.  Rubin  des-  c r i b e d the o p e r a t i o n i n the l e t t i n g - g o phase as g r i e f work. G r i e f work i s the l e t t i n g - g o of former i d e n t i t i e s which are a s s o c i a t e d with r o l e s incompatible with the a n t i c i p a t e d  new  role. F i n a l l y , Rubin examined the model i n r e l a t i o n t o attainment of maternal role.33 - ^ I b i d . , p.  <phe study showed that a l l of  242.  -'-'Reva Rubin, "Attainment of Maternal Role, P,art 11, Models and R e f e r r a n t s . " Nursing Research. XVI ( F a l l , 1967), 343-346.  20 the  s u b j e c t s began with t h e i r own mothers,  o r i e s o f t h e i r mothers,  or r e v i v e d mem-  f o r each phase o f r o l e a t t a i n m e n t .  The mothers were then r e p l a c e d by peers i n p a r a l l e l o r h i g h e r stages toward r o l e attainment.  I t was found t h a t p r i m i p a r a s  mostly chose peer models from the extended f a m i l y . work i n r e l a t i o n t o the s u b j e c t ' s mothers i n v o l v e d for  and s e p a r a t i o n from c o m f o r t i n g maternal c a r e . V.  The g r i e f longing  34  SLEEP NEEDS  During the l a s t twenty y e a r s c o n s i d e r a b l e r e s e a r c h has been 'carried out on the many a s p e c t s o f s l e e p .  Conse-  q u e n t l y , s l e e p needs have become more p r e d i c t a b l e .  Research  i n t o the nature o f s l e e p has shown t h a t s l e e p occurs i n c y c l e s of  approximately e i g h t y - f i v e  to n i n e t y minutes i n the young  adult.35 During a t o t a l o f about seven and o n e - h a l f hours s l e e p the average a d u l t , h a s about f o u r to s i x sleep per  cycles  n i g h t . A s l e e p c y c l e c o n s i s t s o f two phases, the f i r s t  of which I s termed n o n - r a p i d eye movement (NREM) s l e e p , and the  second o f which i s termed r a p i d eye movement (REM) s l e e p . NREM s l e e p c o n s i s t s o f f o u r s t a g e s .  Stage 1 i s  a l i g h t s l e e p from which a person may be, e a s i l y woken.  The  s l e e p i n c r e a s e s i n depth with each stage and i s deepest i n stage 4.  An a d u l t goes from wakefulness t o stage 1 when he  3  ^ I b i d . , p. 344.  35 -'-'Nathaniel Kleitman, Sleep and Wakefulness (Chicago: U n i v e r s i t y o f Chicago Press, 1963), p. 112. -^Susanna Lee Garner and Pamela M i t c h e l l , "Comfort and S l e e p , " Concepts B a s i c t o N u r s i n g (McGraw H i l l Book Company, 1973), p. 438.  21 f a l l s a s l e e p and then proceeds  t o stage 2, then to stage 3,  and then t o Stage 4 over a p e r i o d of around minutes. minutes,  The i n d i v i d u a l remains  twenty t o t h i r t y  i n stage 4 f o r around  thirty  a f t e r which time he moves back through the stages t o  stage 1 or 2.  The i n d i v i d u a l then moves i n t o a p e r i o d o f REM  s l e e p which may l a s t f o r t e n t o t h i r t y minutes.  At the end  of  the REM p e r i o d the i n d i v i d u a l p r o g r e s s e s from stage 1 o r 2  to  stages 3 and 4, thereby b e g i n n i n g another s l e e p cycle. ''' 3  The c h a r a c t e r o f the s l e e p c y c l e changes with the l e n g t h of time the i n d i v i d u a l remains a s l e e p . of  The m a j o r i t y  stage 3 and 4 s l e e p occurs d u r i n g the f i r s t h a l f o f the  n i g h t ' s s l e e p w h i l e the m a j o r i t y of REM s l e e p occurs i n the l a s t h a l f o f the n i g h t ' s s l e e p .  J  I f , however, an i n d i v i d u a l  i s awakened, the s l e e p c y c l e i s n o t resumed a t the stage i n which the i n t e r r u p t i o n occurred but, r a t h e r , i t begins a g a i n at  stage I .  of  s l e e p , the missed NREM s l e e p i s made-up before the missed  3  9  Furthermore,  stage 1-REM s l e e p .  when there has been a d e f i c i t  A l s o , i t was noted by Garner and M i t c h e l l  t h a t "people who a r e d e p r i v e d o f stage 1-REM s l e e p have d i f f i c u l t y i n c o p i n g with r e c e n t s t r e s s f u l e x p e r i e n c e s . " of  Some  the b e h a v i o u r a l changes manifested with stage 1-REM s l e e p  d e p r i v a t i o n are increased a p p e t i t e , anxiety, and d i f f i c u l t y i n c o n c e n t r a t i n g .  , 38-39. k  3 7  I b i d . , pp.  3 8  I b i d . , p. 439.  3 9  I b i d . , p. 442.  k  °Ibid., p. 443.  irritability,  Stage 1-REM s l e e p d e p r i v a -  t i o n i s thought t o o c c u r when an i n d i v i d u a l s l e e p s a t i n t e r v a l s o f l e s s t h a n one hour o r f o r a t o t a l o f o n l y t h r e e t o hi  f o u r hours every t w e n t y - f o u r h o u r s . W r i t i n g on s l e e p needs d u r i n g the m a t e r n i t y c y c l e , W i l l i a m s drew a t t e n t i o n t o the f a c t t h a t women may be i n a s t a t e of acute sleep d e p r i v a t i o n immediately f o l l o w i n g 42 delivery. VI.  THE POSTPARTUM BLUES  I n the few s t u d i e s t h a t have been done on the development o f Postpartum B l u e s the scope has been l i m i t e d . H a m i l t o n commented on the inadequacy o f the l i t e r a t u r e i n i n t h i s area.  I n h i s r e v i e w o f the l i t e r a t u r e H a m i l t o n  s t a t e d t h a t i n I838 E s q u i r o l suggested t h a t the i n c i d e n c e o f m e n t a l i l l n e s s i n the puerperium f a r exceeded cases h o s p i t a l i z e d .  J  the number o f  L a t e r i n the n i n e t e e n t h c e n t u r y o t h e r s  d e s c r i b e d a t r a n s i t o r y m e n t a l i l l n e s s i n which t h e r e was conf u s i o n , e x c i t e m e n t , and i n s o m n i a .  This t r a n s i t o r y  mental  i l l n e s s , H a m i l t o n s a i d , was r e f e r r e d t o a s " m i l k f e v e r " b e cause i t s o c c u r r e n c e was observed t o c o i n c i d e w i t h the b e g i n n i n g of m i l k f l o w .  Moloney, i n 1952* d e s c r i b e d a m i l d  depress  i o n r e a c t i o n o f despondency, f a t i g u e , i n a b i l i t y t o t h i n k c l e a r l y , and t e a r f u l n e s s i n the f i r s t week p o s t p a r t u m .  44  ^ I b i d . , p. 442. ^ B a r b a r a W i l l i a m s "Sleep Needs D u r i n g the M a t e r n i t y C y c l e , " N u r s i n g Outlook, XIV ( F e b r u a r y , 1967), 54. ^ H a m i l t o n , op. c i t . , p. 107. ^ I b i d . , p. 108.  23 In 1955 S e l a r e r e p o r t e d t h a t a h i g h p e r c e n t a g e o f women e x p r e s s e d f e e l i n g s o f m i l d t o moderate d e p r e s s i o n toward the end o f t h e f i r s t postpartum week.  J  Hamilton c i t e d a  s t u d y by P l e s c h e t e and o t h e r s i n 1956 which r e v e a l e d t h a t s i x t y p e r c e n t o f p u e r p e r a l women r e p o r t e d some degree o f d e p r e s s i o n a t some t i m e i n t h e six-week p e r i o d .  Due t o t h e  shortcomings o f t h e l i t e r a t u r e , H a m i l t o n conducted a n e x p l o r a t o r y study u n d e r t a k e n t o f u r t h e r d e l i n e a t e Postpartum B l u e s . The s t u d y showed l a c k o f energy and f a t i g u a b i l i t y , e p i s o d e s o f c r y i n g , a n x i e t y and f e a r , c o n f u s i o n , headaches, i n s o m n i a , worry about p h y s i c a l symptoms and s t a t e s , and n e g a t i v e a t t i t u d e s toward t h e husband. H a m i l t o n n o t e d t h e s i m i l a r i t y o f t h e symptoms t o the prodromal symptoms o f t h e more severe p u e r p e r a l d e p r e s s ion.  He suggested t h a t s e v e r e i n s o m n i a i s f r e q u e n t l y a n a n t e -  cedent t o p u e r p e r a l d e p r e s s i o n .  Y e t i n s o m n i a was r e p o r t e d  o n l y o c c a s i o n a l l y by women i n t h i s s t u d y .  Therefore, Hamilton  suggested t h e p o s s i b i l i t y t h a t t h e syndromes may be s i m i l a r i n cause and s t r u c t u r e and t h a t r a p i d r e c o v e r y o r d e t e r i o r a t i o n may  be determined by t h e a b i l i t y o r i n a b i l i t y t o s l e e p . A s t u d y by Yalom and o t h e r s showed a c o r r e l a t i o n  of s l e e p l e s s n i g h t s w i t h h i g h d e p r e s s i o n s e l f - r a t i n g 47 i n the puerperium.  '  scores  The a u t h o r s l i k e w i s e p o s t u l a t e d t h a t  some o f t h e v a r i a b l e s a s s o c i a t e d w i t h postpartum d e p r e s s i o n ^ I  D  i  d  .  46  ^°Ibid., pp. 108-111. 47 'Yalom and Others, op. c i t . , p. 20.  24 a l s o c o r r e l a t e w i t h Postpartum  Blues.  The v a r i a b l e s  cited  i n t h e s t u d y were low p a r i t y and h i g h r e c u r r e n c e r a t e o f 48 Postpartum B l u e s . Other s t u d i e s have a l s o c i t e d Postpartum 49 Blues as a f a c t o r m  t h e development o f p u e r p e r a l d e p r e s s i o n .  I n a d d i t i o n t o these f a c t o r s t h e study by Yalom e t a l showed o t h e r f a c t o r s o f p a s t h i s t o r y r e l a t e d t o t h e d e v e l opment o f ' P o s t p a r t u m B l u e s . of p r e v i o u s pregnancy,  The f a c t o r s were g r e a t e r d i s t r e s s  greater menstrual d i f f i c u l t i e s ,  lower  age o f menarche, i r r e g u l a r i t y o f p e r i o d s , and a s h o r t e r l e n g t h of m e n s t r u a l flow.-5°  The m e n s t r u a l d i f f i c u l t i e s g i v e n were  dysmenorrhoea and p r e m e n s t r u a l t e n s i o n , each o f which have ~ been c i t e d i n a n o t h e r study as a f a c t o r i n p u e r p e r a l d e p r e s s ion.51 The .occurrence o f Postpartum  31ues a t a time when  hormone l e v e l s a r e d r a s t i c a l l y changed i s n o t e d i n t h e l i t e r ature.  Baker compared t h e mood changes o f Postpartum  Blues  to the emotional i n s t a b i l i t y o c c u r r i n g a t puberty, i n the p r e - m e n s t r u a l phase, and a t t h e menopause, when major a l t e r a t i o n s i n hormonal l e v e l s o c c u r . ^  2  Although reference to the  l i k e l y r e l a t i o n s h i p o f hormone l e v e l s t o mood i s commonplace 48  *°Ibid., p. 26.  49t ^Hamilton,  op. c i t . , p. 111$ Melges, P s y c h i a t r i c Syndromes," Psychosomatic M e d i c i n e , ( J a n u a r y - F e b r u a r y , 1968), 10?$ R. P a f f e n b a r g e r , P u z z l e o f t h e Postpartum P s y c h o s e s , " J o u r n a l o f eases, X I I I ( F e b r u a r y , 1961), 161-73.  "Postpartum XXX, "The P i c t u r e Chronic Dis-  ^°Yalom and Others, op. c i t . , p. 25. ^ B r i c e P i t t , " • A t y p i c a l " Depression F o l l o w i n g C h i l d b i r t h , " B r i t i s h J o u r n a l o f P s y c h i a t r y , CXIV (1968), 1329; Melges, op. c i t . , p. 98. ^ Baker, 2  op. c i t . , p. 34.  7  i n the l i t e r a t u r e , no d e f i n i t i v e s t u d i e s t o date have proved a relationship. R e f e r r i n g t o common emotional r e a c t i o n s i n the puerperium,  Baker suggested  t h a t h o s p i t a l r e s t r i c t i o n s cause  a n x i e t y and f r u s t r a t i o n t o b u i l d up so t h a t when the mothers go home they experience r e a c t i o n s t o these f e e l i n g s . ^  In a  study by Larsen, l a c k o f emotional support from nurses,  doc-  t o r s , and husbands d u r i n g l a b o u r was c i t e d as the most s t r e s s f u l f e a t u r e o f the h o s p i t a l s t a y . ^ * During the puerperium a t home, the s t r e s s e s were r e p o r t e d as d i f f i c u l t y a d j u s t i n g to the baby's needs, t o housework r o u t i n e , and t o other c h i l d ren's needs, and t o i n t e r f e r e n c e from members o u t s i d e o f the household,  i n c r e a s e d company, and worry over a b i l i t y t o cope  with the f a m i l y ' s needs. Gordon, Kapostins, and Gordon r e p o r t e d a study which showed maternal r o l e c o n f l i c t and p e r s o n a l i n s e c u r i t y as f a c t o r s r e l a t e d t o abnormal emotional r e a c t i o n s t o pregnancy and c h i l d b e a r i n g . ^ maternal r o l e were:  Items r e l a t e d t o c o n f l i c t with  no r e l a t i v e s a v a i l a b l e f o r h e l p w i t h  baby care; d i f f e r e n c e s i n l e v e l s o f education and o c c u p a t i o n of the parents o f the new baby and t h e i r p a r e n t s : and the  5 3  Ibid.,  p. 41.  V i r g i n i a L. Larsen, " S t r e s s e s o f the C h i l d b e a r i n g Year," American J o u r n a l o f P u b l i c H e a l t h . LVI ( J a n u a r y , 1 9 6 6 ) , J  33. 5 5  Ibid.,  p. 3 4 - 3 5 .  66  . R i c h a r d E. Gordon, E l i E. Kapostins and Katherine K. Gordon, "Factors i n Postpartum Adjustment," O b s t e t r i c s and Gynecology. XXV (February, 1 9 6 5 ) , 1 5 9 - 6 6 . J  26 husband o f t e n away from home.  The p e r s o n a l i n s e c u r i t y  items  were p r i m i p a r i t y ; c o m p l i c a t i o n s o f pregnancy i n the f a m i l y h i s t o r y ; the husband's f a t h e r dead; the woman's mother dead; the woman's e d u c a t i o n i n c o m p l e t e ; and no p r e v i o u s e x p e r i e n c e with babies.  I l l n e s s d u r i n g o r a p a r t from pregnancy were  i t e m s r e l a t e d t o both  factors.  In a n o t h e r s t u d y , L a r s e n and Others l i s t e d  social  s t r e s s items a s those c i t e d and o t h e r s used by Gordon and Gordon.  Among the o t h e r items were unplanned pregnancy,  i n t e r - r e l i g i o u s m a r r i a g e , p a r e n t s s e p a r a t e d , and husband's p a r e n t s separated.-''  A d d i t i o n a l l y , two s t r e s s f a c t o r s r e -  p o r t e d by B i b r i n g were n o t e d .  These f a c t o r s were a weak  r e l a t i o n s h i p between the woman and h e r male p a r t n e r and a weak r e l a t i o n s h i p between the woman and h e r mother. VII.  SUMMARY  T h i s r e v i e w o f the l i t e r a t u r e was p r e s e n t e d i n five parts.  The f i r s t p a r t r e v i e w e d the l i t e r a t u r e  c o n s i d e r e d the puerperium puerperium  was  a s a developmental  crisis.  which The  viewed a s a stage o f development, d u r i n g which  time c e r t a i n t a s k s must be a d e q u a t e l y a c h i e v e d . of the t a s k s t o be a c h i e v e d was a crisis situation.  The  nature  seen t o f r e q u e n t l y c o n s t i t u t e  The l i t e r a t u r e a l s o p o i n t e d out t h a t  57  ~- L—a^rfswe.n» and Ovtuhuecriss,i Pxx e&nuImimV. i r g i n i a L. r ecuxu d i c tuxuu i o n and provement o f Postpartum Adjustment ( u n p u b l i s h e d r e s e a r c h r e p o r t , Washington, 1968), 13-25.  -^Grete L. B i b r i n g , " R e c o g n i t i o n o f P s y c h o l o g i c a l S t r e s s o f t e n N e g l e c t e d i n 0 B Care" H o s p i t a l T o p i c s . I L (September, 1966), 101-102.  2? professional assistance  i n the management^of a c r i s i s  improve the i n d i v i d u a l ' s s t r e n g t h and The  can  maturity.  second p a r t reviewed the l i t e r a t u r e which  i d e n t i f i e d some of the many normal changes o c c u r r i n g i n the puerperium.  I t was  found t h a t b i o p h y s i c a l and  psychosocial  changes are profound, e s p e c i a l l y i n the e a r l y puerperium. Environmental changes i n v o l v e d i n adjustment to the t a l environment and f a m i l y with a new were shown to be The  r o u t i n e s , and  s t r u c t u r e and  hospi-  then r e i n t e g r a t i o n to a  an a l t e r e d p a t t e r n of needs  great.  t h i r d s e c t i o n reviewed the l i t e r a t u r e which  d e a l t with some concepts of r o l e theory.  I t was  indicated  t h a t attainment of the maternal r o l e i s a p r o c e s s reached by s e q u e n t i a l The needs.  steps. f o u r t h p a r t reviewed the l i t e r a t u r e on  Frequent i n t e r r u p t i o n s of s l e e p or an  amount of s l e e p was  shown to be  sleep  inadequate  detrimental.  F i n a l l y , the l i t e r a t u r e reviewed i n the  fifth  p a r t examined f a c t o r s r e l a t i n g to the Postpartum Blues. many c o n f l i c t s and  needs c r e a t e d by the changing r o l e of  t h i s p e r i o d were shown to be prominent. c i t y of r e s e a r c h  The  i n the a r e a p o i n t e d  However, the  scar-  to the u s e f u l n e s s  study to f u r t h e r examine some of the f a c t o r s i m p l i c a t e d the development of Postpartum  Blues.  of a in  CHAPTER I I I . RESEARCH DESIGN AND  DEVELOPMENT  OF THE STUDY T h i s study area  of British  research.  was c o n d u c t e d i n t h e G r e a t e r  Columbia u s i n g  Information  t h e d e s c r i p t i v e method o f  p e r t i n e n t t o the study  by means o f t h e i n t e r v i e w method o f d a t a cause o f the nature sample s i z e  pital  gathered  collection.  the interview  Patient records  Be-  relevant medical  seemed t h e most  were r e v i e w e d  f r o m w h i c h t h e s u b j e c t s were c h o s e n .  provided  was  o f the i n f o r m a t i o n r e q u i r e d and the s m a l l  of the population,  s u i t a b l e method.  Vancouver  i n the hos-  These  records  h i s t o r y and demographic  data.  T w a n t y - n i n e p o s t p a r t u m women were i n t e r v i e w e d i n h o s p i t a l and once i n t h e i r u s u a l p l a c e s I. The  once  of residence.  SELECTION OF THE STUDY GROUP  Setting The  s u b j e c t s were c h o s e n f r o m t h e p o p u l a t i o n  o b s t e t r i c s and gynecology h o s p i t a l i n the G r e a t e r area  following approval  part  Director  o f the study  of Nursing  Vancouver  by t h e h o s p i t a l a d m i n i s t r a t i o n .  A l e t t e r requesting permission first  of an  t o conduct the  i n t h e h o s p i t a l was s e n t  of that hospital,  .ary ;of t h e p r o p o s e d r e s e a r c h . i o n t o view p a t i e n t r e c o r d s  together  The l e t t e r  t o the  with  requested  a summr permiss-  and t o approach p o t e n t i a l s u b j e c t s .  28  29 The  Subjects The  s u b j e c t s s e l e c t e d were t h i r t y - o n e p o s t p a r t u m  women, s i x t e e n o f whom were p r i m i p a r a s a n d f i f t e e n were m u l t i p a r a s . order  No r e s t r i c t i o n s were p l a c e d  t h a t Postpartum  whatever p a r i t y dropped from  Blues  Two p r i m i p a r a s  study  were  due t o t h e i r h o s p i t a l i z a t i o n a t a n d  b e y o n d t h e t i m e when t h e home i n t e r v i e w was The  on p a r i t y i n  c o u l d be s t u d i e d i n r e l a t i o n t o  t h e sample i n c l u d e d .  the study  o f whom  following criteria  scheduled.  for eligibility  t o the  were a p p l i e d : S u b j e c t s must be w i l l i n g  study.  Two p o t e n t i a l  s u b j e c t s who were a p p r o a c h e d  some h e s i t a n c e when i n v i t e d  to participate  t h e r e f o r e were n o t i n c l u d e d . t h a t any h e s i t a n c y b e f o r e s t u d y may r e d u c e giving,  to participate  showed  i n the study and  The i n v e s t i g a t o r  considered  agreement t o p a r t i c i p a t e  t h e commitment  i n the  in.the  to correct information-  a n d t o t h e s e c o n d i n t e r v i e w a t home. S u b j e c t s must s p e a k f l u e n t E n g l i s h , must h a v e  the  last  three years  or s i m i l a r  i n Canada, a n d must be o f A n g l o - S a x o n  ethnic origin.  These c r i t e r i a  p o p u l j a t i o n t o a more homogeneous ered  that vastly  different  limited  background.  among t h e  of the r e s u l t s  the study. S u b j e c t s must h a v e l i v e d w i t h  new  t h e sample  I t was c o n s i d -  background experiences  subjects could i n f l u e n c e the i n t e r p r e t a b i l i t y of  spent  baby f o r a t l e a s t  toward s e l e c t i n g s h i p s were more  two y e a r s .  the f a t h e r o f the  This c r i t e r i a  was d i r e c t e d  s u b j e c t s whose m a r i t a l o r p a r t n e r likely  t o be s t a b l e .  relation-  30 The age o f the s u b j e c t must be between s i x t e e n and t h i r t y - f i v e y e a r s .  T h i s c r i t e r i a was  s e t because o f a  h i g h e r i n c i d e n c e r a t e o f both f o e t a l and m a t e r n a l  complica-  t i o n s under s i x t e e n y e a r s and over t h i r t y - f i v e y e a r s of S u b j e c t s must have had no major d i s e a s e  T h i s c r i t e r i a was  1  throughout  the c h i l d b e a r i n g p r o c e s s , o r any c h r o n i c h a n d i c a p p i n g according to s e l f - r e p o r t .  age.  disease,  set to avoid  c o n f l i c t i n g f a c t o r s b i a s i n g the r e s u l t s o f the  study.  S u b j e c t s must have had a v e r t e x - p r e s e n t i n g v a g i n a l delivery.  For p r i m i p a r a s - w i t h i n the time p e r i o d of e i g h t e e n  hours from the s t a r t o f r e g u l a r c o n t r a c t i o n s t e n m i n u t e s a p a r t to the e x p u l s i o n of the p l a c e n t a , and f o r m u l t i p a r a s - twelve hours.  The average d u r a t i o n of l a b o u r i s c o n s i d e r e d t o be  about f o u r t e e n hours f o r p r i m i p a r a s and about e i g h t h o u r s f o r  2 multiparas. head was  O u t l e t - f o r c e p s a s s i s t a n c e i n the d e l i v e r y o f the  c o n s i d e r e d a d m i s s i b l e . A l s o , e p i s i o t o m i e s and  and second degree p e r i n e a l l a c e r a t i o n s were a c c e p t e d . these l i m i t s extraneous o f the  first Beyond  f a c t o r s a g a i n might b i a s the r e s u l t s  study. The newborn i n f a n t s o f s u b j e c t s must show no  evi-  dence o f i l l n e s s o r d e f o r m i t y and must e q u a l o r exceed the b i r t h weight of s i x pounds.  The  i n f a n t ' s medical  d a t a were examined f o r t h i s i n f o r m a t i o n .  history  The Apgar S c o r e s  r e c o r d e d a t one and a t f i v e minutes a f t e r b i r t h ranged beErna Z i e g e l and C a r o l y n C. Van Blarcom, Obstetr i c a l N u r s i n g (New York: The M a c m i l l a n Company, 1972), p.  233.  2  Ibid.  31 tween e i g h t assessment  and t e n a t each a p p r a i s a l and t h e P e d i a t r i c i a n ' s o f each baby's c o n d i t i o n  In a d d i t i o n , written  subjects  c o n s e n t form, a copy  was  favourable.  were r e q u i r e d  o f which  to sign a  i s included  i n Appen-  d i x A. Initial  Contact with the Subjects Patient  bility  records  of subjects  were i n i t i a l l y  f o r the study.  The e l i g i b l e  were t h e n a p p r o a c h e d by t h e i n t e r v i e w e r for  the subjects  then introduced graduate that  h e r s e l f by'name a n d s t a t e d  student a t the U n i v e r s i t y  s i x weeks f o l l o w i n g  told and  that  the study  one i n t h e s u b j e c t s '  later.  that  s h e was a  Columbia and  on m o t h e r s ' f e e l i n g s i n t h e of t h e i r babies.  The p o t e n t i a l s u b j e c t s  involved  one i n t e r v i e w  homes a b o u t t h r e e  Confi-  were  and o n e - h a l f  o f the  INSTRUMENTATION  A v a r i e t y o f i n s t r u m e n t s were u s e d t o o b t a i n  for  this  study.  Two s e m i - s t r u c t u r e d  use i n the h o s p i t a l i n t e r v i e w  interview, review  weeks  women.  II.  in  also  i n the h o s p i t a l  P a r t i c i p a t i o n i n t h e s t u d y was t h e n r e q u e s t e d  postpartum  time  The i n v e s t i g a t o r  of British  the b i r t h  d e n t i a l i t y was e x p l a i n e d .  subjects  a t a convenient  and t h e h o s p i t a l . s t a f f .  s h e was c o n d u c t i n g a s t u d y  first  reviewed f o r e l i g i -  were d e v e l o p e d .  o f the l i t e r a t u r e  mation relevant"  interview  s c h e d u l e s , one  a n d one f o r u s e i n t h e home  These were d e s i g n e d  a n d were i n t e n d e d  t o the research  data  problem.  following a  to obtain  infor-  The Beck D e p r e s s i o n  32  Inventory, a standardized instrument  t o measure t h e degree  of d e p r e s s i o n , was used i n t h i s s t u d y .  Also, a question-  n a i r e on Postpartum,Blues, was developed t o o b t a i n t h e s e l f perceptions of the subjects.  The i n s t r u m e n t s  used i n t h i s  study a r e shown i n Appendix B. Each i n t e r v i e w conducted i n t h e h o s p i t a l and i n t h e s u b j e c t ' s home took between t h i r t y and seventy m i n u t e s t o complete.  To ensure anonymity, numbers were used t o i d e n t i f y  d a t a r a t h e r than t h e names o f t h e s u b j e c t s . H o s p i t a l I n t e r v i e w Schedule Some o f t h e q u e s t i o n s i n t h i s schedule were i n c l u ded t o o b t a i n background i n f o r m a t i o n .  Such q u e s t i o n s  cerned p l a c e o f r e s i d e n c e , m a r i t a l s t a t u s , p a r i t y , date o f c o n f i n e m e n t , s e x o f baby, and drugs  con-  expected  administered  while i n the h o s p i t a l . Some q u e s t i o n s were used t o o b t a i n d a t a t o ensure t h a t r e s p o n d e n t s met t h e c r i t e r i a o f e l i g i b i l i t y t o t h e s t u d y . These q u e s t i o n s concerned age, n a t i o n a l i t y , and l e n g t h o f time i n Canada, h i s t o r y o f any major i l l n e s s o r p s y c h i a t r i c  dis-  o r d e r , l e n g t h o f time l i v e d w i t h p a r t n e r , confinement date and time, l e n g t h o f l a b o u r , c o n d i t i o n o f perineum, w e i g h t o f baby and Apgar Score o f baby, and c u r r e n t h e a l t h s t a t u s o f the respondent and o f h e r baby. Other q u e s t i o n s were used t o o b t a i n i n f o r m a t i o n i n r e g a r d t o f a c t o r s mentioned i n t h e l i t e r a t u r e a s i m p l i c a t e d i n t h e development o f Postpartum B l u e s .  To p r o v i d e  informa-  t i o n t o a s s i s t i n a n s w e r i n g q u e s t i o n 1 ( c o n f l i c t w i t h mater-  33 n a l r o l e ) o f the study q u e s t i o n s on f a c t o r s l i k e l y  t o cause  r o l e - c o n f l i c t i n c l u d e d : the m a r i t a l s t a t u s , r e s i d e n c e , and  o c c u p a t i o n of the parents  education,  o f the respondent and the p a r -  ents o f h e r husband? the respondent's e a r l y e x p e c t a t i o n o f motherhood: the number o f c h i l d r e n a t home and the age o f the youngest c h i l d 5  the i n c i d e n c e o f any p h y s i c a l o r emotion-  a l problems w i t h any p r e v i o u s c h i l d b e a r i n g o r w i t h the p r e g nancy, l a b o u r , and b i r t h j u s t concluded? any problems i n c h i l d b e a r i n g experienced  by the respondent's immediate f e -  male r e l a t i v e s : the amount o f e d u c a t i o n a l p r e p a r a t i o n f o r childbirth?  concerns  labour, or b i r t h ,  experienced  d u r i n g t h i s pregnancy,  the amount o f time the husband i s away  fr.om home overnights  e x p e c t a t i o n s r e g a r d i n g the l a b o u r and  b i r t h experience} the presence  of the husband d u r i n g the  l a b o u r and b i r t h process} s e l f - p e r c e p t i o n s o f s i g n i f i c a n t a i d d u r i n g the l a b o u r and b i r t h process} and i n f a n t f e e d i n g style. To p r o v i d e i n f o r m a t i o n t o answer q u e s t i o n I I c r i n e f a c t o r s r e l a t e d t o the menstrual q u e s t i o n s o f menstrual  (endo-  c y c l e ) o f the study  h i s t o r y and l e n g t h o f time t r y i n g t o  conceive were i n c l u d e d . Finally,  t o p r o v i d e i n f o r m a t i o n t o a s s i s t i n answer-  i n g q u e s t i o n I I I ( r e d u c t i o n i n s l e e p c y c l e s ) o f the study questions  on s l e e p were i n c l u d e d . T h i s schedule was v e r b a l l y a d m i n i s t e r e d by the  investigator. Home Interview  Schedule  T h i s schedule was prepared  t o c o l l e c t data t o a s s i s t  i n answering two q u e s t i o n s asked i n the study.  Questions  asked to p r o v i d e i n f o r m a t i o n f o r q u e s t i o n I ( c o n f l i c t maternal  with  r o l e ) i n c l u d e d concerns ahout the baby, adjustment  difficulties,  and  e x t r a h e l p ; r e l a t i o n s h i p with mother and  husband; f e e l i n g s of happiness,  r e c e n t memory, d i s t r a c t -  a b i l i t y , and c o n c e n t r a t i o n power, f e e l i n g s of dependency, blocked g o a l s , and  entrapment.  These q u e s t i o n s were s t r u c -  tured i n a s i m i l a r manner to those i n the Beck Inventory, for  as was  t h i s was  the o r d e r i n g of the q u e s t i o n s .  t h a t the respondent was  Beck Depression  Inventory  immediately  a d m i n i s t r a t i o n of the schedule. was  The  The  reason  asked to answer the f o l l o w i n g the v e r b a l same format f o r both  used to f a c i l i t a t e the respondent's task of s e l e c t i n g  the most a p p r o p r i a t e answer.  Questions  regarding sleep  p r o v i d e d i n f o r m a t i o n f o r q u e s t i o n I I I of the The  Depression  Beck Depression  Inventory  T h i s instrument person who  study.  i s depressed.  f a c i l i t a t e s the r e c o g n i t i o n of a The  i n v e n t o r y was  developed  to  q u a n t i t a t i v e l y a s s e s s the degree of d e p r e s s i o n based on  char-  acteristic  symptoms and a t t i t u d e s e s t a b l i s h e d i n the l i t e r a -  ture.  i n v e n t o r y c o n s i s t s of twenty-one c a t e g o r i e s of  The  symptoms and a t t i t u d e s , each of which d e s c r i b e s a p a r t i c u l a r b e h a v i o u r a l m a n i f e s t a t i o n of d e p r e s s i o n . a t t i t u d e c a t e g o r i e s i n c l u d e mood, g u i l t , a c c u s a t i o n , s o c i a l withdrawal,  and  The  symptom-  pessimism,  self-  others.  Each category c o n t a i n s f o u r q u e s t i o n s which have n u m e r i c a l values ranked i n . order of s e v e r i t y from zero to three.  Beck's s t a t i s t i c a l t e s t s showed the instrument  to be  v a l i d and r e l i a b l e . postpartum  J  The i n v e n t o r y was used i n a study o f  mood change i n Jamaican women i n 1972.  Aitken  and Z e a l l e y confirmed the v a l i d i t y o f the Beck instrument, and more r e c e n t l y , P u r n e l l proved  i t t o be an a c c u r a t e aid.-*  The q u e s t i o n s on weight l o s s were; c o n s i d e r e d uns u i t a b l e f o r use with postpartum  women because o f the weight  l o s s normally o c c u r r i n g i n t h i s p e r i o d .  Therefore, f o u r  q u e s t i o n s were s u b s t i t u t e d f o r the o r i g i n a l ones. tended  I t was i n -  t o analyze these q u e s t i o n s on weight s e p a r a t e l y t o  d e t e c t a n y ^ d i f f e r e n c e s t h a t ^maychave R e s u l t e d from the s u b s t i tution.  However, i n view o f the i n s i g n i f i c a n t f i n d i n g s o f  the i n v e n t o r y , separate a n a l y s i s was n o t done. The Blues Q u e s t i o n n a i r e T h i s was an open-ended q u e s t i o n n a i r e t o e l i c i t the s e l f p e r c e p t i o n and knowledge o f s u b j e c t s c o n c e r n i n g Postpartum Blues.  The data obtained from t h i s q u e s t i o n n a i r e was  u s e f u l i n a s s e s s i n g t h e degree o f d i s t r e s s f e l t by those who experienced the Postpartum  Blues.  The omission o f the f i r s t  two q u e s t i o n s and the a d d i t i o n o f another two q u e s t i o n s was  -^A.T. Beck and. Others, "An Inventory f o r Measuring Depression," A r c h i v e s o f General P s y c h i a t r y , IV (June, 1968),  564-69.  4 J.R.T. Davidson, "Postpartum Mood Change m Jamaican Womens A D e s c r i p t i o n and D i s c u s s i o n on i t s S i g n i f i c a n c e , " B r i t i s h J o u r n a l o f P s y c h i a t r y , C;XX, (1972), 66O-63. ^R.C.B. A i t k e n and^A.K. Z e a l l y , "Measurement o f Moods," B r i t i s h J o u r n a l o f H o s p i t a l Medicine, IV (August, 1970), 221-24; Margery D. F u m e l l , "Adolescent Depression and I n t e r p e r s o n a l Behaviour" (Unpublished Master's T h e s i s , Univ e r s i t y o f B r i t i s h Columbia, 1973), 98-102.  36 made f o r the home i n t e r v i e w .  The m o d i f i e d Blues  Question-  n a i r e i s shown i n Appendix B. III. The educator  instruments  PRE-TEST  used were reviewed  by a nurse-  i n the m a t e r n a l - c h i l d area, a nurse-educator  i n the  r e s e a r c h area, and a p s y c h o l o g i s t engaged i n n u r s i n g r e s e a r c h . S e v e r a l adjustments were made t o reduce ambiguity.  The i n -  struments,  Schedule,  with the e x c e p t i o n o f the Home Interview  were a d m i n i s t e r e d t o two s u b j e c t s i n the same h o s p i t a l i n which the study was conducted.  A few f u r t h e r adjustments were made  f o r the purpose of c l a r i t y . administered  The Home Interview Schedule  was  t o two postpartum women i n t h e i r own homes i n  the Greater Vancouver a r e a . made t o the schedule  Likewise, a few, adjustments were  t o reduce  ambiguity.  The use of the p r e t e s t , as suggested  by A b d e l l a h  and Levine, i n c r e a s e d the v a l i d i t y and r e l i a b i l i t y o f the d a t a - c o l l e c t i n g instruments.^  Moreover, the p r e t e s t enabled  the i n v e s t i g a t o r t o g a i n some p r o f i c i e n c y i n the use o f the instruments. The Blues Q u e s t i o n n a i r e was a d d i t i o n a l l y p r e t e s t e d on twelve postpartum women i n t h e i r f i r s t  t e n days a t home.  The q u e s t i o n n a i r e was a d m i n i s t e r e d by n u r s i n g students i n the b a c c a l a u r e a t e program o f the U n i v e r s i t y of B r i t i s h  Columbia.  Faye G. A b d e l l a h and Eugene Levine, B e t t e r P a t i e n t Care Through Nursing Research (New York* The Macmillan Company, 1965), P. :."3.21.  No changes were made as the instrument the r e q u i r e d  seemed t o o b t a i n  information. IV.  THE INTERVIEWING PROCEDURE  The h o s p i t a l i n t e r v i e w was conducted d u r i n g the afternoon,  e x c l u d i n g the times t h a t meals were served,  were being f e d , v i s i t o r s were p r e s e n t ,  n u r s i n g treatment was  i n progress, o r the s u b j e c t was otherwise  engaged.  p i t a l Interview Schedule was v e r b a l l y administered, f o r the data which was obtained  babies  The Hosexcept  from the p a t i e n t r e c o r d .  At  the c o n c l u s i o n o f the i n t e r v i e w the s u b j e c t was g i v e n the i n v e s t i g a t o r ' s name i n w r i t i n g , h e r telephone  number, and  the date agreed upon f o r the home i n t e r v i e w .  I t was s t a t e d  t h a t the i n v e s t i g a t o r would telephone  the s u b j e c t on the day  p r i o r t o the i n t e r v i e w t o e s t a b l i s h the time o f the i n t e r v i e w . Any  questions  then the Beck Depression  the s u b j e c t had were d i s c u s s e d and Inventory  were g i v e n to the. s u b j e c t . use  Questionnaire  The s u b j e c t was i n s t r u c t e d i n the  of the s e l f - r e p o r t instruments.  c o l l e c t e d the instruments  and Blues  The i n v e s t i g a t o r l a t e r  and thanked the s u b j e c t f o r h e r  assistance. The Home Interview Schedule was used i n the home interview.  The f i r s t p a r t was administered  v e r b a l l y by  the i n v e s t i g a t o r and the second p a r t was s e l f - a d m i n i s t e r e d by the s u b j e c t , a l o n g with the Beck Depression The  Blues Q u e s t i o n n a i r e ,  then a d m i n i s t e r e d The  Inventory.  r e v i s e d f o r the home i n t e r v i e w , was  verbally.  Any q u e s t i o n s were d i s c u s s e d .  s u b j e c t was a g a i n thanked f o r h e r p a r t i c i p a t i o n and t o l d  38 t h a t a summary o f r e s u l t s  of the  completion  E a c h s u b j e c t had  o f the study.  s t u d y w o u l d be m a i l e d  ed a summary o f t h e r e s u l t s  o f the  I n t e r a c t i o n s With  Group  the Study  D u r i n g the collection  time  o f the d a t a ,  s t u d y p o p u l a t i o n were n o t remaining  thirty-one  group openly the  i n c l u d e d i n the  their  The  willingness  remainder  Approximately  o r more b e d s .  but  the  less  that a possible  readily  t o one  prior. rarely  that  they remain  study  their  the  study.  about  There  confidentiality.  As  o f the u n i t ,  were no  the  indications  i n any  way  res-  o f the i n f o r m a t i o n r e q u e s t e d . h o u r was  the time I t was  a l l o w e d f o r each  f o r the  i n t e r v i e w was  i n t e r v i e w and scheduled  d i s c o v e r e d that postpartum  have much t i m e  of i n t e r r u p t i o n s .  offered^ . own  t o the f u n c t i o n i n g  accepted.  was  in their  reduction i n confidentiality  the c o n t e n t  where p o s s i b l e  hospital  the  of a s s i s t a n c e to  interviewing site  concerned  disruptive  s u g g e s t i o n was  t h e day  formed the  study group i n d i c a t e d  s u b j e c t s a l l suggested  Up  Most o f  by a s k i n g q u e s t i o n s a b o u t  A separate  rooms, a s t h e y were n o t  tricted  study.  t w o - t h i r d s o f t h e g r o u p were i n rooms c o n t a i n i n g  two  t h i s was  t o be  potential  the study might h e l p f u t u r e  of the  to cooperate  investigator for  initially  desire  investigator i n order that  mothers.  to the  s u b j e c t s o f the  s u b j e c t s who  expressed  previously request-  study.  available  o n l y two  on  that  Consequently,  ment s y s t e m  became e x t r e m e l y  r a p p o r t was  facilitated  by  the  c a n be  women i n  guaranteed  investigator's  flexible.  the p r e s e n c e  on  free  appoint-  Establishment o f f l o w e r s and  of cards  39 i n the rooms or the forthcoming a l s o observed  Christmas  season.  I t was  how eager postpartum women a r e t o d i s c u s s the  r e c e n t events encompassing the b i r t h o f the baby.  Attention  to t h i s need was p r e f e r a b l y g i v e n a t the c o n c l u s i o n o f the a d m i n i s t r a t i o n o f the H o s p i t a l Interview Schedule.  However,  on a few o c c a s s i o n s the order o f the schedule was foregone i n order t o d e a l with the content the s u b j e c t u r g e n t l y wished t o express. Any  r e q u e s t s f o r a d v i c e were d i s c u s s e d .  i n v e s t i g a t o r gave i n f o r m a t i o n the respondent  When the  was encouraged  to form h e r own c o n c l u s i o n s r a t h e r than t o accept a readymade d e c i s i o n .  S e v e r a l o f the q u e s t i o n s asked c o u l d be best  answered by the respondent's  p h y s i c i a n and the s u g g e s t i o n was  made t o t h a t e f f e c t . On t e l e p h o n i n g the respondents without  a t t h e i r homes,  e x c e p t i o n , they a l l s a i d t h a t they had been e x p e c t i n g  the c a l l .  Times were arranged  f o r the v i s i t s and f o r some  p l a c e s d i r e c t i o n s f o r best r o u t e s o f access t o the l o c a t i o n were obtained. and  Most o f the v i s i t s l a s t e d between f o r t y - f i v e  seventy minutes, although  the i n t e r v i e w instruments r e -  q u i r e d only twenty t o t w e n t y - f i v e minutes t o complete. The respondents  d i s p l a y e d a need t o d i s c u s s home a c t i v i t i e s and  future plans. Of the two respondents  e l i m i n a t e d from the study,  one remained under p s y c h i a t r i c care i n h o s p i t a l a t seven weeks a f t e r confinement.  The husband r e p o r t e d t a k i n g h i s w i f e t o  h o s p i t a l three weeks a f t e r confinement because o f manic behaviour.  The second respondent  e l i m i n a t e d from the study  40 was a l s o admitted t o a p s y c h i a t r i c u n i t three weeks a f t e r confinement because o f manic behaviour.  T h i s woman was d i s -  charged from the u n i t a f t e r two weeks o f h o s p i t a l i z a t i o n . The i n v e s t i g a t o r telephoned t o enquire how the woman was managing a t home and v i s i t e d  once a t the woman's r e q u e s t .  No unusual behaviour was noted.  The woman spoke f r e e l y o f  her thoughts and f e e l i n g s d u r i n g the manic s t a t e experienced and d e s c r i b e d some of h e r a c t i v i t i e s .  The i n v e s t i g a t o r i n -  formed the woman about the Postpartum C o u n s e l l i n g S e r v i c e i n Vancouver,  and gave h e r a pamphlet  d e s c r i b i n g the s e r v i c e s  offered.' V. Responses  STATISTICAL ANALYSIS f o r each item o f the data which was  c i t e d i n the l i t e r a t u r e as i n f l u e n c i n g the development o f Postpartum Blues were d i v i d e d i n t o "yes" and "no" c a t e g o r i e s . Then the two c a t e g o r i e s f o r each item were compared t o the i n c i d e n c e o f Postpartum Blues by means of the Chi-square t e s t . The c h i - s q u a r e t e s t i s a non-parametric t e s t o f s i g n i f i c a n c e based on the c h i - s q u a r e d i s t r i b u t i o n and used when the s i z e o f the study p o p u l a t i o n i s s m a l l .  7  The v a l u e  p r o v i d e d by the computation o f c h i - s q u a r e i s a measure o f o  the p r o b a b i l i t y o f o b t a i n i n g the value by random sampling. The minimum s i g n i f i c a n c e l e v e l was s e t a t <  .05.  7 'Abdellah and Levine, op. c i t . , 8  Ibid.  p. 350.  '  VI.  SUMMARY  This chapter outlined r e s e a r c h used  f o r this  to  gather  of  t h e s t u d y g r o u p was  developed  i n f o r m a t i o n r e q u i r e d f o r the study. described.  described.  Finally,  The  used  selection  The i n s t r u m e n t s w h i c h  f o r t h e s t u d y a n d t h e Beck D e p r e s s i o n The p r e - t e s t  described.  t h e d e s c r i p t i v e method o f  s t u d y a n d t h e i n t e r v i e w method  described.  41  Inventory  and the i n t e r v i e w i n g p r o c e d u r e  t h e method o f s t a t i s t i c a l  were  analysis  were  were was  CHAPTER IV. ANALYSIS  Characteristics c r i b e d and shown cidence ed.  OF THE DATA  o f the study  i n frequency  o f Postpartum  Blues  p o p u l a t i o n are des-  distribution  i n the study  tables.  p o p u l a t i o n was  F u r t h e r a n a l y s i s o f t h e d a t a was c a r r i e d  the q u e s t i o n s  asked  i n the  conflict,  study.  and  the incidence of f a c t o r s r e l a t e d certain  difficulties  sleep deficiencies.  incidence square  used  t o the menstrual  i n the study  role cycle  compared w i t h t h e  population.  t o d e t e c t any s i g n i f i c a n t  tween t h e two g r o u p s . t r i b u t i o n s were u s e d  related  information  to maternal  T h e s e d a t a were t h e n  o f Postpartum Blues  t e s t was  assess-  out t o answer  Thus t h e d a t a were examined t o p r o v i d e concerning  The i n -  The c h i  d i f f e r e n c e be-  D e s c r i p t i v e a n a l y s i s and f r e q u e n c y i n the a n a l y s i s o f these  I.  CHARACTERISTICS  OF  dis-  data.  THE  STUDY POPULATION The  study p o p u l a t i o n c o n s i s t e d of twenty-nine  p a r t u m women who  had g i v e n b i r t h  to apparently healthy  term i n f a n t s a t a s e l e c t e d h o s p i t a l ber. with  The age, b i r t h - p l a c e ,  education,  erences.  Blues.  C h i square  tests  o f Decernlived  o f the study  The r e m a i n i n g  a r e d e s c r i b e d and shown i n r e l a t i o n  Postpartum  full-  and l e n g t h o f t i m e  t h e f a t h e r o f t h e baby were c h a r a c t e r i s t i c s  p o p u l a t i o n d e s c r i b e d and t a b u l a t e d . tics  d u r i n g t h e month  post-  characteris-  to the i n c i d e n c e o f  showed no s i g n i f i c a n t  diff-  Age The ages o f t h e women ranged from twenty t o t h i r t y f i v e y e a r s , w i t h a mean average o f t w e n t y - s i x y e a r s and f o u r months.  Table 1 i l l u s t r a t e s t h i s i n f o r m a t i o n . Table 1 Percentage D i s t r i b u t i o n o f t h e Study P o p u l a t i o n by Age  Age  Number  Percentage  20-24 y e a r s 25-29 y e a r s 30-35 y e a r s TOTAL  8  28 58 14 100  _4  29  Birthplace The m a j o r i t y o f t h e s t u d y p o p u l a t i o n (80 p e r c e n t ) was bom  i n Canada.  Two women (7 p e r c e n t ) were b o r n i n G r e a t B r i t -  a i n : two women (7 p e r c e n t ) were b o r n i n H o l l a n d : one woman (3 p e r c e n t ) was b o r n i n Denmark, and one woman (3 p e r c e n t ) was born i n t h e U n i t e d S t a t e s o f America, as shown i n Table 2. Table 2 Percentage D i s t r i b u t i o n o f the Study P o p u l a t i o n by B i r t h p l a c e Birthplace Canada  Number  f  Percentage  23  80  2  7  Holland  2  7  Denmark  1  3  U n i t e d S t a t e s o f America  1  3  29  100  Great  TOTAL  Britain  kk  M a r i t a l Status Twenty-seven (93 p e r c e n t ) o f t h e women i n t h e s t u d y group were m a r r i e d .  The r e m a i n i n g two (7 p e r c e n t ) were  l i v i n g i n a s t a b l e common-law r e l a t i o n s h i p .  The range i n the  l e n g t h o f time l i v e d w i t h t h e f a t h e r o f t h e newborn i n f a n t was from two y e a r s and s i x months t o t e n y e a r s as i l l u s t r a t e d i n Table 3«  The mean average l e n g t h o f time was f o u r y e a r s  and n i n e months. Table 3 Percentage D i s t r i b u t i o n o f t h e Study P o p u l a t i o n by Length o f Time L i v e d w i t h F a t h e r Of Newborn I n f a n t Time  Number  Percentage  2-4 y e a r s  19  65  5-7 y e a r s  8  28  8-10 y e a r s  _2  7  TOTAL  29  100  The l e v e l o f e d u c a t i o n a l a t t a i n m e n t ranged  from  Education  Grade t e n t o a U n i v e r s i t y degree a s shown i n Table 3« F i v e women (17 p e r c e n t ) had n o t completed h i g h s c h o o l , f o u r t e e n women (48 p e r c e n t ) had g r a d u a t e d from h i g h s c h o o l , four- women (14 p e r c e n t ) had some p o s t - h i g h s c h o o l t r a i n i n g , w h i l e s i x women (21 p e r c e n t ) were u n i v e r s i t y g r a d u a t e s .  Table 4 Percentage D i s t r i b u t i o n of the Study P o p u l a t i o n by Highest Edu- - • . c a t i o n a l , Attainment . ' • ' ". . :  L e v e l Completed  Number  Percentage  5  17  14  48  Some Post High School T r a i n i n g  4  14  U n i v e r s i t y Degree  _6  21  TOTAL  29  100  Grade X o r XI High School  Occupation A l l o f the women except one had been employed f o l l o w i n g completion o f t h e i r e d u c a t i o n .  Nevertheless,  a l l o f the women s t a t e d t h a t they had no i n t e n t i o n s o f seeking employment f o r a t l e a s t one t o two y e a r s f o l l o w i n g the b i r t h o f t h e i r  infants.  Parity P a r i t y was c l a s s i f i e d i n t o f o u r c a t e g o r i e s : p r i m i p a r i t y , m u l t i p a r i t y with no other c h i l d a t home, m u l t i p a r i t y with one c h i l d a t home, and m u l t i p a r i t y w i t h two c h i l d r e n a t home.  There were f o u r t e e n women ( f o r t y -  e i g h t p e r c e n t ) i n the f i r s t category, 3 women (10 per- . ' c e n t ) i n the second category, ten women (35 p e r c e n t ) i n the t h i r d category, and two women ( 7 p e r c e n t ) i n the l a s t category.  Table 5 shows t h i s i n f o r m a t i o n dichotomized  46 i n t o those who experienced Postpartum  Blues and those who  did not. Table 5 P a r i t y by Incidence o f Postpartum Blues i n the Study Population  Parity  Postpartum Blues Number  Primipara Multipara  - no other c h i l d  Multipara  - 1 other c h i l d  Multipara  - 2 other c h i l d r e n  TOTAL  No Postpartum Number  , 8  6  3  0  l 7  3  _2  0  20  9  Blues  Confinement Date The p r o x i m i t y o f the confinement estimated confinement  date t o the  date v a r i e d between seventeen  e a r l y and seventeen days l a t e .  days  Of the women who d e l i v e r e d  t h e i r i n f a n t s one t o seven days e a r l y s i x developed  Post-  partum Blues while f i v e d i d n o t develop the episode, and of those who d e l i v e r e d t h e i r i n f a n t s e i g h t t o seventeen e a r l y one developed Postpartum op the episode.  days  Blues while two d i d n o t d e v e l  However, of. the women who d e l i v e r e d  i n f a n t s one t o seven days l a t e , e i g h t developed  their  Postpartum  Blues w h i l e one d i d not develop the episode, and o f those who d e l i v e r e d t h e i r i n f a n t s e i g h t t o seventeen days l a t e f i v e developed Postpartum  Blues while one d i d n o t . A l -  though  the d i f f e r e n c e was not s i g n i f i c a n t when the c h i  square t e s t was used, the d i s c r e p a n c i e s are probably b e s t e x p l a i n e d by the f a c t t h a t the m a j o r i t y o f the h o s p i t a l i n t e r v i e w s were conducted b e f o r e Christma's Day.  The women  who were c o n f i n e d a f t e r t h e i r expected date a l l s t a t e d they were ).anxious t o be home before Christmas Day.  that  The  women a l s o expressed 1 t h e i r disappointment over the e x t e n s i o n of t h e i r pregnancies beyond t h e i r expected dates o f c o n f i n e ment as they were t i r e d o f the pregnant s t a t e .  The informa-  t i o n on confinement dates i s shown i n Table 6. Table 6 P r o x i m i t y o f Confinement Date^ t o Estimated '"Confinement Date by Incidence <• \. o f Postpartum Blues i n ' the Study P o p u l a t i on . r  Difference In Time 1-7 8-17 1-7 8-17  days  Postpartum Blues Number  early  days days  early late  days  late  TOTAL  No Postpartum Blues Number  6  5  1  2  8  1  -1  1  20  9  D u r a t i o n o f Labour The d u r a t i o n o f l a b o u r f o r p r i m i p a r a s v a r i e d from t h r e e hours and f o r t y - f i v e minutes t o f o u r t e e n hours and t e n minutes, with a mean average time o f t e n hours and e l e v e n minutes.  T h i s was almost f o u r hours s h o r t e r than  48 the  average quoted i n the l i t e r a t u r e .  Of the p r i m i p a r a s  1  s t u d i e d one had a l a b o u r o f l e s s than f i v e hours d u r a t i o n , nine had a l a b o u r o f between f i v e and t e n hours d u r a t i o n , and f o u r had a l a b o u r o f between t e n and f i f t e e n hours, as shown i n Table ?. The d u r a t i o n o f l a b o u r f o r m u l t i p a r a s v a r i e d from one hour and t h i r t y minutes t o e l e v e n hours and t h i r t y f i v e minutes, with a mean average time o f f i v e hours and f o r t y - f i v e minutes.  T h i s average time a l s o was c o n s i d e r a b l y  l e s s than the average o f e i g h t hours quoted i n the l i t e r a 2 ture.  Of the m u l t i p a r a s s t u d i e d f i v e had l a b o u r s o f l e s s  than f i v e hours, nine had l a b o u r s o f between f i v e and t e n hours, and one had a l a b o u r o f between t e n and f i f t e e n h o u r s  #  T h i s i n f o r m a t i o n i s a l s o i l l u s t r a t e d i n Table ?. Table 7 D u r a t i o n of-Labour f o r P r i m i p a r a s and .Multiparas by I n c i d e n c e . o f ." Postpartum Blues i n the . Study P o p u l a t i o n - -\ Duration of Labour  1-5  - ; Postpartum Blues ,_No Postpartum Blues Primiparas"Multiparas: Primiparas Multiparas  hours  0  4  1  5 - 1 0 hours  6  7  10 - 15 hours  2  1  8  12  TOTAL 1  -  1: 3 2  2 0  6  3  it S and C a r o l y n C. Van Blarcom, O b s t e t r i c Nursing (6th ed.; New York: The Macmillan Company, 1972), p.285. E  2  r  n  a  z  Ibid.  i  e  e  l  49 Medication Analgesic predominantly  drugs a d m i n i s t e r e d  Demerol, Phenergan and L i d o c a i n e . '  women (62 p e r c e n t )  r e c e i v e d 50, 75,  stage  100 m i l l i g r a m s  separately  o f Seconal  Jwith  (3 p e r c e n t )  had t h e dose r e p e a t e d  study  (90 p e r c e n t )  into the  canal to effect  (3 p e r c e n t )  . D e m e r o l i" once.  outside  r e c e i v e d an i n j e c t i o n  Nitrous  oxide  t h e t i c were u s e d t o p r o v i d e One  all  Twenty-six o f the of Lidocaine  o f the dura  of Lidocaine  mater i n One woman  into  also to effect  and P e n t r a n e i n h a l a t i o n  each regional anaes-  a n a l g e s i a f o r one women (3 p e r c e n t ) .  woman d i d n o t r e c e i v e a n y f o r m  short  received  regional anaesthesia.  p u d e n d a l n e r v e by way o f t h e v a g i n a , anaesthesia.  during the  One woman  received injections  t h e lumbar e p i d u r a l space spinal  per-  o f Phenergan i n t r a m u s c u l a r l y ,  o r i n cdnouncfeoh  group  had t h e dose  orally  N i n e women (31 p e r c e n t )  of labour.  25 o r 50 m i l l i g r a m s  either  o r 100 m i l l i g r a m s o f  I n a d d i t i o n t o D e m e r o l t h r e e women ( 10  once.  c e n t ) were g i v e n first  were  Eighteen  Two women (7 p e r c e n t )  Demerol i n t r a m u s c u l a r l y . repeated  during labour  o f a n a l g e s i a owing t o a  l a b o u r and an i n t a c t : p e r i n e u m .  While  i n t h e case-room  o f t h e women were g i v e n a n o x y t o c i c d r u g t o s t i m u l a t e  uterine  contractions after  prevent  excessive  who p l a n n e d injection reduce  blood  delivery  loss.  not to breast  Also  two women (7  f e e d were g i v e n  o f L a c t o s t a t t o suppress  the p o s s i b i l i t y  o f t h e baby i n o r d e r t o  of breast  percent)  an i n t r a m u s c u l a r  l a c t a t i o n and thereby  engorgement.  50 F o l l o w i n g d e l i v e r y n i n e t e e n women (66 p e r c e n t ) accepted  their first declined  100 m i l l i g r a m s o r a l l y  Seconal  postpartum  sedation.  their  second  their  third  postpartum  night, while  t o enhance s l e e p on  t e n women (34 p e r c e n t )  S i x women (21 p e r c e n t ) t o o k S e c o n a l on  postpartum  n i g h t , f i v e women (17  p e r c e n t ) on  n i g h t a n d one woman (3 p e r c e n t ) on h e r f o u r t h night i nhospital.  d u r i n g the postpartum  Other  given  s t a y were F r o s s t ' s 292's,  hospital  D a r v o n Compound, T a n d e a r i l ,  oral medications  Ergometrine,  and S t i l b o e s t r o l .  F r o s s t ' s 292's o r D a r v o n Compound were o r d e r e d b y most o f the a t t e n d i n g p h y s i c i a n s , e i t h e r f o u r - h o u r l y o r s i x - h o u r l y as r e q u i r e d f o r t h e r e l i e f "after-pains,"  o f p a i n from p e r i n e a l  o r b r e a s t engorgement.  sutures,  Twenty-one women  (72  p e r c e n t ) t o o k between one a n d f o u r t e e n d o s e s o f F r o s s t ' s  292  t a b l e t s a n d two women (7 p e r c e n t ) t o o k  one a n d t h i r t e e n  d o s e s o f D a r v o n Compound c a p s u l e s r e s p e c t i v e l y . (3 p e r c e n t ) r e c e i v e d E r g o m e t r i n e  tablets  for  o f the uterus.  t h r e e days t o a i d i n v o l u t i o n  three times  (3 p e r c e n t ) r e c e i v e d ^ t i i b d e s t r o i ^ t a b l e t s for  joint-pain relief. to  No s i g n i f i c a n t  daily  daily  F i n a l l y , one  f o r f o u r days f o r  differences i n relation  m e d i c a t i o n and i n c i d e n c e o f Postpartum  p o p u l a t i o n were  daily  One woman  three.times  f o u r days t o a i d s u p p r e s s i o n o f l a c t a t i o n .  woman r e c e i v e d T a n d e a r i l t h r e e t i m e s  One woman  Blues i n the study  found.  Episiotomy Twenty-five had  women (86 p e r c e n t ) i n t h e s t u d y  episiotomies repaired with  women (14 p e r c e n t ) h a d i n t a c t  sutures. perineums..  The r e m a i n i n g  group four  51 B i r t h Weight The b i r t h weights of the i n f a n t s ranged between s i x pounds and nine pounds s i x ounces.  Seven i n f a n t s  p e r c e n t ) weighed between s i x and seven pounds, infants  fourteen  (49 p e r c e n t ) weighed between seven and e i g h t pounds,  seven i n f a n t s  (24 p e r c e n t ) weighed between e i g h t and n i n e  pounds, while one i n f a n t and  (24  t e n pounds.  (3 p e r c e n t ) weighed between nine  Table 8 shows t h i s i n f o r m a t i o n compared  with the i n c i d e n c e of Postpartum B l u e s . Table 8 B i r t h Weight of I n f a n t s by Incidence of Postpartum Blues i n the Study P o p u l a t i o n .  B i r t h Weight  Postpartum Blues  No Postpartum Blues  6-7  pounds  4  3  7-8  pounds  10  4  8-9  pounds  6  1  _0  1  20  9  9-10  pounds  TOTAL  H e a l t h Status The h e a l t h s t a t u s o f each mother and i n f a n t was checked by the w r i t t e n medical r e c o r d and by a s k i n g the mothers. II.  ASSESSMENT OF THE INCIDENCE OF POSTPARTUM BLUES  Data p r o v i d e d by the Blues Q u e s t i o n n a i r e r e v e a l e d  t h a t a l l women h a d h e a r d some i d e a s a b o u t - t h e  o f Postpartum  phenomenon.  women who l a t e r r e p o r t e d h a v i n g thought  that  Blues and a l l had  E l e v e n o f t h e twenty experienced Postpartum  t h e e p i s o d e was a d e p r e s s i o n s t a t e w h i l e a l l o f  t h e n i n e women who l a t e r r e p o r t e d n o t h a v i n g Postpartum state. of  Blues thought  that  self-reporting  The from  of  the i n c i d e n c e o f Postpartum  fatigue,  cited  change i n l i f e s t y l e .  instance  collec-  t h e e p i s o d e was  fatigue.  Nine  a n x i e t y , t h r e e women  one woman c i t e d  stances of intolerance,  Blues  R e a s d n s ^ g i v e r i - f o r t h e development  f o u r women c i t e d  were r e p o r t e d a s f i f t e e n  women cited  hormones, a n d one woman  The e f f e c t s  o f Postpartum  Blues  instances of depression, four i n frustration,  or i r r i t a b i l i t y ,  one  o f a n x i e t y , a n d one i n s t a n c e o f o v e r s e n s i t i v i t y .  Most o f t h e s e crying  study.  B l u e s were p r e d o m i n a n t l y  body a d j u s t m e n t s ,  capable  B l u e s was c o n -  i n f o r m a t i o n c o n c e r n i n g Postpartum  and examined.  Postpartum  cited  t h a t women were  t h e t w e n t y women who e x p e r i e n c e d  classified  experienced  t h e e p i s o d e was a d e p r e s s i o n  Therefore, the assumption  sidered acceptable f o r this  ted  Blues  spells.  Postpartum were b r i e f ,  e f f e c t s were r e p o r t e d l y a c c o m p a n i e d by s h o r t However, f i v e women r e p o r t e d t h e e f f e c t s o f  Blues as c r y i n g lasting  from  only.  The c r y i n g  two t o f i f t e e n m i n u t e s ,  e x c e p t i o n o f two s p e l l s w h i c h l a s t e d respectively.  spells reported  These r e s u l t s  thirty  are similar  with the  and s i x t y  minutes  t o those r e p o r t e d  2  by Yalom a n d o t h e r s .  I r v i n D. Yalom a n d O t h e r s , " ^ P o s t p a r t u m ilues' Syndrome/"Archives o f General P s y c h i a t r y . XVIII (January,  1965), 16-27:  The time o f occurrence of Postpartum w i t h i n two weeks o f confinement extended  i n t o the t h i r d week.  Blues was  i n a l l hut one case which Ten women experienced Post-  partum Blues w h i l e i n h o s p i t a l and seventeen women experienced Postpartum  Blues a f t e r r e t u r n i n g home.  Accordingly,  seven women experienced the episode twice, three women once only i n h o s p i t a l , and t e n women once only a t home.  Unfor-  t u n a t e l y , most o f the women who experienced Postpartum  Blues  a t home were unable t o r e c a l l the exact date o f occurrence. Therefore, i n f e r e n c e s about whether o r n o t the occurrence o f Postpartum  Blues was a c o n t i n u a t i o n o f the episode i n h o s p i t a l  or a d i s c r e t e episode i n seven women can only be s p e c u l a t i v e . The d u r a t i o n o f Postpartum  Blues experienced by  the women w h i l e i n the h o s p i t a l d i f f e r e d from t h a t experienced a t home.  The d u r a t i o n o f Postpartum  Blues r e p o r t e d w h i l e  i n the h o s p i t a l v a r i e d from l e s s than one hour f o r two women to two days f o r two women.  Four women r e p o r t e d the d u r a t i o n  to be f o u r t o s i x hours and the remaining two women r e p o r t e d it  t o be one day.  However, the d u r a t i o n o f Postpartum  Blues  a t home was r e p o r t e d t o be from one hour f o r three women t o up t o f o u r t e e n days i n t e r m i t t a n t l y f o r one woman.  Two women  r e p o r t e d the episode t o l a s t from f o u r t o s i x hours, one woman f o r one day, seven women f o r two t o three days i n t e r m i t t a n t l y , and two women f o r f o u r t o seven days i n t e r m i t t a n t l y . The d i f f e r e n c e i n the two d u r a t i o n times might be due t o the f a c t t h a t there were p o t e n t i a l l y more people  available.for  s o c i a l i n t e r a c t i o n and t h a t there was only p a r t i a l  respon-  54 sibility account ient",  f o r t h e baby i n t h e h o s p i t a l . i s the social  as suggested  A l s o t o be t a k e n  into  d e s i r a b i l i t y norm o f b e i n g a "good  pat-  by  Baker.  J  With r e g a r d t o a s s i s t a n c e i n overcoming Blues, while man  seven  o f t h e t e n women who e x p e r i e n c e d  i n h o s p i t a l r e p o r t e d t h a t n o one h e l p e d  Postpartum  the episode them.  One wo-  r e p o r t e d t h a t ,her h u s b a n d a n d a n u r s e h e l p e d h e r , one  woman r e p o r t e d t h a t reported  the nurses helped her,  that a r e l a t i v e  i n d i c a t e postpartum while  helped her.  a n d one woman  T h i s f i n d i n g may w e l l  women's n e e d f o r e m o t i o n a l a s s i s t a n c e  i n t h e h o s p i t a l a s c l a i m e d by A u e r b a c h a n d a l s o b y  Fielding.  Of t h e s e v e n t e e n  women who e x p e r i e n c e d  Postpartum  B l u e s a t home, t e n r e p o r t e d s i g n i f i c a n t  a s s i s t a n c e from  husbands,  a relative  and  f o u r r e p o r t e d a s s i s t a n c e from  o n l y t h r e e r e p o r t e d no a s s i s t a n c e .  p a r t u m B l u e s f o r two o f t h e s e that  o f the t h i r d  consistant with  or friend  The d u r a t i o n o f P o s t -  t h r e e women was one h o u r ,  while  woman was one d a y . However, t h e f i n d i n g o f  the need f o r e m o t i o n a l is  their  s u p p o r t a t home i n t h e e a r l y  puerperium  t h e c l a i m s o f A u e r b a c h a n d Rice.-*  Postpartum  B l u e s was c o n s i d e r e d  unpreventable  A.A. Baker, P s y c h i a t r i c D i s o r d e r s i n O b s t e t r i c s (Salisbury: The S a l i s b u r y P r e s s L t d . , 1967), p . 34. J  4 A l i n e A u e r b a c h , " M e e t i n g t h e Needs o f New M o t h e r s , " C h i l d & F a m i l y . VI ( W i n t e r , 1967) 13; J a n e F i e l d i n g , , " S t u d y . , of S e l e c t e d Behaviours o f P r i m i p a r o u s M o t h e r s During the F i r s t T h r e e P o s t Partum D a y s , " The N u r s i n g P r o c e s s , (New Y o r k : T e a c h e r s C o l l e g e P r e s s ) , 1972, p . 38. ^ A u e r b a c h , I b i d . ; E l i z a b e t h P. R i c e , " A f t e r O f f i c e H o u r s , " O b s t e t r i c s a n d G y n e c o l o g y , X X I I I ( F e b r u a r y , 1964), 313.  by  thirteen  sode.  o f the seventeen  Two women t h o u g h t  women who e x p e r i e n c e d  the e p i -  t h a t adequate r e s t and r e l a x a t i o n  would p r e c l u d e t h e development o f Postpartum  B l u e s a n d two  women were u n c e r t a i n b u t t h o u g h t  a t t i t u d e " may  affect  a "positive  t h e outcome. Postpartum  B l u e s was n o t c o n s i d e r e d t o be a b a d  e x p e r i e n c e by e l e v e n o f t h e s t u d y g r o u p who d e v e l o p e d t h e episode.  F o u r women c o n s i d e r e d t h e e p i s o d e  ant but stated considered and  that  i t was a l e a r n i n g  i t t o be a n u n p l e a s a n t  t o be u n p l e a s -  experiences  one woman  experience but forgettable,  one woman c o n s i d e r e d i t t o be a b a d e x p e r i e n c e  of g u i l t  feelings  over h e r i n i t i a l  sex o f h e r i n f a n t .  A t t h e same t i m e ,  she h a d r e s o l v e d h e r g u i l t d i d n o t have a l a s t i n g what u n e x p e c t e d postpartum  disappointment  because with the  t h i s woman s t a t e d  f e e l i n g s and the Postpartum  effect.  that  Blues  T h e s e f i n d i n g s were some-  by t h e i n v e s t i g a t o r whose e x p e r i e n c e  women i n d i c a t e d  that  the event  with  o f Postpartum  B l u e s was o f t e n long-remembered w i t h n e g a t i v e f e e l i n g s . possible  e x p l a n a t i o n m i g h t be t h a t  the incidence o f Post-  partum B l u e s a s s o c i a t e d w i t h p r o l o n g e d n e g a t i v e is  A  feelings  l o w a n d t h a t a much l a r g e r p o p u l a t i o n w o u l d be n e e d e d t o  reveal  it.  eliminated negative another  Or i t m i g h t be t h a t  the s e l e c t i o n  t h o s e women most l i k e l y  feelings after  the event  e x p l a n a t i o n m i g h t be t h a t  viously reporting feelings perienced  t o be l e f t  criteria with  o f Postpartum the postpartum  Blues.  Postpartum  t o Postpartum  Yet  women p r e -  t o the i n v e s t i g a t o r l o n g - l a s t i n g  subsequent  strong  negative  Blues had indeed n o t ex-  B l u e s , b u t had s u f f e r e d  an undetected  Postpartum Depression.  On the o t h e r hand, the f i n d i n g s a r e  c o n s i s t e n t with those o f two other s t u d i e s . The Beck Depression  Inventory d i d n o t prove t o be  a u s e f u l measure i n p r e d i c t i n g the development o f Postpartum Blues i n the women a t home on the b a s i s of t h e i r t o t a l  score  on the i n v e n t o r y a d m i n i s t e r e d a t the h o s p i t a l i n t e r v i e w . A l l but one o f the women's t o t a l s c o r e s on the i n v e n t o r y  adminis-  t e r e d while i n h o s p i t a l were between zero and t h i r t e e n , the non-depressed category.  The t o t a l scores o f the twenty-six  women were d i v i d e d i n t o two groups;™—those below seven and those from seven t o f o u r t e e n .  The s c o r e s were then compared t o the  i n c i d e n c e o f Postpartum Blues, both i n the h o s p i t a l and a t home. One  The c h i square  t e s t showed no s i g n i f i c a n t d i f f e r e n c e s .  woman had a t o t a l score o f seventeen  she experienced home.  i n the h o s p i t a l and  Postpartum Blues both i n the h o s p i t a l and a t  The Beck Depression  Inventory s c o r e s p r o v i d e d by the  home i n t e r v i e w were n o t r e f l e c t i v e of the i n c i d e n c e o f Postpartum Blues i n the women a t home.  When compared t o the  i n v e n t o r y s c o r e s p r o v i d e d a t the h o s p i t a l i n t e r v i e w the home i n v e n t o r y s c o r e s exceeded the h o s p i t a l i n v e n t o r y s c o r e s i n nine i n s t a n c e s . was  None o f the s c o r e s on the home i n v e n t o r y  g r e a t e r than n i n e . In view o f these f i n d i n g s the Beck Depression I n -  ventory d i d n o t prove u s e f u l i n p r e d i c t i n g m i l d , ' t r a n s i t o r y states of depression.  Regarding  moderately  depressed  states  B r i c e . P i t t , '"Maternity Blues. *" B r i t i s h J o u r n a l o f P s y c h i a t r y , CXX (1973);;433l. Yaldm an^;0^hers; 1 6 c r c i t . :  . _> ;  57 there was o n l y one woman whose h o s p i t a l i n v e n t o r y s c o r e was i n t h i s category.  T h i s woman developed Postpartum  the h o s p i t a l and a t home.  Furthermore,  the d u r a t i o n o f P o s t -  partum Blues f o r t h i s woman was three t o f o u r days, mittantly.  A l s o t h i s woman r e p o r t e d t h a t f e e l i n g s  to the Postpartum  Blues i n  interconsequent  Blues experience were t h a t i t was a " t h o r -  oughly unpleasant" e x p e r i e n c e .  I t might w e l l be t h a t the Beck  Depression Inventory would c o n s i s t e n t l y d i f f e r e n t i a t e between postpartum  women who are; moderately o r h i g h l y depressed and  those who a r e non-depressed III.  or mildly  depressed.  INCIDENCE OF STRESS ITEMS RELATED TO MATERNAL ROLE CONFLICT  Data p r o v i d e d by the i n t e r v i e w schedules showed t h a t a l l o f the study p o p u l a t i o n r e p o r t e d some s t r e s s r e l a t e d t o maternal r o l e c o n f l i c t .  items  The f r e q u e n c i e s o f each  item were c a t e g o r i z e d a c c o r d i n g t o the i n c i d e n c e o f Postpartum Blues.  The c h i square t e s t was then used f o r each item t o  determine  the s i g n i f i c a n c e o f the d i f f e r e n c e between the group  who experienced Postpartum experience Postpartum  Blues and the group who d i d n o t  Blues.  The items were t a b u l a t e d i n the  manner d e s c r i b e d and under the headings o f t  inadequate p r e -  p a r a t i o n f o r maternal r o l e s a n x i e t y about maternal r o l e s  con-  f l i c t w i t h other r o l e s and d i s t r e s s i n g events d u r i n g the puerperiumj  inadequate h e l p o r support from s i g n i f i c a n t other  persons; and emotional and c o g n i t i v e  changes.  7  'Richard Gordon and Katherine Gordon, " S o c i a l F a c t o r s i n P r e v e n t i o n o f Postpartum Emotional P r o b l e m s , " O b s t e t r i c s and Gynecology XV, 4 ( A p r i l , I960), 433} F r a n c i s J . Kane, J n r . , "Emotional and C o g n i t i v e Disturbance i n the E a r l y Puerperium," B r i t i s h J o u r n a l o f P s y c h i a t r y , 114 (1968), 99.  y  58  There was no s i g n i f i c a n t d i f f e r e n c e a t the .05 l e v e l f o r any of the items. Further to t h i s ,  each s t r e s s item r e l a t e d t o mater-  n a l r o l e c o n f l i c t was a s s i g n e d a value o f one and t o t a l s were made f o r every woman i n each o f the f i v e groups under the headings  d e s c r i b e d above.  These s c o r e s .were then t a b u l a t e d  a c c o r d i n g t o the i n c i d e n c e of Postpartum  Blues, f o r examples  Number o f emotional and c o g n i t i v e changes number o f woman who developed Postpartum Blues  0  1  2  3  4  3  7  5  2  3  k  1  0  0  number o f women who d i d not develop Postpartum Blues  The c h i square t e s t was used to t e s t f o r cant d i f f e r e n c e s i n each o f the f i v e groups.  signifi-  There were no  s i g n i f i c a n t d i f f e r e n c e s a t the .05 l e v e l . F i n a l l y , a l l o f the s t r e s s items o f the f i v e groups were t o t a l l e d f o r each woman, then d i v i d e d i n t o three c a t e g o r i e s of 1-5 items, 6-10 items, and 11-15 g o r i e s were then c l a s s i f i e d .into Postpartum Postpartum  items.  The c a t e -  Blues and no  Blues and the c h i square t e s t was used t o t e s t f o r  significant differences.  Again, there were no s i g n i f i c a n t  d i f f e r e n c e s a t the .05 l e v e l . Inadequate  P r e p a r a t i o n f o r Maternal Role The mothers o f a l l the women i n the study group  were a l i v e .  Two women were r a i s e d by a d o p t i v e p a r e n t s who,  59 for  the purposes  as t h e i r  own p a r e n t s .  pendently  study,  Blues while  were r e g a r d e d  S i x women h a d p a r e n t s  o f each other.  Postpartum Ten  of this  Four  o f these  two d i d n o t e x p e r i e n c e  items  who l i v e d  inde-  experienced Postpartum  o f t h e women h a d h u s b a n d s whose f a t h e r s were d e a d .  o f t h e s e women d e v e l o p e d who d i d n o t . separately.  Postpartum  Blues  Table  9 illustrates  this  Postpartum  compared w i t h  Blues.  This finding,  p e r h a p s due t o t h e s m a l l s i z e  information.  women  although not s i g n i f i c a n t ,  of the population.  developed  Postpartum  f i n d i n g s r e p o r t e d i n two s t u d i e s . s t u d i e s were t h a t l e s s  than  experienced  o f t h e women whose e d u c a t i o n a l a t t a i n m e n t  high school completion  three living  f i v e women h a d l e s s  a h i g h s c h o o l g r a d u a t i o n and a l l f i v e  Blues. Seven  One woman's h u s b a n d h a d p a r e n t s who were  With r e g a r d t o education,  all  women  f o r most  than completion  The f a c t  was l e s s  that  than  Blues might  The f i n d i n g s  was  support  o f t h o s e two  of high school  education  8 represents a stress Fourteen  factor  i n postpartum  experience  Postpartum  Postpartum  Blues.  ;men,eleven experienced Postpartum  Blues.  Postpartum  Blues while  four did  The h u s b a n d s o f t h i r t e e n  had .a h i g h e r e d u c a t i o n t h a n h i s p a r e n t s .  ience  adjustment.  women h a d a h i g h e r e d u c a t i o n t h a n t h e i r p a r e n t s a n d  t e n o f t h e s e women e x p e r i e n c e d not  emotional  Of t h e s e  women  t h i r t e e n -wo-  B l u e s and f o u r d i d n o t exper-  The h u s b a n d s o f e l e v e n women h a d a  h i g h e r e d u c a t i o n t h a n t h e i r w i v e ' s parents,,- n i n e  o f these  !  women  R i c h a r d E . Gordon, E l i E . K a p o s t i n s and K a t h e r i n e K. Gordon, " F a c t o r s i n P o s t p a r t u m Admustment," O b s t e t r i c s a n d G y n e c o l o g y , XXV ( F e b r u a r y , 1965), 159.  v  : 60 experienced Postpartum  Postpartum Blues.  9.  t o o c c u p a t i o n s i x women's h u s b a n d s  a h i g h e r o c c u p a t i o n t h a n . t h e i r " p a r e n t s a n d a l l of -'-these  women e x p e r i e n c e d not  two d i d n o t e x p e r i e n c e  T h i s i n f o r m a t i o n i s shown i n T a b l e  In r e l a t i o n had  Blues while  significant  Postpartum  Blues.  While  this  f i n d i n g was  t h e l a c k o f s i g n i f i c a n c e may be due t o t h e  small size  of the population.  suggestive  o f support  Certainly  f o r the f i n d i n g s  the f i n d i n g i s 1  o f a study  reported  Q by  Gordon, K a p o s t i n s ,  and Gordon.  That  study  when t h e h u s b a n d ' s o c c u p a t i o n was h i g h e r t h a n parents al  i t constituted  a stress  factor  adjustment.  ^However, t h e f i n d i n g  i n g Postpartum  B l u e s may be e n t i r e l y  by c h a n c e .  Three  Postpartum  the episode.  emotion-  o f a l l s i x women  than  did n o t experience  that  that of h i s  i n postpartum  husbands had a h i g h e r o c c u p a t i o n o f t h e s e women e x p e r i e n c e d  showed  Table  develop-  F o u r women's  t h e women's p a r e n t s . B l u e s w h i l e one  9 shows t h i s  infor-  mation. Regarding an  i n t e r r e l i g i o u s marriage.  Postpartum in  religion  Blues.  this  A l l o f t h e s e women  experienced  C h u r c h a n d one i n t h e P r o t e s t a n t  f i n d i n g was n o t s i g n i f i c a n t  the  small size  all  f i v e women d e v e l o p e d  coincidence.  women who h a d  I n f o u r i n s t a n c e s one p a r t n e r was r e a r e d  t h e Roman C a t h o l i c  Although  t h e r e were f i v e  i t i s possible that  o f t h e p o p u l a t i o n may a c c o u n t Postpartum  On t h e o t h e r hand,  Gordon, K a p o s t i n s ,  faith.  for this.  That  B l u e s m i g h t w e l l be a  i t might support  a n d Gordon,  the f i n d -  op. c i t . , p . 162.  6i ings  i n a study  that marriages hazards  that  r e p o r t by L a n d i s .  1 0  The L a n d i s  study  showed  between C a t h o l i c s a n d P r o t e s t a n t s i n v o l v e  do t h o s e  b e t w e e n members o f one  Table  more  faith.  9  I n c i d e n c e o f S t r e s s Items R e l a t e d t o Maternal C o n f l i c t — I n a d e q u a t e Preparation f o r Maternal R o l e — B y Incidence o f Postpartum Blues i n the Study Population  Item  Postpartum Blues  Husband's f a t h e r Parents  dead  separated  Husband's p a r e n t s Education school  less  separated  that  Husband's e d u c a t i o n than h i s parents  7  3  k  2  1  0  5  0  high  Education h i g h e r than  parents  No P o s t p a r t u m  10  higher il  2  Husband's e d u c a t i o n h i g h e r than w i f e ' s parents  9  2  Husband's o c c u p a t i o n than h i s parents  6  0  Husband's o c c u p a t i o n h i g h e r than wife's parents  3  1  Interreligious  5  0  higher  marriage  J u d s o n T. L a n d i s , " M a r r i a g e s o f M i x e d and Nonm i x e d R e l i g i o u s F a i t h , " A m e r i c a n S o c i o l o g i c a l Review, X I V (June, 1 9 9 ) , 0 6 . k  k  Blues  , 62 -  (  A n x i e t y about Maternal  mothers.  Only  two women h a d n o t a l w a y s e x p e c t e d  Both  o f t h e s e women e x p e r i e n c e d  All  b u t one o f t h e women c l a i m e d  good r e l a t i o n s h i p w i t h who r e s p o n d e d well, that  Role  t h e i r mothers.  Postpartum  Blues.  t o have a v e r y  The e x c e p t e d  woman,  t h a t she d i d n o t g e t a l o n g w i t h h e r m o t h e r  experienced  Postpartum  Blues.  finding  c a n n o t be c o n v i n c i n g w i t h o u t  ment o f s o c i a l d e s i r a b i l i t y . woman h a d a l e s s ers.  pregnancy,or  one's  a measure-  I t c o u l d be t h a t more t h a n one  than adequate r e l a t i o n s h i p w i t h  On t h e o t h e r hand,  very  Because o f t h e v a l u e  s o c i e t y p l a c e s on h a v i n g a g o o d r e l a t i o n s h i p w i t h  mother t h i s  and  t o become  their  moth-  i t c o u l d be t h a t d u r i n g t h e r e c e n t  a p r e v i o u s p r e g n a n c y t h e women h a d r e m i n i s c e d  r e s o l v e d any p a s t c o n f l i c t s  t h e i r mothers i n the p r o c e s s  i n their relationships  of maternal  role  with  attainment  11 described  by Rubin. All  b u t two women c l a i m e d  r e l a t i o n s h i p with who r e s p o n d e d was  alright,  t h e i r husbands.  t o have a v e r y c l o s e The e x c e p t e d  that t h e i r r e l a t i o n s h i p with both  experienced  Postpartum  f i n d i n g may i n p a r t r e p r e s e n t s o c i a l than a c t u a l i t y . reported  However, t h e f a c t  two women,  their  Blues.  desirability  husbands Again, rather  that twenty-eight  women  t h a t t h e i r h u s b a n d s gave c o n s i d e r a b l e a s s i s t a n c e  w i t h baby c a r e a n d h o u s e h o l d  d u t i e s does s u p p o r t  this  Reva R u b i n , " A t t a i n m e n t o f M a t e r n a l R o l e , M o d e l s a n d R e f e r r a n t s , " N u r s i n g R e s e a r c h , XVI ( F a l l , 343-46.  this  —  finding.  Part I I , 196?),  In the study population there were fourteen primiparas and three multiparas who had given b i r t h to one infant but who had no infant care experience i n r e l a t i o n to that infant.  Of these seventeen women, eleven experienced  Postpartum Blues while s i x did not experience the episode. The six women who did not experience Postpartum Blues were a l l primiparas.  Therefore, the number of primiparas who  experienced Postpartum Blues was lower than that expected. Even including the three - multiparas' mentioned, fewer of the women engaged i n t h e i r f i r s t own baby-caring experience developed Postpartum Blues^than did the multiparas with other children.  Table 10 shows t h i s information. This f i n d i n g , then, i s i n contradiction to the  findings of other studies which show that more primiparas than miltiparas experienced d i f f i c u l t y i n postpartum adjust12  ment.  Perhaps this i s by chance, i n view of the small  study population.  On the other hand, t h i s population may  have had fewer stress factors than had the populations of the other studies. Those study populations were larger, were more heterogeneous i n nature, and were residents of c i t i e s in the United States of America.  Then again, i n this study  a l l but one of the seventeen women engaged i n their  first  own baby-care experience had attended prenatal c l a s s e s . Only one woman had experienced a previous physical problem with childbearing and t h i s was a threatened delivery at twenty-four weeks gestation. t-Gordon and Gordon, op. c i t . , Others, op. c i t . , p. 2 4 .  immature  This woman experp. 4 3 4 : Yalom and  ienced Postpartum  Blues.  E x c e p t i n g the two women with adoptive parents f o r whom there was no i n f o r m a t i o n a v a i l a b l e , seven women had mothers o r s i s t e r s who had experienced problems i n c h i l d bearing.  F i v e o f these women developed  while two d i d n o t develop Postpartum i n Table 10.  Postpartum  Blues.  Blues  T h i s i s shown  Again, i n view o f the s m a l l numbers, t h i s  i n g i s hard t o i n t e r p r e t .  find-  However, the f i n d i n g i s n o t i n c o n -  s i s t e n t with the f i n d i n g o f twenty percent r e p o r t e d by Larsen and Others.  J  Of the seventeen p r i m i p a r a s and m u l t i p a r a s with no p r e v i o u s own baby-care  experience, three p r i m i p a r a s had no  p r e v i o u s experience with baby c a r e . veloped Postpartum  Blues.  These three women de-  Once again, t h i s f i n d i n g  cannot  be i n t e r p r e t e d because of the s m a l l s i z e of the study population.  However, the f i n d i n g does suggest t h a t no p r e v i o u s  experience with baby care i s a f a c t o r i n Postpartum.Blues. Larsen and others r e p o r t e d t h a t l i t t l e  o r no p r e v i o u s  child-  care experience occurred i n s i x t e e n p e r c e n t o f those with postpartum  emotional d i f f i c u l t i e s i n a study i n 1968. A l l but one o f the seventeen women with f i r s t bab-  i e s attended p r e n a t a l c l a s s e s . Postpartum  Blues.  The excepted woman experienced  Of the f i f t e e n m u l t i p a r a s , e i g h t attended  p r e n a t a l c l a s s e s while c a r r y i n g the p r e s e n t i n f a n t and the remaining seven women attended p r e n a t a l c l a s s e s with  13  -'Larsen, op. c i t . , l k  Ibid.,  p. 23.  p. 25.  their  -65 last  pregnancy.  Postpartum  Of t h e s e  Blues while  I n f e r e n c e s cannot  seven  women, f i v e  two d i d n o t e x p e r i e n c e  he made f r o m  these  delivery  a n x i e t y d u r i n g pregnancy about  e l e v e n women r e p o r t e d a l i t t l e  women r e p o r t e d a l o t o f c o n c e r n . who were s l i g h t l y  concerned  who were h i g h l y c o n c e r n e d delivery  experienced  information.  by  Larsen  or  no p r e d i c t i v e  Blues.  while  relation  about l a b o u r and  Nevertheless,  f o r postpartum  experienced  the d i r e c t i o n  t h e y were.  Postpartum  o f the study  showed  little  stress.^  t o e x p e c t a t i o n s about l a b o u r and de-  e l e v e n women e x p e c t e d  be e a s i e r t h a n  t h e i r l a b o u r and d e l i v e r i e s Of t h e s e  e l e v e n women, e i g h t  Blues and three d i d n o t e x p e r i e n c e  the  episode.  ies  t o be a b o u t t h e same a s t h e y were a n d none o f t h e s e  36.  F i v e women e x p e c t e d  their  l a b o u r s and d e l i v e r -  ^ V i r g i n i a L. L a r s e n , " S t r e s s e s o f t h e C h i l d b e a r i n g A m e r i c a n J o u r n a l o f P u b l i c H e a l t h , L V I ( J a n u a r y , 1966), 1  Year,"  this  suggestive of a r e l a t i o n -  i n which s t r e s s e s d u r i n g pregnancy  In  Blues  10 shows  i s i n c o n t r a s t t o the f i n d i n g s  value  and f o u r  A l l f o u r women  Table  Blues and concern  d e l i v e r y were n o t s i g n i f i c a n t . the tendency  labour  d u r i n g pregnancy about l a b o u r and  These f i n d i n g s ,  of  concern  Postpartum  the episode.  Postpartum  s h i p between Postpartum  to  previous  S e v e n o f t h e e l e v e n women  experienced  four d i d not experience  livery,  from  classes. Regarding  while  data about the  o f i n f o r m a t i o n t h e m u l t i p a r a s remembered  prenatal  and  the episode.  f i n d i n g s because o f t h e  s m a l l numbers a n d b e c a u s e o f i n s u f f i c i e n t amount  experienced  66 women e x p e r i e n c e d women e x p e c t e d  Postpartum  Blues.  The r e m a i n i n g  t h e i r l a b o u r s t o be h a r d e r  S e v e n o f t h e t h i r t e e n women e x p e r i e n c e d while  s i x did not experience  thirteen  than they were.  Postpartum  Blues  T a b l e 10  the episode.  illus-  trates this information. 10  Table  I n c i d e n c e o f S t r e s s - -I;tems R e l a t e d . . t o M a t e r n a l Role C o n f l i c t s r - A n x i e t y About M a t e r n a l ' ,Role--by I n c i d e n c e o f Postpartum * Blues i n the Study P o p u l a t i o n  Item  Postpartum  Primipara or multip a r a w i t h no c h i l d ren  previous  No P o s t p a r t u m  5  2  3  0  experience  with babies A few c o n c e r n s d u r i n g pregnancy about l a b o u r and d e l i v e r y  7  A l o t o f concerns pregnancy about and d e l i v e r y  4  0  E x p e c t e d l a b o u r t o be e a s i e r t h a n i t was  8  3  Changed i n f a n t f r o m bottle feeding  7  3  Only  during labour  breast to  two women h a d a few c o n c e r n s  during t h e i r pregnancies Blues.  Blues  11  Mother o r s i s t e r had problems with c h i l d bearing No  Blues  However, t w e l v e  about  baby  a n d b o t h women e x p e r i e n c e d women h a d a few c o n c e r n s  care  Postpartum  a n d one woman  a  l o t o f concerns  while  still  a b o u t baby c a r e a f t e r c o n f i n e m e n t a n d  i n the h o s p i t a l .  w i t h a few c o n c e r n s did of  n o t develop concerns  maining  E i g h t o f the twelve  developed  Postpartum  developed  Postpartum  Blues.  Postpartum  Blues while  develop;Postpartum  Blues.  Postpartum  Blues.  Of t h e s i x t e e n r e -  Blues while  i n hospital five  puerperal  a b o u t baby c a r e were  o r m u l t i p a r a s w i t h no c h i l d r e n a t home.  t h e n , 'that more o f t h e s e women d i d n o t e x p e r i e n c e Blues might the  d i d not  Eleven o f the thirteen  women i n h o s p i t a l who h a d c o n c e r n s primiparas  indicate  t h a t the concerns  forthcoming maternal  with maternal  role  f o u r women h a d s l i g h t  "wind" p a i n s .  Postpartum  Postpartum  were p r e p a r a t o r y t o  a t home r a t h e r t h a n  b a b i e s a t home a n d i n e a c h c a s e the baby's  The f a c t ,  conflict  role.  Only  concern  the concern  about  was r e g a r d i n g  T h r e e o f t h e s e women  B l u e s a t home w h i l e  their  experienced  one d i d riot.  T h i r t e e n women b e g a n b r e a s t f e e d i n g t h e i r initially  while  month l a t e r . Blues while their  episode.  initially ing  i n the h o s p i t a l  five  d i d not.  initially  Postpartum  while  i n the. h o s p i t a l ,  Blues while  The r e m a i n i n g  partum Blues w h i l e  feeding  five  o f whom  one d i d n o t e x p e r i e n c e  t e n women began b r e a s t f e e d i n g  i n t h e h o s p i t a l b u t changed  w i t h i n one month.  Postpartum  S i x women b e g a n b o t t l e  while  babies  a n d were c o n t i n u i n g one  E i g h t o f t h e s e women e x p e r i e n c e d  infants  experienced the  four  The one woman w i t h a l o t  women who r e p o r t e d no c o n c e r n s ' w h i l s t  e l e v e n women d e v e l o p e d  women  to bottle  feed-  S e v e n o f t h e s e women d e v e l o p e d  Post-  three d i d not develop  Postpartum  Blues.  1  68 This  10.  i n f o r m a t i o n i s shown i n T a b l e The  reason  f o r t h e changes and the time  o f t h e changes a r e a s f o l l o w s J  birth  b r e a s t f e e d i n g because  o f inadequate  following  f i v e women milk supply,  tween s i x a n d t e n d a y s a n d one a t t w e n t y - e i g h t  stopped f o u r be-  d a y s ; one  woman h a d i n v e r t e d n i p p l e s w h i c h became c r a c k e d a n d s h e changed  the s t y l e  of infant  d e s i r e d h e r husband relief style  with  was  days;  days;  i n the f e e d i n g and t o g i v e h e r  one woman h a d a b r e a s t a b s c e s s  the feeding s t y l e  allergic  nine  t o share  f e e d i n g a t n i g h t , a n d she c h a n g e d t h e f e e d i n g  a t nine  changed  f e e d i n g a t f o u r days;; one woman  a t t e n days;, one woman's i n f a n t  t o b r e a s t - m i l k a n d was c h a n g e d  and f i n a l l y  and she  to formula a t  one woman h a d c o m p l i c a t i o n s  following  the e p i d u r a l a n a e s t h e s i a g i v e n d u r i n g l a b o u r , and h e r baby was  changed  t o formula a t s i x  C o n f l i c t w i t h Other The Puerperium  days.  Roles and D i s t r e s s i n g Events  S e v e n women h a d :unplanned t h e s e women e x p e r i e n c e d experience  the episode.  Although  Blues while  no c o n c l u s i o n s c a n be drawn  that  two o f t h e s e women who e x p e r i e n c e d P o s t p a r t u m a l o t o f concerns  t h e i r pregnancies Such a f i n d i n g  and  i t i s interesting  t o note Blues  l a b o u r and d e l i v e r y  s c a l e might l e n d support  "those w i t h  adjustments  t o the  t h e more s e r i o u s p r o b l e m s  l a b o u r a n d d e l i v e r y were t h e o n e s who h a d p o o r  social  during  a n d one woman r e p o r t e d a few c o n c e r n s .  on a l a r g e r  c l a i m by R i c e t h a t  about  Five of  two d i d n o t  this  about  finding,  pregnancies.  from  reported  insignificant  Postpartum  During  a n d who h a d n o t p l a n n e d  their  personal preg-  nancies.  16 Of t h e e i g h t women who h a d p r e v i o u s l y e x p e r i e n c e d  Postpartum two  Blues,  s i x experienced  d i d n o t experience  i t .  the episode again  Three  of the remaining  m u l t i p a r a s who h a d n o t p r e v i o u s l y e x p e r i e n c e d Blues developed baby w h i l e  Postpartum  w h i c h showed t h a t was  the  to the f i n d i n g s  the occurrence  s t u d y may have p r e c l u d e d  infant  sex-preferences.  of other studies  psychiatric  Blues  disorders.  findings.  Three  o f t h e s e women h a d i n f a n t s  s e x , none o f whom e x p e r i e n c e d  six  o f whom e x p e r i e n c e d  not  experience  Postpartum  o f the n o t - p r e f e r r e d sex,  Postpartum  B l u e s a n d two o f whom d i d  the episode.  Adjustment d i f f i c u l t i e s housework r o u t i n e ,  i n relation  o t h e r c h i l d r e n ' s needs,  and r e l a t i o n s ,  p o r t e d as a problem  and  find-  o f p r e v i o u s Postpartum  significant  E i g h t women h a d i n f a n t s  neighbours  These  of this  were e l e v e n women i n t h e s t u d y p o p u l a t i o n who  of the p r e f e r r e d Blues.  Postpartum  t h e s m a l l sample s i z e a n d t h e r e s t r i c t i o n s o f  There had  the episode.  h i g h l y p r e d i s p o s i n g t o postpartum  Nevertheless,  four  Blues following the b i r t h  one d i d n o t d e v e l o p  i n g s do n o t l e n d s u p p o r t  while  t o baby's needs,  interference  from  a n d i n c r e a s e d company were n o t r e -  by any o f t h e study p o p u l a t i o n .  • ^ E l i z a b e t h P. R i c e , " A f t e r O f f i c e H o u r s , " G y n e c o l o g y . X X I I I ( F e b r u a r y , 1964), 311.  This  Obstetrics  —  17 F r e d e r i c k T. M e l g e s , " P o s t p a r t u m P s y c h i a t r i c S y n dromes, P s y c h s o m a t i c M e d i c i n e . XXX ( J a n u a r y , 1968), 9 8 5 Brice P i t t , "'Atypical', Depression Following C h i l d b i r t h , " B r i t i s h J o u r n a l o f P s y c h i a t r y . CXIV (1968), 1332? Yalom, op. c i t . , p . 26.  70 c o u l d w e l l be b e c a u s e o f t h e h i g h a t t e n d a n c e  o f t h e study-  p o p u l a t i o n a t p r e n a t a l c l a s s e s where a d j u s t m e n t  difficulties  are discussed'.  Table  11  I n c i d e n c e o f S t r e s s Items, R e l a t e d t o M a t e r n a l Role C o n f l i c t — C o n f l i c t w i t h Other Roles and D i s t r i s s i n g E v e n t s D u r i n g t h e Puerperium—by Incidence of Postpartum Blues i n the Study P o p u l a t i o n  Item  Postpartum  Pregnancy  unplanned  Blues  No P o s t p a r t u m  5  2  6  2  Preference f o r infant of opposite sex  6  2  D i s t r e s s i n g events puerperium  k  2  Previous Postpartum  Six their Four not  first  women e x p e r i e n c e d d i s t r e s s i n g  week a t home a f t e r  experience the episode. conditions of either  woman d e v e l o p e d  age  i n the  o f t h e s e women d e v e l o p e d  physical  lung  Blues  infection  o f some b l o o d c l o t s  complications labour.  following  S i x hours  Postpartum  was c o n s e q u e n t l y  during  the h o s p i t a l .  B l u e s w h i l e two d i d  The d i s t r e s s i n g  events i n v o l v e d  t h e woman o r h e r b a b y . A second  influenza, vaginally,  One  woman h a d a  and a s w e l l a s the passA t h i r d woman  developed  the e p i d u r a l anaesthesia given during  a f t e r h e r r e t u r n home f r o m  t h e woman d e v e l o p e d and  d i s c h a r g e from  a breast abscess. following  events  Blues  severe headache, treated  the h o s p i t a l  dizziness,  and v o m i t t i n g  i n a general hospital  f o r four  71  days.  One i n f a n t  developed  m i l k a n d was h o s p i t a l i z e d a physiological  jaundice as a r e s u l t  f o r f o u r days.  A second  i n f a n t had  j a u n d i c e w h i c h i n c r e a s e d a f t e r he went homes  t h e r e f o r e he was h o s p i t a l i z e d infant  of breast  f o r five  developed h y p e r a c t i v i t y  days.  Lastly,  a  third  a f t e r g o i n g home a n d he r e c e i v e d  medications f o r the condition.  Inadequate  Help o r Support from S i g n i f i c a n t Only  s t a g e o f l a b o u r , b u t he was p r e s e n t f o r h e r  T h i s woman d e v e l o p e d P o s t p a r t u m  h u s b a n d s were n o t p r e s e n t d u r i n g Three  Persons  one o f t h e h u s b a n d s was n o t p r e s e n t t h r o u g h o u t  his wife's f i r s t delivery.  Other  Blues.  t h e i r wive's  o f t h e s e women d e v e l o p e d P o s t p a r t u m  Four o f the  deliveries.  B l u e s w h i l e one d i d  not experience the episode. All  o f t h e women r e s p o n d e d  i n g l a b o u r , some by more according  that  t h a n one a i d .  to the incidence  o f Postpartum  t h e y were h e l p e d d u r -  The s i g n i f i c a n t  help  B l u e s i s shown i n  Table 1 2 . Table  12  S i g n i f i c a n t H e l p D u r i n g L a b o u r by I n c i d e n c e of Postpartum Blues i n the Study P o p u l a t i o n Significant  Help  Postpartum  Self  Blues  No P o s t p a r t u m  0 16  8  Nurse  5  0  Breathing  3  k  1  0  2  1  Husband  Prenatal Demerol  Class  Blues  ,- ?2 All  o f t h e women s t a t e d  during delivery,  some by more t h a n  that  they  were/helped  one a i d .  The s i g n i f i c a n t  h e l p a c c o r d i n g t o the i n c i d e n c e o f Postpartum in  Blues  i s shown  13.  Table  Table  13  S i g n i f i c a n t H e l p D u r i n g D e l i v e r y By I n c i d e n c e of Postpartum Blues i n the Study P o p u l a t i o n  Significant  Postpartum  Help  No P o s t p a r t u m  Blues  Self  3  0  Husband  6  5  Nurse  3  2  Doctor  6  3  Epidural  3  Breathing  1 1  1  Mirror  S i x t e e n women h a d a n e x t r a p e r s o n , or  sister,  after  their  stay to help f o r the f i r s t r e t u r n home w i t h t h e i r  women, e l e v e n d e v e l o p e d develop stay  the episode.  the episode.  not measurable  because  to  lend  babies.  t o f o u r t e e n days Of t h e s e  Blues while f i v e  Postpartum  sixteen d i d not someone  B l u e s and f o u r d i d  However, e x t r a h e l p a t home was  of inadequate  t h e women's h u s b a n d s h a d e x t r a  Christmas period.  five  m o s t l y a mother  Of t h e women who d i d n o t have  to help, nine developed  not develop  of  Postpartum  Blues  d a t a and because  most  t i m e a t home o v e r t h e  A l l b u t one o f t h e h u s b a n d s were r e p o r t e d  c o n s i d e r a b l e h e l p t o t h e i r wives,  both with  baby  care and household  routines.  None o f the women had husbands who spent  time  away from home o v e r n i g h t . Emotional and C o g n i t i v e Changes Nine women r e p o r t e d some degree  o f mood l a b i l i t y i n  t h a t they experienced v a c i l l a t i n g f e e l i n g s from happiness t o sadness.  Of these women, e i g h t developed Postpartum  while one d i d n o t develop the episode.  Of the remaining  twenty women who r e p o r t e d no mood change, twelve Postpartum  Blues  developed  Blues while one d i d n o t develop the episode.  Emo-  t i o n a l and c o g n i t i v e d i s t u r b a n c e s which o c c u r r e d and t h e i r r e l a t i o n s h i p t o the i n c i d e n c e o f Postpartum  Blues a r e shown  i n Table 14. Table 14 Incidence o f S t r e s s Items R e l a t e d t o Maternal Role C o n f l i c t — E m o t i o n a l and C o g n i t i v e C h a n g e s — b y Incidence o f Postpartum Blues i n the Study P o p u l a t i o n  Item  Postpartum  Blues  No Postpartum  Mood l a b i l i t y  8  1  Slight reduction i n r e c e n t memory  6  2  S l i g h t increase i n distractability  4  1  Decrease  8  0  i n concentration  Increased f e e l i n g s o f dependency  11  1  Because o f t h e i r ins i g n i f i c a n c e these f i n d i n g s were unable t o shed any f u r t h e r l i g h t on the q u e s t i o n o f  Blues  the a s s o c i a t i o n of d i m i n i s h e d mental  f u n c t i o n i n g and sub1Q  j e c t i v e d i s t r e s s as suggested by Kane and o t h e r s . Increased f e e l i n g s of dependency were experienced by twelve women, e l e v e n o f whom developed  Postpartum  and one o f whom d i d n o t developJthe episode.  Blues  Of the remain-  i n g seventeen women who p e r c e i v e d no i n c r e a s e i n t h e i r dependency f e e l i n g s nine developed Postpartum e i g h t d i d n o t develop the episode.  This f i n d i n g , while  below the s i g n i f i c a n t l e v e l o f acceptance, dency f o r Postpartum of dependency.  Blues w h i l e  i n d i c a t e d a ten-  Blues t o occur with i n c r e a s e d f e e l i n g s  T h i s tendency would c e r t a i n l y support the  viewpoint of both Auerbach and R i k e r t h a t i n c r e a s e d depen19 dency needs a r e p r e p a r a t o r y t o maternal r o l e  attainment.  None o f the women r e p o r t e d any f e e l i n g s o f e n t r a p ment.  None o f the women r e p o r t e d t h a t t h e i r g o a l s had been  blocked.  Only one woman s t a t e d t h a t h e r g o a l s had been de-  f e r r e d because of the baby and t h i s woman experienced Postpartum Blues.  F i f t e e n women s t a t e d t h a t t h e i r g o a l s were  more d i f f i c u l t t o a t t a i n because of the b a b i e s . women developed Postpartum the episode.  Ten o f these  Blues and f i v e d i d n o t develop'  Of the remaining t h i r t e e n women who s t a t e d  t h e i r g o a l s as u n a f f e c t e d by the babies n i n e developed  Post-  partum 31ues and f o u r d i d n o t develop the episode. Kane, op. c i t . ,  p. 101.  A u d r e y R i k e r , "New Parent B l u e s , " C h i l d and Family, VI ( S p r i n g , 196?), 11j Auerbach, op. c i t . , p. 12. 7  75 VI.  INCIDENCE OF S P E C I F I C ENDOCRINE FACTORS RELATED TO THE MENSTRUAL CYCLE  I n f o r m a t i o n p r o v i d e d by t h e i n t e r v i e w showed t h a t o n l y one woman h a d n o t e x p e r i e n c e d of The  the menstrual  cycle  one e x c e p t e d  difficulties  woman d e v e l o p e d  women r e p o r t e d t h e f i r s t n i n e and e l e v e n ) . Blues while  in  Blues.  Nine  (age o f menarche b e t w e e n  F i v e o f t h e s e women d e v e l o p e d the episode.  Postpartum  Fifteen of  t w e n t y who d i d n o t r e p o r t t h e d i f f i c u l t y  oped P o s t p a r t u m Although  a t l e a s t one  i n the l i t e r a t u r e .  Postpartum  difficulty  f o u r d i d not develop  the r e m a i n i n g  cited  schedules  Blues while  not significant,  contrast to-the  five  devel-  d i d n o t develop: the e p i s o d e .  the d i r e c t i o n  of this  finding i s  f i n d i n g s r e p o r t e d by Y a l o m a n d o t h e r s  which  20 correlated  e a r l y a g e o f menarche w i t h Of  culty and  Postpartum  t h e s i x women who r e p o r t e d t h e s e c o n d  (irregular periods) five  one d i d n o t d e v e l o p  developed  while  Postpartum  the episode.  Postpartum  Therefore  t e e n o f t h e women who d i d n o t r e p o r t d y s m e n o r r h o e a Blues while Of  Blues  d i f f i c u l t y (dys-  S i x o f t h e s e women e x p e r i e n c e d  two d i d n o t e x p e r i e n c e  Postpartum  diffi-  the episode.  E i g h t women r e p o r t e d t h e t h i r d menorrhoea).  Blues.  seven  d i d n o t develop  four-  developed  the episode.  t h e t h i r t e e n women who r e p o r t e d t h e f o u r t h  Yalom a n d O t h e r s ,  op. c i t . , p . 24.  Blues  difficulty  (premenstrual  depression)  t e n developed  partum B l u e s and t h r e e d i d n o t d e v e l o p Therefore,  velop  the episode.  t e n o f t h e women who d i d n o t r e p o r t  depression developed  Postpartum  Post-  premenstrual  Blues and s i x d i d n o t de-  the episode. E i g h t e e n women r e p o r t e d t h e f i f t h  (premenstrual perienced  irritability).  Postpartum  the episode.  T h i r t e e n o f t h e s e women e x -  Blues while  Therefore,  Postpartum  five  did not experience  o f the remaining  who d i d n o t r e p o r t p r e m e n s t r u a l veloped  difficulty  n i n e t e e n women  irritability,  B l u e s and seven  twelve de-  d i d n o t develop the,  episode. Table menstrual of  no  difficulty  Postpartum  fifth  15 i l l u s t r a t e s  Blues.  difficulties  tendencies  t h e i n c i d e n c e o f each  reported according t o the incidence The f i n d i n g s  o f t h e second  to the  r e p o r t e d by t h e s t u d y p o p u l a t i o n showed  supportive of the f i n d i n g s reported i n the  21 s t u d y by Yalom a n d o t h e r s . The  difficulty  o f short duration o f menstrual  f l o w was n o t r e p o r t e d b y a n y o f t h e s t u d y p o p u l a t i o n .  2 1  Ibid.  77 Table 1 5 Incidence of Menstrual Cycle D i f f i c u l t i e s A c c o r d i n g to Incidence of Postpartum Blues i n the Study P o p u l a t i o n  Difficulty Reported  Age  Number Who Developed Postpartum  o f Menarch 9 - 1 1 y e a r s  Irregular  Blues  Number Who Did Not D e v e l o p P o s t partum B l u e s  5  periods  Dysmenorrhoea  5  1  6  2  Premenstrual  Depression  1 0  3  Premenstrual  Irritability  1 3  5  V.  INCIDENCE OF  S L E E P DEFICIENCY  Information concerning the at  interview schedules. home d u r i n g t h e  s l e e p was  With r e g a r d  f i r s t week, no  collected  to the p a t t e r n o f s l e e p  c o n c l u s i o n s other than i t  was  r e p o r t e d l y b e t t e r t h a n when i n h o s p i t a l ,  due  to i n s u f f i c i e n t  hospital rupted and  sleep obtained  f o r the  l a b o u r was could not  Therefore,  i n t e r v i e w schedule from  were u s e d . t h e day  not  accounted  estimate  beyond the  s l e e p w h i c h may  any  for.  The  prior  study  were  felt  the  of  labour  examined.  have b e e n o b t a i n e d  I t was  drawn  amount o f u n i n t e r -  t o the. o n s e t  s l e e p t h a t t h e y may  scope of t h i s  c o u l d be  o n l y the data from  t h r e e days f o l l o w i n g confinement  Of n e c e s s i t y , any  was  data.  by  during  t h a t t h e women have had  and i t  t o make o b s e r v a t i o n s  on  sleep.  A l s o , i t was improbable t h a t even one s l e e p c y c l e  c o u l d have been completed d u r i n g l a b o u r i n the h o s p i t a l because o f p a i n f u l c o n t r a c t i o n s and because o f n u r s i n g procedures.  Therefore,  the four-day  care  period r e f e r r e d to i n  t h i s s e c t i o n i s a c t u a l l y f o u r twenty-four hour days p l u s the d u r a t i o n of labour which was between one hour and t h i r t y minutes and f o u r t e e n hours and t e n minutes. The number o f s l e e p c y c l e s p o s s i b l e d u r i n g each period of uninterrupted  s l e e p r e p o r t e d by the women f o r each  of the f o u r days was estimated.  A minimum  of eighty-five 22  minutes was counted as equal t o one s l e e p c y c l e .  The num-  ber o f s l e e p c y c l e s f o r each woman was then t o t a l l e d f o r the four-day  period. Next, the data were t a b u l a t e d i n the f o l l o w i n g way: Thirteen sleep cycles or more i n f o u r days  Twelve s l e e p c y c l e s o r l e s s i n f o u r days  Postpartum Blues  3  17  No Postpartum Blues  6  3  The  c h i square t e s t showed a s i g n i f i c a n t d i f f e r e n c e  between the two groups.  The r e s u l t was ? . ? a t the .05 l e v e l . L  The number of s l e e p c y c l e s were t o t a l l e d f o r two days and f o r three days o f the four-day t i o n and were s i m i l a r l y t e s t e d . insignificant.  p e r i o d under examina-  However, the f i n d i n g s were  I t would appear, then, t h a t i f the d e f i c i e n c y  of s l e e p p e r s i s t e d beyond three days, the development o f Post-  N a t h a n i e l Kleitman, Sleep and Wakefulness U n i v e r s i t y o f Chicago Press, 1 9 ^ 3 ) p. 1 1 2 .  (Chicago.-  partum Blues r e s u l t e d .  Perhaps t h i s e x p l a i n s the f a c t noted  i n the l i t e r a t u r e t h a t Postpartum Blues r a r e l y occurs be23  f o r e the t h i r d postpartum day. In accordance w i t h  s l e e p theory  f o u r o r more s l e e p  c y c l e s i n twenty-four hours was regarded as adequate s l e e p , two  o r three c y c l e s as inadequate and zero o r one c y c l e as oh  a sleep deprivation.  Therefore,  twelve o r l e s s s l e e p  cyc-  l e s i n f o u r days c o n s i s t u t e d inadequate s l e e p o r s l e e p dep r i v a t i o n i n the study p o p u l a t i o n .  In view o f the e x e r t i o n  of l a b o u r  the s l e e p needs a r e g e n e r a l l y c o n s i d e r e d  increased  i n the e a r l y puerperium.  Consequently, s l e e p de-  f i c i e n c i e s imposed an even g r e a t e r hardship c o n f i n e d women.  on the r e c e n t l y -  I t i s n o t s u r p r i s i n g , then,  i n g was s i g n i f i c a n t .  t o be  that t h i s  find-  This f i n d i n g i s s i m i l a r to a f i n d i n g 2 *5  r e p o r t e d i n the study by Yalom and o t h e r s . The f i n d i n g i s a l s o s u p p o r t i v e o f the l i t e r a t u r e i n t h a t the l a c k o f s l e e p J  26  may l e a d t o exhaustion In f a c t ,  t h a t precedes  depression.  o f the seventeen women who  experienced  Postpartum Blues a t home seven thought t h a t the episode had been caused by f a t i g u e due t o d e f i c i e n t s l e e p . the p e r c e p t i o n s  o f the study p o p u l a t i o n which i m p l i c a t e d a  P i t t , "Maternity B l u e s , " Others, op. c i t . , p. 16. 2 3  and  Therefore  op. c i t . p . 3 1 ? Yalom k  oh  Susanna Lee Garner and Pamela M i t c h e l l , "Comf o r t and S l e e p , " Concepts B a s i c t o Nursing, (McGraw H i l l Book Company, 1973), p. 3 8 . k  2<  -.  ^Yalom, op. c i t . , p . 20!  26  Riker,  op.  cit.VvCp.  ^14.'  80 reduction supports  i n s l e e p a s a cause this finding  described.  collected  from  by t h e i n t e r v i e w i n s t r u m e n t s  t h e d a t a was d e s c r i b e d .  Data  and second  third  q u e s t i o n when s t a t i s t i c a l l y  the items  of maternal  nificantly  influence  conflict  influence  Blues.  showed t h a t  t o the menstrual  spe-  cycle  t h e development o f P o s t -  Blues.  deficiency,  q u e s t i o n t h e data'showed t h a t  i n t e r m s o f t h e number o f s l e e p c y c l e s  four-day period, s i g n i f i c a n t l y Postpartum  sleep  that  examined d i d n o t s i g -  q u e s t i o n the data  factors related  For the t h i r d  of  showed  the development o f Postpartum  not significantly  partum  analyzed.  question the data  role  For t h e second  did  o b t a i n e d t o answer t h e  q u e s t i o n s and a f f i r m a t i v e l y answered the  For the f i r s t  endocrine  Blues as derived  by the study n e g a t i v e l y answered the  first  cific  were  o f the study p o p u l a t i o n  The i n c i d e n c e o f P o s t p a r t u m  three q u e s t i o n s asked  also  SUMMARY  Selected characteristics  were p r e s e n t e d .  Blues  of the study. VI..'  Data  o f Postpartum  Blues.  deficiencies,  influenced  sleep  over a  the development  Of t h e t w e n t y women who e x p e r i e n c e d seventeen  (85 p e r c e n t ) d e v e l o p e d  Post-  p a r t u m B l u e s w h e r e a s o f t h e n i n e women who d i d n o t e x p e r ience  sleep deficiencies  Postpartum  Blues.  only three  (33 p e r c e n t )  developed  CHAPTER V  SUMMARY,  CONCLUSIONS, AND  RECOMMENDATIONS I. The  purpose o f t h i s  mine t h e i n f l u e n c e of  conflict  The s t u d y was p l a n n e d  questions: influence  Do s p e c i f i c  d e s c r i p t i v e s t u d y was t o d e t e r -  o f c e r t a i n v a r i a b l e s ; upon t h e d e v e l o p m e n t  Postpartum Blues.  following  SUMMARY  t o answer t h e  (1) Do f a c t o r s r e l a t e d t o m a t e r n a l  t h e development o f Postpartum  Blues?  endocrine f a c t o r s r e l a t e d t o the menstrual  influence  t h e development o f Postpartum  Blues?  reduction  i n t h e number o f s l e e p  influence  ment o f P o s t p a r t u m  cycles  theory and research  pertinent  The f i r s t  The s e c o n d  i n the puerperium.  presented  t o Postpartum  s e c t i o n viewed  developmental c r i s i s . occurring  The t h i r d  needs.  s e c t i o n viewed  the f i f t h  The l i t e r a t u r e  were r e p o r t e d  the,develop  and e i g h t y  percent.  as implicated  relevant  Blues i n f i v e  s e c t i o n viewed  s e c t i o n viewed  some  sleep  the Postpartum  r e v i e w showed t h a t  p a r t u m B l u e s syndrome h a s a r e p o r t e d between f i v e  (3) Does a  s e c t i o n viewed t h e changes  The f o u r t h  B l u e s syndrome.  cycle  the puerperium as a  concepts o f r o l e theory. Lastly,  (2)  Blues?  A review o f the l i t e r a t u r e  sections.  role  occurrence  the Post-  o f anywhere  A variety of factors  i n t h e development o f t h e s y n -  81  82/ drome.  The most commonly suggested f a c t o r s were maternal  r o l e c o n f l i c t items, endocrine f a c t o r s , and s l e e p d e f i c i e n c y . The l i t e r a t u r e emphasized  the importance  o f a s s i s t i n g women  to meet t h e i r emotional needs i n the puerperium. s t u d i e s on Postpartum  Research  Blues were l i m i t e d both i n number and  scope. Instruments used t o o b t a i n data r e l e v a n t t o the q u e s t i o n s asked by the study were two s e m i - s t r u c t u r e d i n t e r view schedules and one s e m i - s t r u c t u r e d q u e s t i o n n a i r e . were developed f o l l o w i n g the l i t e r a t u r e review.  These  In addition,  the Beck Depression Inventory was used t o measure the degree of  d e p r e s s i o n p r e s e n t a t the time o f the i n t e r v i e w . The study p o p u l a t i o n c o n s i s t e d o f twenty-nine  postpartum women who d e l i v e r e d f u l l - t e r m , a p p a r e n t l y h e a l t h y i n f a n t s , i n one o b s t e t r i c s and gynecology h o s p i t a l i n the Greater Vancouver a r e a .  Other c r i t e r i a o f e l i g i b i l i t y t o  the study were w i l l i n g n e s s t o p a r t i c i p a t e and c e r t a i n l a n g uage, demographic, h e a l t h , and o b s t e t r i c a l requirements. Two i n t e r v i e w s were conducted,  one i n h o s p i t a l on  the t h i r d o r f o u r t h day, and one i n each woman's home a t around f o u r weeks a f t e r  confinement.  The data:, c o l l e c t e d by. the i n t e r v i e w instruments were d e s c r i p t i v e l y a n a l y z e d .  C h a r a c t e r i s t i c s o f the study  p o p u l a t i o n were d e s c r i b e d and shown i n frequency d i s t r i b u t i o n tables.  The i n c i d e n c e o f Postpartum  Blues was assessed by  i n f o r m a t i o n p r o v i d e d by the Blues Q u e s t i o n n a i r e .  The Beck  Depression Inventory d i d n o t prove t o be a u s e f u l measure i n p r e d i c t i n g the development o f Postpartum  Blues i n the women  a t home on t h e b a s i s administered  a t the h o s p i t a l  maternal r o l e  conflict,  to the menstrual cribed  of their  cycle,  endocrine f a c t o r s  related des-  c o i n c i d e n c e w i t h the development o f  Blues.  included.  The c h i s q u a r e  episode  Data p e r t i n e n t t o  a n d s l e e p d e f i c i e n c i e s were  Postpartum  Postpartum  s c o r e on t h e i n v e n t o r y  interview.  specific  i n terms o f t h e i r  significant  total  Tables containing t h i s t e s t was u s e d  i n f o r m a t i o n were  t o determine any  d i f f e r e n c e s b e t w e e n t h e women who e x p e r i e n c e d B l u e s a n d t h e women who d i d n o t e x p e r i e n c e t h e  i nrelation  three f a c t o r s under The differences  t o each  o f the items c o n s t i t u t i n g the  examination.  results  showed t h a t  f o r items l e a d i n g  or f o r items o f s p e c i f i c the m e n s t r u a l  cycle.  t h e r e were no s i g n i f i c a n t  to maternal r o l e  conflict  endocrine f a c t o r s r e l a t e d t o  However,  t h e r e was a  significant  difference  f o r sleep deficiency.  I t was shown  deficiency  i n t e r m s o f t h e number  o f sleep c y c l e s over a  four-day period, of Postpartum  significantly  Blues.  influenced  that  sleep  the development  The m a j o r i t y o f t h e women ( 8 5 p e r -  c e n t ) who e x p e r i e n c e d s l e e p d e f i c i e n c i e s  developed  Post-  p a r t u m B l u e s w h e r e a s t h e m i n o r i t y o f t h o s e who d i d n o t experience  sleep deficiencies II. On t h e b a s i s  developed  Postpartum  Blues.  CONCLUSIONS  o f the f i n d i n g s  of this  study,  t h e f o l l o w i n g c o n c l u s i o n s were made: 1. P o s t p a r t u m  B l u e s may w e l l be t h e t r i v i a l  ' 84 and  f l e e t i n g phenomenon a s d e s c r i b e d b y P i t t .  women r e p o r t e d P o s t p a r t u m  B l u e s t o be a s s o c i a t e d w i t h  longed negative f e e l i n g s . the  episode as unpleasant  whelming.  ingly men  while  i t lasted  but not as over-  Postpartum  the episode  termittantly  as a learning  B l u e s may, i n f a c t ,  as the l i t e r a t u r e The  for this  B l u e s was o f no g r e a t i m p o r t a n c e .  f o u r women v i e w e d  pro-  Most o f t h e women r e p o r t e d v i e w i n g  T h e r e f o r e , , i t was--concluded t h a t ,  tion,Postpartum  None o f t h e  1  suggested.  popular  Furthermore,  experience.  be b e n e f i c i a l  Accord-  t o some wo-  2  l o n g e s t d u r a t i o n o f Postpartum  Blues occurred i n -  over a p e r i o d o f between f o u r and seven  days w i t h  t h e e x c e p t i o n o f one w h i c h l a s t e d  intermittantly  o v e r two weeks.  This  the assumption  o f the study,  finding  derived  i s i n agreement w i t h  from  tinguished  the l i t e r a t u r e ,  from The  Postpartum  t h a t Postpartum  o t h e r f o r m s o f d e p r e s s i o n by i t s d u r a t i o n .  assumption  that  t h e degree  i n p a r t by t h e s t u d y .  none o f t h e women i n t h e s t u d y  exhibited behaviour vere nature  indicated  stateBe-  symptoms o r  c o n s i s t e n t w i t h d e p r e s s i o n o f a more s e -  than t h e Postpartum  c l u s i o n was n o t d e f i n i t i v e . erity  of severity of  B l u e s c o u l d be m e a s u r e d by t h e s e l f - r e p o r t e d  ments o f t h e women was s u p p o r t e d cause  B l u e s c a n be d i s -  Blues  experienced,  this  N e v e r t h e l e s s , t h e degree  con-  o f sev-  o f t h e e p i s o d e was i n d i c a t e d by t h e women a s n o t s e v e r e .  1  Psychiatry.  Brice. P i t t , "Maternity Blues," B r i t i s h GXX (1973), 432-433.  Journal of  2 Paulette and i t s A p p l i c a t i o n ( J u l y , 1967), 54.  Robischon and Diane S c o t t , "Role Theory i n F a m i l y N u r s i n g , " N u r s i n g Outlook XXVII  85 That the degree by  t h e Beck D e p r e s s i o n  of severity  the findings.  Inventory  o f Postpartum  c o u l d measure  B l u e s was n o t b o r n o u t  T h e r e f o r e , i t was c o n c l u d e d  that  v e n t o r y was n o t a u s e f u l m e a s u r e i n p r e d i c t i n g ment o f P o s t p a r t u m  Blues  on t h e t h i r d  or fourth  be  concluded  that  in  the non-depressed  the i n -  the develop-  on t h e b a s i s o f t h e i n v e n t o r y s c o r e  day postpartum.  Conversely,  i t could  t h e i n v e n t o r y , by p l a c i n g a l l b u t one woman category,  determined  that  Postpartum  B l u e s was a n o n - d e p r e s s e d  state.  However, s u c h a c o n c l u s i o n  w o u l d be i n c o n t r a d i c t i o n  t o the reported f e e l i n g s  s i o n e x p e r i e n c e d b y t h e women i n c o n j u n c t i o n w i t h  o f depresPostpartum  Blues. 2. in  this  The i t e m s  of maternal  role  examined  s t u d y were n o t o f s u f f i c i e n t m a g n i t u d e o r number t o  influence  t h e development o f Postpartum  the items  o f maternal  positive  role  conflict  f o r c e s s u c h ,that t h e i r  the items  of maternal  conflict  b u t must be i n c o m b i n a t i o n  Alternatively,  e f f e c t was n o t s u f f i c i e n t t o  t h e development o f Postpartum role  Blues.  were c o u n t e r - b a l a n c e d b y  influence  tial,  conflict  Blues.  Then a g a i n ,  alorie\ may n o t be i n f l u e n -  with  items n o t p r e s e n t i n  this population.  On t h e o t h e r hand, e q u a l w e i g h t i n g  items  role  in  of maternal  the data a n a l y s i s ,  o f the  c o n f l i c t may h a v e b e e n a f a u l t y thereby masking the t r u e weight  method o f each  item. 3.  The e n d o c r i n e  factors related  c y c l e w h i c h were examined were n o t , influential in  alone  or i n combination,  i n t h e development o f Postpartum  contradiction  o f the findings  to the menstrual  Blues.  This i s  o f a study with a p o p u l a t i o n  of t h i r t y - n i n e . - ^  S o c i o c u l t u r a l d i f f e r e n c e s between the two  p o p u l a t i o n s may account f o r the d i s c r e p a n t f i n d i n g s . 4.  Sleep d e f i c i e n c y i s d e t r i m e n t a l t o the emo-  t i o n a l w e l l - b e i n g of postpartum women.  The m a j o r i t y o f the  women p e r c e i v e d f a t i g u e due t o s l e e p d e f i c i e n c y as the underl y i n g cause o f the development o f Postpartum Blues. there was l i t t l e  However,  the women c o u l d do i n the h o s p i t a l , and  sometimes a t home, about i n c r e a s i n g the amount o f u n i n t e r r u p ted s l e e p . 5.  The h o s p i t a l environment and r o u t i n e s a r e n o t  conducive t o adequate s l e e p f o r most postpartum women. The m a j o r i t y o f the women r e p o r t e d h o s p i t a l n o i s e s and r o u t i n e s i n c l u d i n g the 5 a.m. i n f a n t - f e e d i n g as d i s r u p t i v e o f t h e i r sleep. 6.  P u b l i c Health Nurses should p l a y a g r e a t e r r o l e  i n e d u c a t i o n and support  o f postpartum women a t home.  ber o f women had some q u e s t i o n s  A num-  on s e l f o r baby care t h a t a  P u b l i c Health Nurse c o u l d have answered.  Further  information  on what i s normal f o r i n f a n t s with regard  t o suoh t h i n g s as  e a t i n g , s l e e p i n g , and e l i m i n a t i o n h a b i t s , and s k i n c o n d i t i o n would have b e n e f i t t e d most p r i m i p a r a s . been helped  Other women c o u l d have  by more s p e c i f i c advice ox*, j u s t from  reassurance  that they were good mothers.  I r v i n D. Yalom and Others, "'Postpartum Blues' Syndrome," A r c h i v e s of General P s y c h i a t r y . XVIII (January. 1968), 24. J  87  III. The  results  RECOMMENDATIONS  of this  study  (1)  indicate that;  p o s t p a r t u m women . f r e q u e n t l y e n c o u n t e r s l e e p d e f i c i e n c y ! s l e e p d e f i c i e n c y i s an i n f l u e n t i a l (3)  of Postpartum Blues; have a n u n d e r s t a n d i n g problems, classes:  f a c t o r i n t h e development  women who a t t e n d e d  h u s b a n d s who a t t e n d e d  t h e i r wives' labour w i v e s a t home; (5) a b o u t baby c a r e ,  prenatal  classes  o f the puerperium and i t s i n h e r e n t  judged by t h e r e f l e c t i o n (4)  (2)  o f content  learned a t  p r e n a t a l c l a s s e s and a t  a n d d e l i v e r y were v e r y  supportive  p o s t p a r t u m women a t home have  particularly  of their  questions  a b o u t f e e d i n g a n d a b o u t what  i s n o r m a l f o r a baby o f t h a t a g e ; (6) p o s t p a r t u m women commonly  view h o s p i t a l n u r s i n g  p h y s i c i a n s as very are  reticent  staff,  p u b l i c h e a l t h n u r s e s , and  busy p e o p l e and c o n s e q u e n t l y ,  to call  upon them f o r  In view o f these  t h e women  advice.  results  t h e f o l l o w i n g recommenda-  t i o n s a r e made: 1.  Regarding f u r t h e r research, that:  ( a ) a--study  o f a l a r g e r a n d more d i v e r s e p o p u l a t i o n time o t h e r  t h a n D e c e m b e r - J a n u a r y be c o n d u c t e d ;  (b) a b e t t e r method o f c o l l e c t i n g be the  used;  a social  sleep  ( c ) i n t e r v i e w s be c o n d u c t e d  episode  at a  o f Postpartum  Blues,  data  during  and (d)  d e s i r a b i l i t y measure be u s e d ; ( e )  /instruments  f o r data  •oh a l a r g e r s c a l e .  c o l l e c t i o n be p r e t e s t e d r  :  '  \  * 88 2.  Regarding education, dance a t p r e n a t a l  that  (a) a higher  atten-  c l a s s e s of expectant  parent  couples  o f a l l s o c i o - e c o n o m i c g r o u p s be a c t i v e l y  sought;  ( b ) more e d u c a t i o n  be  within  made a v a i l a b l e , p o s s i b l e  visual  self-use kits;  which i n c l u d e ly  the h o s p i t a l  to include  (e) p r a c t i c e  sessions  d i s c u s s i o n s and r e h e a r s a l  encouraged;  (d) a "handout" sheet  information  on t i p s  er's confidence  containing  toward p r e v e n t i n g  i n h e r new r o l e . b e  Regarding nursing review current  permit a longer sleep;  routines  mentally  period  postpartum  who a d v i s e s  als  i n s l e e p and  day t o a u n i t  that  environ-  and i n t e r r u p t i o n s .  (a) c l a s s i f i c a t i o n s persons as t o  on m a t t e r s o f i n f a n t c a r e ,  A l t e r n a t i v e l y , that health  e s t a b l i s h common r o u t i n e s  m o t h e r s on s u c h m a t t e r s ; son  pro-  m o v i n g women a f t e r  made among h e a l t h r e s o u r c e  feeding.  care  o f t i m e t o be a v a i l a b l e  a r e few n o i s e s  Regarding resources be  provided.  more c o n d u c i v e t o r e s t a n d c o m f o r t  where t h e r e 4.  t h e moth-  and n u r s i n g  (b) consider  their first  Post-  p r a c t i c e , that h o s p i t a l s : (a)  cedures t o reduce disturbances  for  of like-  p r o b l e m s t o be e n c o u n t e r e d by t h e m o t h e r be  partum B l u e s and toward f a c i l i t a t i n g  3.  audio-  such as  profession-  for advising  (b) g r e a t e r  between t h e h o s p i t a l a n d p u b l i c  liahealth  agencies be e s t a b l i s h e d to ensure c o n s i s t e n t and  immediate feedback of i n f o r m a t i o n r e g a r d i n g  c l i e n t s to both  parties.  F u r t h e r to r e s o u r c e s ,  t h a t a l i a s o n nurse  ployed by h o s p i t a l s c o u l d : (a) i n t e r a c t  em-  with  postpartum women i n h o s p i t a l to determine t h e i r needsj ing;  (b) f a c i l i t a t e i n d i v i d u a l or group l e a r n -  (c) c o o r d i n a t e two-way r e f e r r a l s and  change of i n f o r m a t i o n with other h e a l t h or h e a l t h - r e l a t e d personnel  i n the community.  ex-  ,90  BIBLIOGRAPHY BOOKS Abdellah, Faye G., and Eugene L e v i n e . B e t t e r P a t i e n t Care Through Nursing Research. New York: The Macmillan C ompany, 196 5. Baker, A.A. Psychiatric Disorders i n Obstetrics. The S a l i s b u r y Press L t d . , 1967.  Salisbury:  B i d d l e , Bruce, and Edwin J . Thomas ( e d s . ) . Role Theory: Concepts and Research. New York: John Wiley & Sons, Inc., 1966. Caplan, G e r a l d . An Approach to Community Mental H e a l t h . New York: Grune & S t r a t t o n , Inc., 1961. F i e l d i n g , Jane. "Study of S e l e c t e d Behaviours of P r i m i parous Mothers During the F i r s t Three Post Partum Days," The N u r s i n g Process, ed. Marie Seedor. New York: Teacher's C o l l e g e Press, 1972. Fowler, Mary M. " P s y c h o l o g i c a l Needs of the Puerperium," M a t u r a t i o n a l C r i s i s of C h i l d b e a r i n g , ed. Ann C l a r k . Honolulu: U n i v e r s i t y of Hawaii, 1971. Garner, Susanna Lee, and Pamela M i t c h e l l . "Comfort and Sleep S t a t u s , " Concepts Basic to Nursing, ed. Pamela Mitchell. New York: McGraw-Hill Book Company, 1973. Hamilton, James Alexander. Saint Louis: The C.V.  Postpartum P s y c h i a t r i c Mosby Company, 1962.  Problems.  Hardyck, C u r t i s D., and Lewis F. P e t r i n o v i c h . Introduction to S t a t i s t i c s f o r the B e h a v i o u r a l S c i e n c e s . Philadelphia: W.B. Saunders Company, 1969. Kleitman, N a t h a n i e l . Sleep and Wakefulness. v e r s i t y of Chicago P r e s i ^ 1963.  Chicago:  Myles, Margaret F. A Textbook f o r Midwives. E.&S. L i v i n g s t o n e L t d . , 1961.  Edinburgh:  Uni-  Parad, Howard J . (ed.). C r i s i s I n t e r v e n t i o n : Selected Readings. New York: Family S e r v i c e s A s s o c i a t i o n of America, 1965. Peck, Sharon S., and Rana L. Peck. "Postpartum Needs of the Family," M a t e r n i t y N u r s i n g Today, ed. Joy P. Clausen. New York: McGraw H i l l Book Company, 1973.  92. Wiedenbach, E r n e s t i n e . Family-Centred M a t e r n i t y Nursing. New York: G.P. Putnam's Sons, 1967. Wrightsman, Lawrence S. S o c i a l Psychology In the S e v e n t i e s . Monterey: Brooks/Cole P u b l i s h i n g Company, 1972. Yoshioka, Ruth. " M a t u r a t i o n a l C r i s i s of Pregnancy," M a t u r a t i o n a l C r i s i s o f C h i l d b e a r i n g , ed. Ann C l a r k . Honolulu: U n i v e r s i t y of Hawaii, 1971, 15-22. PERIODICALS A i t k e n , R.C.B., and A.K. Z e a l l y . "Measurement of Moods," B r i t i s h J o u r n a l of H o s p i t a l Medicine, IV, (August, 1970), 215-224. Auerbach, A l i n e B. "Meeting the Needs of New Mothers," C h i l d and Family. VI (Winter, 196?), 9-17. Beck, A.T., and Others. "An Inventory f o r Measuring Dep r e s s i o n , " A r c h i v e s of General P s y c h i a t r y , IV (June,  1968), 561-571.  B i b r i n g , Grete L. "Recognition of P s y c h o l o g i c a l S t r e s s Often Neglected i n 0 B Care," H o s p i t a l T o p i c s , XLIV (September, 1966), 100-103. Caplan, G e r a l d . " P s y c h o l o g i c a l Aspects of M a t e r n i t y Care," American J o u r n a l of P u b l i c Health, XLVII (January, 1957),  25-31.  earner, C h a r l e s . "After-Baby B l u e s , " Today's H e a l t h . VC (December, 1967), 33-35. Davidson, J.R.T. "Postpartum Mood Change i n Jamaican Women: A D e s c r i p t i o n and D i s c u s s i o n on i t s S i g n i f i canae," B r i t i s h J o u r n a l of P s y c h i a t r y . XCCI (1972),  659-663.  E i s l e r , Jeanne, John A. Wolfer, and Donna D i e r s . " R e l a t i o n s h i p s Between Need f o r S o c i a l Approval and P o s t o p e r a t i v e Recovery and Welfare," Nursing Research, XXI (NovemberDecember, 1972), 520-525. Gordon, Richard E., and Katherine Gordon. " S o c i a l F a c t o r s i n P r e v e n t i o n of Postpartum Emotional F a c t o r s , " Obs t e t r i c s and Gynecology, XV ( A p r i l , i960), pp. 433Gordon, R i c h a r d E., E l i Kapostins, and Katherine Gordon, "Factors i n Postpartum Adjustment," O b s t e t r i c s and Gynecology, XXV (February, 1965), 158-166.  Grimm, E l a i n e R., and Wanda R. V e n e t . "The R e l a t i o n s h i p o f E m o t i o n a l A d j u s t m e n t and A t t i t u d e s t o t h e C o u r s e and Outcome o f P r e g n a n c y , " P s y c h o s o m a t i c M e d i c i n e , X X X V I I I ( J a n u a r y , 1966), 34-49. Highley, Betty. "Maternal Role C o n t e n t , V o l . 1. Boulders sion f o r Higher Education,  Identity," Defining C l i n i c a l W e s t e r n I n t e r s t a t e Commis196?, pp. 33-4-3.  J a r r a h i - Z a d e h , A l i , and O t h e r s . " E m o t i o n a l and C o g n i t i v e Changes i n P r e g n a n c y and E a r l y P u e r p e r i u m , " B r i t i s h J o u r n a l o f P s y c h i a t r y . CXV (1969), 797-805. Kane, F r a n c i s J . J n r . , and O t h e r s . " E m o t i o n a l and Cogn i t i v e Disturbance i n the E a r l y P u e r p e r i u m , " - B r i t i s h J o u r n a l o f P s y c h i a t r y , GXIV ( J a n u a r y , 1968), 99-102. L a n d i s , J u d s o n T. " M a r r i a g e s o f M i x e d and Non-mixed R e l i g i o u s F a i t h , " A m e r i c a n S o c i o l o g i c a l Review,  ( j u n e , 1949), 401-407T  XIV  L a r s e n , V i r g i n i a L. " S t r e s s e s o f the C h i l d b e a r i n g Year," A m e r i c a n J o u r n a l o f P u b l i c H e a l t h . L V I ( J a n u a r y , 1966),  32-36.  L i t t l e , C r a w f o r d , and N e i l I . M c P h a i l . "Measures o f Dep r e s s i v e Mood a t M o n t h l y I n t e r v a l s , " B r i t i s h J o u r n a l o f P s y c h i a t r y . XCCII (1973), 447-452. M e l g e s , F r e d e r i c k T. " P o s t p a r t u m P s y c h i a t r i c Syndromes," P s y c h o s o m a t i c M e d i c i n e . XXX ( J a n u a r y - F e b r u a r y m 1968),  pp. 95-108.  Murphy, George E., and O t h e r s . " ' L i f e S t r e s s ' i n a Normal Populations A S t u d y o f 101 Women H o s p i t a l i z e d f o r N o r m a l D e l i v e r y , " J o u r n a l o f N e r v o u s and M e n t a l D i s e a s e , CXXXV ( F e b r u a r y , 1962), 150-161. P a f f e n b a r g e r , R. Psychoses,"  "The P i c t u r e P u z z l e o f the P o s t p a r t u m Journal of Chronic Diseases. X I I I (1961),  161-173. Pitt,  Brice. chiatry,  "'Maternity CXX (1973),  Blues',"  Rice,  E l i z a b e t h P. "After Office Gynecology, XXIII (February,  431-433.  British  Journal of  Psy-  H o u r s , " O b s t e t r i c s and  1964), 307-315.  R i k e r , Audrey. "New Parent Blues," C h i l d ( S p r i n g , .1967), 10-17.  and  Family.  VI  R o b i n , A.A. "The. P s y c h o l o g i c a l Changes o f Normal P a r t u r i t i o n P s y c h i a t r i c Q u a r t e r l y , XXXVI ( J a n u a r y , 1962), 129-150.  R o b i s c h o n , P a u l e t t , and D i a n e S c o t t . " R o l e T h e o r y and I t s A p p l i c a t i o n i n F a m i l y N u r s i n g , " N u r s i n g O u t l o o k , XXXVI  ( J u l y , 1969), 52-57.  Rubin,  Reva.  " P u e r p e r a l Change," N u r s i n g  ember, 1961), 753-755.  Outlook,  IX  (Dec-  R u b i n , Reva. " A t t a i n m e n t o f t h e M a t e r n a l R o l e . P a r t Is P r o c e s s e s , " N u r s i n g R e s e a r c h , XVI (Summer, 1967),  237-245.  Rubin, Reva, "Attainment o f M a t e r n a l R o l e . and R e f e r e n t s , " N u r s i n g R e s e a r c h . XVI 342-347.  P a r t I I . Models ( F a l l , I967),  Rubin, Reva. " C o g n i t i v e S t y l e i n Pregnancy," American J o u r n a l o f N u r s i n g . LXX (March, 1970), 502-508. Tod,  E.M.  1964),  " P u e r p e r a l D e p r e s s i o n , " The 1264-1266.  Lancet,  XI  (December,  Williams, Barbara. " S l e e p Needs D u r i n g t h e M a t e r n i t y C y c l e , " N u r s i n g O u t l o o k . XV ( F e b r u a r y , I967), 53-55. Yalom, I r v i n D., and O t h e r s . " P o s t p a r t u m B l u e s ' Syndrome," A r c h i v e s o f G e n e r a l P s y c h i a t r y , X V I I I ( J a n u a r y , 1968),  16-27.  OTHER F u r n e l l , M a r g a r y D. " A d o l e s c e n t D e p r e s s i o n and I n t e r p e r s o n a l Behaviour." Unpublished Master's T h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1973. J o r d a n , A. D o r r e e n . "An E v a l u a t i o n o f a F a m i l y - C e n t r e d M a t e r n i t y Care H o s p i t a l Program." Unpublished Research Project, Calgary, 1971. Larsen, V i r g i n i a L. " P r e d i c t i o n and Improvement o f P o s t partum Adjustment." Unpublished Research Report, Washington, 1968.  APPENDIX A  ..95  r96 A  # I,  , agree t o  participate  i n a study a t  Hospital  Maternity  Unit.  The  i s o f mother's f e e l i n g s  study  after  -  that? 2 interviews w i l l  on t h e f o u r t h  home. will  s i x weeks  t h e i r babies are born.  I understand  about  i n the f i r s t  day a f t e r t h e b i r t h  f o u r weeks a f t e r  the b i r t h  The i n t e r v i e w s w i l l each  be h e l d , one a t t h e h o s p i t a l  take about  half  o f t h e baby, a n d one a t o f t h e baby, when I am a t  be h e l d  a t my  convenience,  o f one h o u r .  - no r i s k s a r e i n v o l v e d a n d no names w i l l -  I am f r e e  t o withdraw from  - On r e q u e s t I w i l l  be  used.  t h e s t u d y a t any time.  be g i v e n knowledge o f t h e r e s u l t s .  i-.  Signature  of Participant  Signature  of Researcher  Date  and  98 B  HOSPITAL INTERVIEW Code  No.  Address Phone Date o f  Interview  Age Gravida ParityEstimated  date  of Confinement  Confinement  Date: T.imej .-Outcome:  Apgar Score Birth  P  (1)  o f Baby  (2)  W e i g h t o f Baby  Length  1st 2nd 3rd  of Labour -  Drugs A d m i n i s t e r e d -  Episiotomy  If not How  M  stage stage stage  TOTAL  1 s t stage 2nd s t a g e 3rd s t a g e Postpartum  or L a c e r a t i o n Sutures  Canadian,  l o n g have y o u  what c o u n t r y a r e y o u lived  i n Canada  Have y o u had any m a j o r i l l n e s s t h i s pregnancy Have y o u Are  you  e v e r had and  from  during or apart  from  a psychiatric disorder  t h e baby w e l l a t p r e s e n t  What i s y o u r m a r i t a l  status:  M  S  W  D  C/L  No. y e a r s l i v i n g w i t h husband Are your p a r e n t s a l i v e : Where a r e they l i v i n g :  or partner  M.  F.  M.  F.  Are your husband's p a r e n t s a l i v e : Where a r e they l i v i n g :  M.  M.  F. F.  What i s your r e l i g i o n What i s your husband's r e l i g i o n ; Were you brought w i t h a r e l i g i o u s Was your husband:  Yes  background:  Yes  No  No  Do you f o l l o w your r e l i g i o n Does your husband  follow h i s r e l i g i o n  What was the h i g h e s t e d u c a t i o n completed: - self - husband your mother, - your f a t h e r . - your husband's mother, - your husband's f a t h e r " What i s your o c c u p a t i o n : Are y o u p l a n n i n g t o work I f yes, when do you.begin work Had you always expected some day t o become a mother: - Yes - No What i s your husband's o c c u p a t i o n : Is he working:  No  " P a r t - t i m e '•-  Full-time^  What i s the o c c u p a t i o n o f : your mother your f a t h e r your husband's mother your husband's f a t h e r How many c h i l d r e n do you have a t home: How o l d i s your youngest  child  •  ^Shift-work •  100 Did you have any p h y s i c a l problems with any p r e v i o u s pregnancy: No - labour  A little  A lot  A little  A lot  No  V  - birth  No  Did you have any emotional  A little  -  A lot_  problems with any  - p r e v i o u s pregnancy i No,  A little  A lot_  - labour  No  A little  A lot_  - birth  No  A little  Avlot  Did your mother o r s i s t e r s have any problems with pregnancy, labour, or b i r t h : No A little A lot Who What At what age d i d your p e r i o d s How many days do your p e r i o d s  start: last  Are your p e r i o d s r e g u l a r Have you had t r o u b l e with p a i n f u l p e r i o d s : No A little How l o n g f o r When d i d i t stop What d i d you do f o r i t : take medicine go t o bed Have you f e l t depressed  apply heat  A lot  miss work  o r i r r i t a b l e before your p e r i o d s :  - o f f the p i l l  No  A little  A lot  - on the p i l l  No  A little  A lot  For how l o n g were you t r y i n g t o become pregnant: Did you a t t e n d p r e n a t a l c l a s s e s : No Where  A few  All  To l e a r n more about pregnancy, labour, b i r t h , and baby care, did you: - read books No A little A lot - t a l k with f r i e n d s or r e l a t i v e s who are n o t p r o f e s s i o n als No  A little  A lot  -101  t a l k with your doctor or nurse With  Did  t h i s pregnancy,  No_ Who  A  A lot  little  d i d y o u have c o n c e r n s a b o u t :  - labour  No  A little  A lot_  - birth  No  A little  A lot_  - baby c a r e  No  A little  A lot_  - y o u r husband  No  A little  A lot.  - your family or friends  No  A  little,  A lot_  - your doctor or nurses  No  A  little  A lot  you discuss these with:  Do y o u h a v e a n y c o n c e r n s now a b o u t : - baby c a r e ~  m  o  n  No  y  e  No  - housing -  o  t  h  e  Mo No  r  A little. A little. A little. A  little  A lot_ A lot_ A lot_ A lot  Have y o u h a d p r e v i o u s e x p e r i e n c e w i t h b a b i e s a n d t h e i r No Is y o u r husband  Alot  A  A lot  away f r o m home: No  Was y o u r s l e e p i n t e r r u p t e d l a b o u r s t a r t e d due t o : -  A little  piles  little  d u r i n g t h e l a s t week b e f o r e y o u r No How many t i m e s e a c h  - varicose  veins  -frequency  of urine  night  No How many t i m e s e a c h  night  No - other  care:  How many t i m e s e a c h  night  No How many t i m e s e a c h  night  102 Average amount of s l e e p Did,you f e e l r e s t e d when you got up i n the morning How many hours o f s l e e p d i d you have i n the 24 hours before your l a b o u r s t a r t e d Total How many hours o f s l e e p have you had each day s i n c e the baby was born Straight sleep Day  1  Day  2 ;  Day  3  Interrupted  C  Total \  r  ' ;  Did you expect  l a b o u r t o be:  - e a s i e r than i t was - about the same as i t was - harder than i t was Was your husband p r e s e n t d u r i n g the l a b o u r and d e l i v e r y : No  How l o n g  Who or what helped you the most d u r i n g l a b o u r : Who o r what helped you the most d u r i n g the b i r t h : Why d i d you come t o t h i s h o s p i t a l t o have your baby: -  no reason your doctor a t t e n d s here f r i e n d s a d v i s e d you you decided i t was the best f o r you  How a r e you f e e d i n g your baby: - bottle - breast How i s the f e e d i n g going Some mothers d e f i n i t e l y p r e f e r a boy o r g i r l ; preference: Yes No  do you have a  When i s a s u i t a b l e time f o r me t o v i s i t you a t home Date  Time  __  103 >  BECK INVENTORY Case Number:  NAME:. DATE:  123556 7 ( )  8  ( )  9 ( )  10  11  12  (a)  A. 0 1 2  <• - :•• I do n o t f e e l sad. I f e e l sad. I am sad a l l the time and I can't snap out of i t . 3 I am so sad or unhappy t h a t I can't stand i t .  B. 0 I am n o t p a r t i c u l a r l y discouraged about the future. 1 I f e e l discouraged about the f u t u r e . 2 I f e e l I have n o t h i n g to l o o k forward t o . 3 I f e e l t h a t the f u t u r e i s hopeless and t h a t t h i n g s cannot improve. C  0 I do n o t f e e l l i k e a f a i l u r e . 1 I f e e l I have f a i l e d more than the average person 2 As I l o o k back on my l i f e , a l l I can see i s a l o t of f a i l u r e s . 3 I f e c i as i f I am a complete f a i l u r e as a person. ' .  D .  „  0,;I g e t as much s a t i s f a c t i o n out o f t h i n g s as I used t o . 1 I don't enjoy t h i n g s the way I used t o . 2 I don't g e t r e a l s a t i s f a c t i o n out o f a n y t h i n g anymore. 3 I am d i s s a t i s f i e d o r bored with e v e r y t h i n g .  (  )  E.  (  )  F.  0 1 2 3  I I I I  don't f e e l p a r t i c u l a r l y g u i l t y . f e e l g u i l t y a good p a r t o f the time. f e e l q u i t e g u i l t y most o f the time. f e e l g u i l t y a l l of the time.  . 0 1 2 3  I I I I  don't f e e l I am b e i n g punished. f e e l I may be punished. expect t o be punished. f e e l I am b e i n g punished.  104  13  (  14 (  )  G-  )  H.  0 1 2 3  I I I I  don't f e e l d i s a p p o i n t e d i n myself. am d i s a p p o i n t e d i n myself. am d i s g u s t e d with myself. hate myself.  0 I don't f e e l I am any worse than anybody e l s e . 1 I am c r i t i c a l o f myself f o r my weaknesses or mistakes. 2 I blame myself a l l the time f o r my f a u l t s . 3 I blame myself f o r e v e r y t h i n g bad t h a t happens.  15 (  )  I. 0 I don"t have any thoughts o f k i l l i n g myself. 1 I have thoughts o f k i l l i n g myself, but I would n o t c a r r y them out. 2 I would l i k e t o k i l l myself. 3 I would k i l l myself i f I had the chance.  16  (  )  J.  17  (  )  K.  0 1 2 3  I don't c r y any more than u s u a l . I c r y more now than I used t o . I c r y a l l the time now. I used t o be a b l e t o c r y , but now I can't c r y even though I want t o .  0 I am no more i r r i t a t e d now t h a t I ever am. 1 I g e t annoyed o r i r r i t a t e d more e a s i l y than I used t o . 2 I f e e l i r r i t a t e d a l l the time now. 3 I don't g e t i r r i t a t e d a t a l l by the t h i n g s t h a t used t o i r r i t a t e me. 18  (  )  L. _. • r - 0 I have "not T o s t i n t e r e s t i n other people. 1 I am l e s s i n t e r e s t e d i n other people than I used t o be. 2 I have l o s t most o f my i n t e r e s t i n other people. 3 I have l o s t a l l o f my i n t e r e s t i n other people.  19  (  )  M. 0 I make d e c i s i o n s about as w e l l as I ever could, 1 I put o f f making d e c i s i o n s more than I used t o , 2 I have g r e a t e r d i f f i c u l t y i n making d e c i s i o n s than b e f o r e . 3 I can't make d e c i s i o n s a t a l l any more.  105  20  (  )  N.  0 I don't f e e l I look any worse than I used t o . 1 I am w o r r i e d t h a t I am l o o k i n g o l d or unattractive. 2 I f e e l t h a t there a r e permanent changes i n my appearance that make me l o o k u n a t t r a c t i v e . 3 I believe that I look ugly.  21 (  )  0. 0 I can work about as w e l l as b e f o r e . 1 I t takes an e x t r a e f f o r t t o g e t s t a r t e d a t doing something. 2 I have t o push myself very hard t o do a n y t h i n g . 3 I can't do any work a t a l l .  22  (  )  P. 0 I can s l e e p as w e l l as u s u a l . 1 I don't s l e e p as w e l l as I used t o . 2 I wake up 1-2 hours e a r l i e r than u s u a l and f i n d i t hard to g e t back t o s l e e p . 3 I wake up s e v e r a l hours e a r l i e r than I used to and cannot g e t back to s l e e p .  23  (  )  Q.  2k (  25  (  )  )  0 1 2 3  I I I I  0 1 2 3  My a p p e t i t e i s no worse than u s u a l . My a p p e t i t e i s n o t as good a s i t used t o be. My a p p e t i t e i s much worse now. I have no a p p e t i t e a t a l l anymore.  don't g e t more t i r e d than u s u a l . g e t t i r e d more e a s i l y than I used t o . g e t t i r e d from doing almost a n y t h i n g . am too t i r e d t o do a n y t h i n g .  R.  S.  0 I am n o t l o s i n g as much weight as i s to be expected. 1 I f e e l I am not l o s i n g more weight than i s to be expected. 2 I am l o s i n g more weight than i s t o be expected. 3 I am l o s i n g a l o t more weight than i s t o be expected I am p u r p o s e l y t r y i n g to l o s e weight by eating less. yesC no  26  (  )  T.  0 I am no more w o r r i e d about my h e a l t h than u s u a l . 1 I am w o r r i e d about p h y s i c a l problems such as aches and p a i n s ; or upset stomach; or constipation. 2 I am v e r y w o r r i e d about p h y s i c a l problems and i t s hard to t h i n k o f much e l s e . 3 I am so w o r r i e d about my p h y s i c a l problems, t h a t I cannot t h i n k about a n y t h i n g e l s e .  106  27  (  )  U. 0 I have n o t n o t i c e d any r e c e n t change i n my i n t e r e s t i n sex. 1 I am l e s s i n t e r e s t e d i n s e x t h a n I u s e d t o b e . 2 I am much l e s s i n t e r e s t e d i n s e x now. 3 I have l o s t i n t e r e s t i n sex c o m p l e t e l y .  Time e l a p s e d since c l i n i c a l interview.  IQ? "BLUES" QUESTIONNAIRE  # Have y o u h e a r d  o f t h e "baby b l u e s " ?  What do y o u t h i n k t h e y  are?  Have y o u h a d " t h e b l u e s " f o l l o w i n g  the b i r t h  When? How  l o n g d i d they  What e f f e c t Did If  last?  d i d " t h e b l u e s ' h a v e on y o u ?  you cry? s o , f o r how  long?  how many  times?  What d i d y o u do t o g e t b a c k t o n o r m a l ? Did  others help?  Who  helped?  What d i d t h e y do t h a t  helped?  What do y o u t h i n k c a u s e d  "the b l u e s " ?  Do y o u t h i n k " t h e b l u e s " c a n be How?  prevented?  of this  baby?  108 HOME INTERVIEW Since coming home, have you taken* Type and Dose sleeping p i l l s pain k i l l e r s vitamins other  Amount  or t r a n q u i l i z e r s  How many hours s l e e p have you had i n the l a s t 3 days: s t r a i g h t sleep Day 1  interrupted sleep  Total  •  Day 2 Day 3 Do you have any concerns about the baby: No  A few  Alot  I f yes, what a r e your concerns? Have you found i t d i f f i c u l t a d j u s t i n g t o t h e : - baby's needs  No  A little  Alot  - housework routine  No  A little.  A lot.  - other c h i l d ren's needs  No  A  little  Alot  -interference from n e i g h bours and relations No  A  little  Alot  - increased company  A  little  A lot  No  Did you have a r e l a t i v e o r c l o s e f r i e n d s t a y with you t o h e l p you? I f yes, f o r how l o n g :  109  0 1 2 3  I I I I  0 1 2 3  My My My My  0 1 2 3  I f e e l v e r y happy a l l o f t h e t i m e I f e e l happy most o f t h e t i m e Sometimes I f e e l happy and sometimes I f e e l I do n o t f e e l happy any o f t h e t i m e  0 1 2 3  I c a n remember t h i n g s a s w e l l a s I c o u l d b e f o r e R e c e n t l y , I c a n n o t remember t h i n g s a s w e l l a s I c o u l d Recently, I f o r g e t a l o t Recently, I f o r g e t everything  0 1 2 3  I I I I  0 1 2 3  I am n o t d i s t r a c t e d by t h i n g s any more t h a n u s u a l R e c e n t l y , I am d i s t r a c t e d by t h i n g s more t h a n u s u a l R e c e n t l y , I am d i s t r a c t e d by t h i n g s much more t h a n u s u a l R e c e n t l y , I am d i s t r a c t e d by a n y t h i n g a t a l l  0 1 2 3  I I I I  0 1  I f e e l that having I f e e l that having keep t o my p l a n s I f e e l that having I f e e l that having altogether  2 3  0 1 2 3  g e t a l o n g w i t h my m o t h e r v e r y w e l l do n o t g e t a l o n g w i t h my m o t h e r v e r y w e l l g e t a l o n g w i t h my m o t h e r r a t h e r b a d l y c a n n o t s t a n d my m o t h e r husband/partner husband/partner husband/partner husband/partner  and and and and  I I I I  a r e v e r y c l o s e t o each o t h e r get along a l r i g h t do n o t g e t a l o n g v e r y w e l l j u s t p u t up w i t h e a c h o t h e r  sad  can c o n c e n t r a t e as w e l l as I c o u l d b e f o r e cannot c o n c e n t r a t e as w e l l as I c o u l d before c a n n o t c o n c e n t r a t e on t h i n g s f o r l o n g a t a l l c a n n o t c o n c e n t r a t e on a n y t h i n g a t a l l  feel feel feel feel  that that that that  I I I I  do n o t n e e d t o be c a r e d f o r n e e d t o be c a r e d f o r a l i t t l e more t h a n u s u a l n e e d t o be c a r e d f o r a l o t more t h a n u s u a l n e e d t o be c a r e d f o r most o f t h e t i m e t h e baby has n o t i n t e r f e r e d w i t h my t h e baby makes i t h a r d e r f o r me t o  plans  t h e baby makes me p o s t p o n e my p l a n s t h e b a b y f o r c e s me t o g i v e up my p l a n s  I f e e l t h a t h a v i n g t h e baby does n o t t r a p me I f e e l t h a t h a v i n g t h e baby c a s t s t h e " d i e so t h a t I s t a y where I am ' I f e e l t h a t t h e baby has t r a p p e d me i n t o a s i t u a t i o n I w o u l d r a t h e r have l e f t I f e e l t h a t t h e baby has t r a p p e d me i n t o a n i m p o s s i b l e situation  lib "BLUES" QUESTIONNAIRE Have you had "the b l u e s " f o l l o w i n g the b i r t h o f t h i s baby? When? How l o n g ,<|id they  last?  What e f f e c t d i d "the b l u e s " have on you? Did you c r y ? I f so, f o r how long? how many times? What d i d you do t o g e t back t o normal? Did  others h e l p ?  Who  helped?  What d i d they do t h a t  helped?  What do you t h i n k caused  "the b l u e s " ?  Do you t h i n k "the b l u e s " can be prevented? How? Do you t h i n k having had the b l u e s was a bad experience?  

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