Perinatal Provider Toolkit Archives - MC3 - Michigan Clinical Consultation & Care

Perinatal Provider Toolkit

How to Talk to Patients About Their EDPS Scores

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Kara Kucinski |

Feb 25, 2025

How to Talk to Patients About Their EDPS Scores

EPDS Score

Score < 10

Score > 10

Positive Score on Question 10

Does not suggest depression

Clinical support staff educates woman about the importance of emotional wellness:

“From the screen, it seems like you are doing well. Having a baby is always challenging and every woman deserves support. Do you have any concerns that you would like to talk to us about?”

Suggests patient is depressed

“You may be having a difficult time or be depressed. What things are you most concerned about? Getting help is the best thing you can do for you and your baby. It can also help you cope with the stressful things in your life (give examples). You may not be able to change your situation right now, but you can change how you cope with it. Many effective support options are available.”

Suggests patient may be at risk of self-harm or suicide

“It sounds like you are having a lot of strong feelings. It is really common for women to experience these kinds of feelings. Many effective support options are available. I would like to talk to you more about how you have been feeling recently.”

Contact clinical support staff to arrange follow-up care if needed. Give woman information about community resources (e.g., support groups).

“My office staff and I are available to help you and provide ongoing support.”

If woman is already in treatment, ensure follow up appointment is scheduled.

ALWAYS DISCUSS ALL SUPPORT/TREATMENT OPTIONS INCLUDING PSYCHOEDUCATION, COMMUNITY, AND PSYCHOSOCIAL SUPPORTS

This resource has been adapted with permission from the MCPAP for Moms Pediatric Toolkit for Postpartum Depression.

Recommended toolkit resources

Perinatal Provider Toolkit

Assessment of Depression Severity

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Kara Kucinski |

Feb 25, 2025

Assessment of Depression Severity

EPDS Score or Clinical Assessment

EPDS 0-8

EPDS 9-13

EPDS 14-18

EPDS ≥19

Signs and symptoms of Depression

Signs and symptoms in each column may overlap

Limited to no symptoms

Mild symptoms

Moderate symptoms

Severe symptoms

Reports occasional sadness

Mild apparent sadness but brightens up easily

Reports pervasive feelings of sadness or gloominess

Reports continuous sadness and misery

Fairly calm

Occasional feelings of edginess and inner tension

Continuous feelings of inner tension/intermittent panic

Unrelenting dread or anguish, overwhelming panic

Sleeps as usual

Slight difficulty drifting off to sleep

Sleep reduced or broken by at least two hours

Less than two or three hours of sleep

Normal or increased appetite

Slightly reduced appetite

No appetite – food is tasteless

Needs persuasion to eat

No difficulties in concentrating

Occasional difficulty in concentrating

Difficulty concentrating and sustaining thoughts

Unable to read or converse without great initiative

No difficulty starting everyday activities

Mild difficulties starting everyday activities

Difficulty starting simple, everyday activities

Difficulty accomplishing much of anything, including grooming/bathing self

Normal interest in surroundings and friends

Reduced interest in surroundings and friends

Loss of interest in surroundings and friends

Emotionally paralyzed, inability to feel anger, grief, or pleasure

No thoughts of self-reproach, inferiority

Mild feelings of guilt, inferiority

Persistent self-accusations, feelings of guilt

Feeling useless or like a burden to loved ones

No suicidal ideation

Fleeting suicidal thoughts

Suicidal thoughts are common

History of severe depression and/or active preparations for suicide

This resource has been adapted with permission from the MCPAP for Moms Pediatric Toolkit for Postpartum Depression.

Recommended toolkit resources

Perinatal Provider Toolkit

Discussing Antidepressant Use with Perinatal Patients

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Kara Kucinski |

Feb 25, 2025

Discussing Antidepressant Use with Perinatal Patients

(Discussion should include yet not be limited to the below)

Overview

Both medication and non-medication options should be considered
Encourage non-medication treatments (e.g., psychotherapy) in addition to medication treatment or as an alternative when clinically appropriate
No decision regarding whether to use antidepressants during pregnancy is perfect or risk-free, and there are also risks to having untreated mental health symptoms in the perinatal period
SSRIs are among the best studied class of medications during pregnancy
Also, taking antidepressants is compatible with breastfeeding

Risks of antidepressant use during pregnancy

No increase in birth defects compared to untreated mental health symptoms in pregnancy
The preponderance of evidence does not suggest birth complications (preterm birth, babies that are born a little smaller, etc) when compared to untreated depression/anxiety
Studies do not suggest long-term effects on children
Possible PNAS (poor neonatal adaptation syndrome)—not particularly common but when it does occur, baby can be a bit jittery or fussy for a few hours to days. Generally, no medical intervention is required and there are no long term negative effects.

Risks of under treatment or no treatment of depression during pregnancy

Increases the risk of pregnancy complications
Increases the risk of postpartum depression
Can make it harder for moms to take care of themselves and their babies
Can make it harder for moms to bond with their babies

If lactating: SSRIs and some other antidepressants are considered a reasonable treatment option during breastfeeding. The benefits of breastfeeding while taking antidepressants generally outweigh the risks. The amount of medication that goes into the breast milk is relatively small and there is no evidence of significant short or long term consequences to babies who are exposed to SSRIs through breast milk.

See Antidepressant Treatment Algorithm for guidelines on prescribing medications.

Recommended toolkit resources

Perinatal Provider Toolkit

Summary of Emotional Complications During Pregnancy and the Postpartum Period

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Kara Kucinski |

Feb 25, 2025

Summary of Emotional Complications During Pregnancy and the Postpartum Period

Baby Blues

Perinatal Depression

Perinatal Anxiety

Posttraumatic Stress Disorder (PTSD)

Obsessive-Compulsive Disorder

Postpartum Psychosis

What is it?

Common and temporary experience right after childbirth when a new mother may have sudden mood swings, feeling very happy, then very sad, or cry for no apparent reason.

Depressive episode that occurs during pregnancy or within a year of giving birth.

A range of anxiety disorders, including generalized anxiety, panic, social anxiety and PTSD, experienced during pregnancy or the postpartum period.

Distressing anxiety symptoms experienced after traumatic events(s).

Intrusive repetitive thoughts that are scary and do not make sense to mother/expectant mother. Rituals (e.g., counting, cleaning, hand washing). May occur with or without depression.

Very rare and serious. Sudden onset of psychotic symptoms following childbirth (increased risk with bipolar disorder). Usually involves poor insight about illness/symptoms, making it extremely dangerous.

When does it start?

First week after delivery. Peaks 3-5 days after delivery and usually resolves 10-12 days postpartum.

Most often occurs in the first 3 months postpartum. Peaks around 3-4 months after delivery. May also begin after weaning baby or when menstrual cycle resumes.

Immediately after delivery to 6 weeks postpartum. Occasionally begins after weaning baby or when menstrual cycle resumes.

May be present before pregnancy/ birth. Can present as a result of traumatic birth. Underlying PTSD can also be worsened by traumatic birth.

1 week to 3 months postpartum. Occasionally begins after weaning baby or when menstrual cycle resumes. May also occur in pregnancy.

Typically presents rapidly after birth. Onset is usually between 2 – 12 weeks after delivery. Watch carefully if sleep deprived for ≥48 hours.

Risk factors

Sensitivity to normal hormonal fluctuations after delivery. Life changes, lack of support and/or additional challenges (difficult pregnancy, birth, health challenges for mom or baby, twins). Prior pregnancy loss. Dysregulated baby-crying feeding, sleep problems. Additionally, any type of trauma (medical, birth, interpersonal) and/or excessive stress (housing instability, food insecurity, financial strain, etc.)

Sensitivity to normal hormonal fluctuations after delivery. Lack of partner support, elevated depression symptoms, more physical problems since birth, less health promoting behaviors. Prior pregnancy loss. Dysregulated baby-crying feeding, sleep problems. Additionally, any type of trauma (medical, birth, interpersonal) and/or excessive stress (housing instability, food insecurity, financial strain, etc.)

Sensitivity to normal hormonal fluctuations after delivery. Family history of OCD, other anxiety disorders. Depressive symptoms. Prior pregnancy loss. Dysregulated baby-crying feeding, sleep problems. Additionally, any type of trauma (medical, birth, interpersonal) and/or excessive stress (housing instability, food insecurity, financial strain, etc.)

Sensitivity to normal hormonal fluctuations after delivery. Bipolar disorder, history of psychosis, history of postpartum psychosis (80% will relapse), family history of psychotic illness, sleep deprivation, medication discontinuation for bipolar disorder (especially when done quickly). Prior pregnancy loss. Dysregulated baby-crying feeding, sleep problems. Additionally, any type of trauma (medical, birth, interpersonal) and/or excessive stress (housing instability, food insecurity, financial strain, etc.)

How long does it last?

A few hours to a few weeks.

2 weeks to a year or longer. Symptom onset may be gradual.

From weeks to months to longer.

From 1 month to longer.

From weeks to months to longer.

Occurs in 1-2 or 3 in 1,000 births.

How often does it occur?

Occurs in up to 85% of women.

Occurs in up to 19% of women.

Generalized anxiety occurs in 6-8% in first 6 months after delivery. Panic disorder occurs in .5-3% of women 6-10 weeks postpartum. Social anxiety occurs in 0.2-7% early postpartum.

Occurs in 2-15% of women. Presents after childbirth in 2-9% of women.

May occur in up to 4% of women.

Occurs in 1-2 or 3 in 1,000 births.

What happens?

Women experience dysphoric mood, crying, mood lability, anxiety, sleeplessness, loss of appetite, and irritability. Postpartum depression is independent of blues, but blues is a risk factor for postpartum depression.

Change in appetite, sleep, energy, motivation, and concentration. May experience negative thinking including guilt, hopelessness, helplessness, and worthlessness. May also experience suicidal thoughts and evolution of psychotics symptoms.

Fear and anxiety, panic attacks, shortness of breath, rapid pulse, dizziness, chest or stomach pains, fear of detachment/doom, fear of going crazy or dying. May have intrusive thoughts of bad things happening to baby or self, and/or of harming one’s baby.

Change in cognition, mood, arousal associated with traumatic event(s) and avoidance of stimuli associated with traumatic event. Specifically, hypervigilance, irritability, intrusive trauma reminders and poor sleep are typical symptoms.

Disturbing repetitive thoughts (which may include harming baby), adapting compulsive behavior to prevent baby from being harmed (secondary to obsessional thoughts about harming baby that scare women).

Mood fluctuation, confusion, marked cognitive impairment. Bizarre behavior, insomnia, visual and auditory hallucinations and unusual (e.g. tactile and olfactory) hallucinations. May have moments of lucidity. May include altruistic delusions about infanticide and/or homicide and/or suicide that need to be addressed immediately.

Resources and Treatment

May resolve naturally. Resources include support groups, psychoeducation and sleep hygiene (asking/accepting other help during nighttime feedings). Address infant behavioral dysregulation—crying, sleep, feeding problems—in context of perinatal emotional complications.

For depression, anxiety, PTSD and OCD, treatment options include individual therapy, dyadic therapy for mother and baby, and medication. Resources include support groups, psycho-education, and complementary and alternative therapies including exercise and yoga. Encourage self-care, including healthy diet and massage. Encourage engagement in social and community supports (including support groups). Encourage sleep hygiene and asking/accepting help from others during nighttime feedings. Address infant behavioral dysregulation—crying, sleep, feeding problems—in context of perinatal emotional complications. Additional complementary and alternative therapy options for depression include bright light therapy, Omega-3 fatty acids, acupuncture and folate.

Requires immediate psychiatric help. Hospitalization usually necessary. Medication is usually indicated. If history of postpartum psychosis, preventative treatment is needed in subsequent pregnancies. Encourage sleep hygiene for prevention (e.g. consistent sleep/wake times, help with feedings at night).

This resource has been adapted with permission from the MCPAP for Moms Pediatric Toolkit for Postpartum Depression.

Recommended toolkit resources

Perinatal Provider Toolkit

Treatment Options by Symptom Severity

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Kara Kucinski |

Feb 25, 2025

Treatment Options by Symptom Severity

EPDS Score or Clinical Assessment

EPDS 0-8

EPDS 9-13

EPDS 14-18

EPDS ≥19

Treatment options

Treatment options in each column may overlap

Limited to no symptoms

Mild symptoms

Moderate symptoms

Severe symptoms

Consider inpatient hospitalization when safety or ability to care for self or baby is a concern

Strongly consider inpatient hospitalization when safety or ability to care for self or baby is a concern

May consider medication

Strongly consider medication

Therapy for mother

Dyadic therapy for mother/baby

Therapy for mother

Dyadic therapy for mother/baby

Therapy for mother

Dyadic therapy for mother/baby

Therapy for mother

Dyadic therapy for mother/baby

Community/social support (including support groups)

Consider as augmentation: Complementary/ Alternative therapies (bright light therapy, Omega-3 fatty acids, acupuncture, folate, massage)

Support with dysregulated baby; crying, sleep, feeding problems

Physical activity

Support with dysregulated baby; crying, sleep, feeding problems

Physical activity

Support with dysregulated baby; crying, sleep, feeding problems

Physical activity

Support with dysregulated baby; crying, sleep, feeding problems

Physical activity

Self-care (sleep, hygiene, healthy diet) and lactation support, if needed

Self-care (sleep, hygiene, healthy diet)

This resource has been adapted with permission from the MCPAP for Moms Pediatric Toolkit for Postpartum Depression.

Recommended toolkit resources

Perinatal Provider Toolkit

Antidepressant Treatment Algorithm

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Kara Kucinski |

Feb 25, 2025

Antidepressant Treatment Algorithm

Is patient currently taking any medication?

If YES

If NO

Symptoms improving but not resolved: Increase dose of current medication

If patient is on therapeutic dose (see table below) for 4 – 8 weeks that has not helped: Consider changing medication, and use the information below to select a course of treatment

Does patient have a history of taking an antidepressant that has helped?

• If YES: Prescribe the same medication that helped the patient in the past, and use the information below to help with dosage

• If NO: Use the information below to select a course of treatment

First Line Treatment

Other SSRI Options

Medication

sertraline (Zoloft)

fluoxetine (Prozac)

citalopram (Celexa)

escitalopram (Lexapro)

Starting dose

25 mg

10 mg

5 mg

How to up

up to 50 mg after 4 days, up to 100 mg after 7 days, then up by 50 mg until symptoms remit

up to 20 mg after 4 days, then up by 10 mg until symptoms remit

up to 10 mg after 4 days, then up by 10 mg up to 20 mg until symptoms remit

Therapeutic range

50 – 200 mg

20 – 60 mg

20 – 40 mg

10 – 20 mg

In general, if an antidepressant has helped, it is best to continue it during lactation

General Side Effects of Medications

Temporary

Nausea
Constipation/diarrhea
Lightheadedness
Headaches

Long-Term

Increased appetite/weight gain
Sexual side effects
Vivid dreams/insomnia

Recommend patients take medication with food to decrease side effects Tell women only to increase dose if tolerating; otherwise wait until side effects dissipate before increasing For effects on fetus/neonate, see Discussing Antidepressant Use with Perinatal Patients.

2. Repeat EPDS in 2 – 4 weeks and re-evaluate depression treatment plan via clinical assessment

If no/minimal clinical improvement after 4-8 weeks

If clinical improvement and no/minimal side effects

If patient has no or minimal side effects, increase dose If patient has side effects that are severe/intolerable, or that do not resolve after 1-2 weeks, switch to a different medication

Reevaluate every month and at postpartum visit

This resource has been adapted with permission from the MCPAP for Moms Pediatric Toolkit for Postpartum Depression.

Recommended toolkit resources

Perinatal Provider Toolkit

Special Considerations for Patients with Bipolar Disorder in the Perinatal Period

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Kara Kucinski |

Feb 25, 2025

Special Considerations for Patients with Bipolar Disorder in the Perinatal Period

Patients with bipolar disorder are very sensitive to disturbances in sleep, and have a higher risk of postpartum psychosis than patients with depression or anxiety. Therefore, make sure to counsel them about the following:

Sleep

Speak with family/friends about what the planned supports will be regarding sleep
Try to get at least one four hour block of uninterrupted sleep per night

Feeding Considerations

If the patient plans to breastfeed, encourage them to meet with a lactation consultant during pregnancy or very soon postpartum regarding how to optimize sleep
If patient is taking lithium, it may not be recommended that she breastfeed. This requires shared decision-making/planning
Some patients may consider formula feeding in order to minimize disruption to sleep (and allow others to feed the baby)

Postpartum Psychosis

Can be precipitated by poor sleep
May have insomnia as a symptom
Patients may start to have odd beliefs or ideas, or speak or behave in bizarre ways
Patients may start to hear voices or see things that others cannot
This is a psychiatric emergency as it increases risk of intentional or unintentional harm to child—instruct patient to present to nearest emergency room
Discuss these symptoms and instructions with patient and, if patient is willing, their close support person/people

Recommended toolkit resources

Perinatal Provider Toolkit

Management of ADHD in the Perinatal Period

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Kara Kucinski |

Feb 25, 2025

Management of ADHD in the Perinatal Period

Treatment of ADHD in the perinatal period is important to preserve overall functioning of the patient, as well as in some cases, to effectively control symptoms of disorders commonly comorbid with ADHD such as depression, anxiety, and substance abuse.

Please reference the algorithm below when caring for perinatal patients with ADHD:

Confirmation of diagnosis of ADHD
Review target symptoms, triggers, and current treatment (pharmacologic and nonpharmacologic)
Review co-morbidities and optimize treatment therein (e.g., is undertreated mood/anxiety disorder contributing to their “ADHD” symptoms?)
Optimize non-pharmacologic treatments: psychoeducation, cognitive training; behavioral interventions: time-management, organizational and planning abilities; reduce workload/driving
Pursue trial off of ADHD medication if this has not been done in recent memory; assess level of functioning/impairment: a. mild to moderate ADHD/functional impairment: stop medication; b. moderate ADHD with co-morbidities (depression/anxiety): consider PRN stimulant use; c. severe ADHD/functional impairment: continue meds

Mild ADHD (Minimal Functional Impairment Off Medication)

Moderate ADHD (Some Functional Impairment Off Medication)

Severe ADHD (Significant Functional Impairment, Including Driving)

Optimize sufficient non-pharmacologic management strategies and ensure self-management strategies in place

Optimize non-pharmacologic strategies; consider when necessary use of stimulant

Maintain medication, consider closer obstetric monitoring for fetal growth and hypertensive disorders of pregnancy

Recommended toolkit resources

Perinatal Provider Toolkit

Risks and Benefits of Stimulant Use in the Perinatal Period

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Kara Kucinski |

Feb 25, 2025

Risks and Benefits of Stimulant Use in the Perinatal Period

Risks involved in the use of stimulants for the treatment of ADHD in pregnancy

no significant concerns for teratogenicity
questionable risk of miscarriage
increased risk of prematurity
some increased risk of adverse placental outcomes (preeclampsia, abruption)
some increased risk of NICU admission and CNS disorders (seizure, NOS), etc.
data are lacking on long term neurodevelopmental effects

Risk involved in the use stimulants for the treatment of ADHD during lactation

excreted in small amounts in breast milk
due to effects on dopamine, may cause decrease in breast milk production
data are lacking on long term neurodevelopmental effects on infants

General considerations

Consider decreasing by small increments weekly when trying to taper down/off
Long acting formulations have less potential to be abused
Higher doses may increase risk for psychosis, especially with the amphetamine class
Let patients know that long acting formulations should not be crushed, cut, or chewed

The decision about whether to prescribe stimulants during the perinatal period should be made jointly with the patient after sharing information about the risks and benefits. For a good review article and demonstration of shared decision-making, please reference this article:

Baker, A. S., & Freeman, M. P. (2018). Management of Attention Deficit Hyperactivity Disorder During Pregnancy. Obstetrics and Gynecology Clinics of North America, 45(3), 495–509. https://doi.org/10.1016/j.ogc.2018.04.010

Recommended toolkit resources

Perinatal Provider Toolkit

Intrusive Thoughts and Thoughts of Infant Harm in the Perinatal Period

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Kara Kucinski |

Feb 25, 2025

Intrusive Thoughts and Thoughts of Infant Harm in the Perinatal Period

An intrusive thought is an involuntary thought/image/idea that is distressing and hard to get rid of.

Common examples: “What if I drop my baby while going down the stairs?” or a mother visualizing throwing her baby in a lake
By itself, not diagnostic of any particular disorder, but most common in anxiety disorders
Sometimes include thoughts of infant harm

These thoughts can be upsetting for patients and concerning to providers, but in the majority of cases, patients with these thoughts are at no increased risk for harming their infant. Providers should be careful when caring for a patient with thoughts of harming their baby. Incorrectly assessing risk and treating a situation as an emergency when in reality it is not, can be greatly traumatizing and stigmatizing to patients.

See the below guidelines for how to tell the difference:

Risk assessment for thoughts of infant harm

Low Risk

Ego dystonic (are upsetting to the patient)
Mother doesn’t want to harm baby, states she will not
Mother has been avoiding certain objects or the infant, to avoid thought-based harm coming to them (e.g., putting away all knives)
Generally, these are patients with isolated intrusive thoughts, anxiety, depression, or OCD
*In this case, having these thoughts does not at all increase the risk that an individual will act on them

High Risk

Ego syntonic (thoughts are not upsetting or may be comforting to the patient)
Patient has symptoms of psychosis (hallucinations, disorganized thinking, delusions)
Patient thinks harming infant would benefit infant/society in some way (due to delusional beliefs)
Has other bizarre beliefs
Patient has a history of trauma and expresses wanting to get revenge on baby’s other parent
Generally, these are patients who are psychotic or who have severe personality disorders
PSYCHIATRIC EMERGENCY—SEND TO ER

Consider using these phrases when talking to a mom about intrusive thoughts

“When a parent is feeling really overwhelmed, it can be really common for her to have thoughts about hurting her baby, even though she wouldn’t want to act on these thoughts. Has this ever happened to you?”
“Do these thoughts upset you?”
“How worried are you that you might act on these thoughts?”
“Parents are sometimes scared to share these thoughts for fear that someone might try to take their baby away from them. However, our goal is to get moms the help they need and to avoid separating them from their babies.”
“In the vast majority of cases, having these thoughts does not increase a parent’s risk of acting on them.”

For more information, please watch MC3’s Intrusive Thoughts and OCD in the Perinatal Period recorded educational presentation.

How to Talk to Patients About Their EDPS Scores

EPDS Score

Recommended toolkit resources

Assessment of Depression Severity

Recommended toolkit resources

Discussing Antidepressant Use with Perinatal Patients

Overview

Risks of antidepressant use during pregnancy

Risks of under treatment or no treatment of depression during pregnancy

Recommended toolkit resources

Summary of Emotional Complications During Pregnancy and the Postpartum Period

Recommended toolkit resources

Treatment Options by Symptom Severity

Recommended toolkit resources

Antidepressant Treatment Algorithm

If YES

If NO

General Side Effects of Medications

Recommended toolkit resources

Special Considerations for Patients with Bipolar Disorder in the Perinatal Period

Sleep

Feeding Considerations

Postpartum Psychosis

Recommended toolkit resources

Management of ADHD in the Perinatal Period

Recommended toolkit resources

Risks and Benefits of Stimulant Use in the Perinatal Period

Risks involved in the use of stimulants for the treatment of ADHD in pregnancy

Risk involved in the use stimulants for the treatment of ADHD during lactation

General considerations

Recommended toolkit resources

Intrusive Thoughts and Thoughts of Infant Harm in the Perinatal Period

Risk assessment for thoughts of infant harm

Consider using these phrases when talking to a mom about intrusive thoughts

Recommended toolkit resources

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