POSTPARTUM BLUES AS A PSYCHOLOGICAL DISORDER IN NEW MOTHER: A CASE REPORT

Background : Postpartum blues is one type of psychological distress. It can happen when a mother fails in taking in phase. It is a normal peripartum occurrence after delivery. Postpartum blues is usually characterized by several clinical symptoms such as irritability, anxiety, fluctuating mood, etc. Early identification can help in proper treatment. Objective : To identify postpartum blues condition and understand the referral system for maternal problems. Methods: This is a qualitative study with a case report method on postpartum mother which assessed with Edinburgh Postnatal Depression Scale (EPDS) and followed up with maternity needs. Results: Evaluation of maternity need by nursing and midwifery concepts bring a significant average decrease in the value of postpartum blues. In the first screening, the score is 11, and now the score showed <9. Conclusion: Early detection and appropriate intervention by healthcare providers to collaborate on mitigating these interrelated risk factors would be more effective in reducing rates of postpartum blues.


INTRODUCTION
Pregnancy and delivery are two stages that cannot be separated. Childbirth is a psychological experience that has a physical, psychological, social, and existential impact both in the short and long term. Pregnancy and childbirth are two stages in life that are prone to potential stress. Birth is a stressful event and there are significant changes in the hormonal condition associated with the birth process, particularly in the stress-related hormones. Every woman as a new mother needs to share their birth story to integrate their intense experiences both physically and emotionally. Being a mother is physiological. It can be positive and empowering or negative and traumatizing, however, it can be negative and cause various emotional disorders during the postpartum period. 1,2 The physiological adaptation process begins after childbirth until the body begins to recover and lasts about six to eight weeks. 3 The postpartum period is a crisis moment for the mother, husband, and family due to physical and psychological changes as well as a family structure that require an adaptation process. Rubin identified that maternal concern was related to the ability to function as a mother as the first observable maternal behavior. Rubin reported that the early puerperal period was characterized by a time of deep sleep before the regeneration process begins. There are three phases of postpartum psychological adaptation that must be passed well and if you fail to take it you will face postpartum blues. The first one or two days were labeled as the "taking-in phase". Mother is described as passive and dependent. Maternal dependence develops into independence during the "takinghold", and the last is letting go, where the mother can handle all her own needs. Rubin uses the term binding-to describe the developmental stages of a mother-child relationship as a process, not a state. 4 Anxiety is a psychosocial disorder that is often experienced by individuals. One type of anxiety or the impact of failure in postpartum adaptation is postpartum blues. Postpartum blues refers to a transient mood depression of new mothers experience as a result of hormonal changes, the responsibilities of having a new baby, and parenting duty. It is a mood disorder that occurs after birth that reflects psychological dysregulation. Most people do not know that it can easily happen to postpartum mothers. Postpartum Blues is categorized as a mild mental disorder syndrome, but if we do not get the right treatment, it will enter the phase of postpartum depression and postpartum psychosis. According to WHO data, the incidence of Postpartum Blues in Indonesia is 50%-70%, and postpartum depression is around 22,4%. Another study reported that severe postpartum depression occurred in about 25% of new mothers and 20% of those who gave birth to a second child or more. 4,5 Postpartum blues has a negative impact on children's development. Moreover, their ability to interact with other children will also be affected. Several studies have reported that symptoms of depression and anxiety are closely related to antepartum and associated with postnatal depression. Early identification can help in the appropriate treatment. Individual therapies that are effective in treating anxiety are cognitive therapy, behavioral therapy, thought stopping, and cognitive behaviors. The presence of health workers such as midwives is expected to reduce the incidence of postpartum blues or other psychological disorders during the puerperium. 4,6

METHOD
This is a case study on postpartum mothers. It focuses on a subject who is observed and researched until the case is completed. This research focuses intensively on one particular object that studies it as a case. The instrument used was the Edinburgh Postnatal Depression Scale (EPDS) as a screening test for postpartum depression and a questionnaire for personal and demographic data. EPDS is consist of 10 questions, in which women were asked to rate their feeling in the last 7 days. Each question was given a score of 0-3 (with a total final score of around 0-30) and filling out the questionnaire take about five minutes. Postpartum mothers were assessed on days 2 and 3. The data that had been collected and after the test results came out, we will intervene according to the results. The mother will be re-screened within two weeks after the first test and during that time the mother will be given treatment. Things to do is follow up and assess the mother's progress until the case is over. This research was conducted after the respondents agreed and fill out the informed consent. 7 A 17-year-old woman, Mrs. Y, gave birth to her first child in a primary health facility. The delivery process is normal and the condition of the mother and baby is normal. When the midwife routinely performed a postpartum examination on the second day, she complained about the mother's feelings that we were not "normal", she felt like she couldn't take care of the baby, fluctuating mood, increased emotional reactivity, and more sensitivity. Now, she lives with her mother-in-law and her husband comes home once a week. The mother-in-law always intervenes in caring for the baby and makes the mothers feel uncomfortable. The EPDS test on the patient showed a score of 11. The patient is allowed to go home after the midwife gives her and also her family (mother-in-law, husband) an explanation about her condition. As a midwife, the solutions that can be given are maximizing the role of the family, advising mothers to get as much rest as possible, comparing psychosocial and psychological interventions, and optimizing learning time to become a mother.

RESULT
The mother undergoes postpartum blues before receiving the nursing intervention. After the nursing intervention, there was a significant decrease in the average postpartum blues score.
This screening was carried out two weeks after the first screening. The patient's EPDS test showed a score <9. Currently, Mrs. Y is in the letting go phase, it means that she can take care of her baby and carry out the role of a mother well.

DISCUSS
Psychiatric issues are quite common in antenatal, natal, and postnatal (periods) with varying degrees of severity and manifestations. Low and middle-income countries can be exposed to a postpartum psychiatric disorder, among women at gender-based risk or with a psychiatric history. The postpartum period is a crisis moment for the mother and family due to physical and psychological changes that need an adaptation process. The postpartum mothers who fail on taking in phase will face postpartum blues. The condition of the mother and family has a big impact on this phase. Postpartum blues is a normal peripartum occurrence experienced by women after childbirth. It commonly occurs on the second or fourth day. The onset may peak on the fifth and fourteenth day after delivery. It is mild and resolves spontaneously, not considered a psychiatric disorder. Postpartum blues is generally characterized by clinical symptoms such as irritability, anxiety, fluctuating mood, and increased emotional reactivity. If the postpartum blues symptoms persist for more than two weeks, the woman may experience more significant symptoms of postpartum depression and postpartum psychosis. 8,9,10 Pathogenesis is largely unknown; however, hormonal changes have long been suggested as a major contributing factor to the development of postpartum mood swings. Other studies also proposed that elevated monoamine oxidase levels or decreased serotoninergic activity during the postpartum period have significant risk factors that could predispose to the development of postpartum blues. 11,12 Besides, psychosocial factors are also a risk factor that can lead to the development of postpartum blues, such as low economic status, ethnic or racial background, gravidity status, planned vs unplanned pregnancy, family history of mood disorder where women whose mothers are having symptoms of postpartum depression is proven to have a higher susceptibility to behavioral and emotional problems. Based on the case Mrs. Y is categorized as a young age, and this is consistent with research that age is often associated with the woman's mental readiness to become a mother. Young-age pregnancy accelerates the physical and psychological risks for a woman and her baby during pregnancy and childbirth. Young age can increase the risk of postpartum blues based on that emotional maturity. 9,11 Sociocultural is also can cause postpartum blues, based on the case of a patient who lives with her mother-in-law who is the mother-in-law always intervenes in taking care of the baby, so, the mother can't explore her ability to be a new mother and her husbands come home once a week which can cause discomfort feeling for the mother. We know that a postpartum mother needs time to know that she is a new mother, she needs support from close people, such as her husband. This condition makes an uncomfortable and depressing feeling performed by the mother. 13 Unfortunately, postpartum psychological disorders are still often undiagnosed and treated. The identification as early as possible can help in appropriate treatment. Several postpartum depression screening tools are available, the most commonly used screening instrument was the Edinburgh Postnatal Depression Scale (EPDS). This questionnaire consists of 10 questions and is routinely performed on women at 6-8 weeks postpartum by their health care workers. The results of the screening scores were categorized into many types with different treatments. The characteristics of psychological symptoms and physical symptoms found in depressive disorders are summarized in the questions contained in the EPDS questionnaire. EPDS is only a screening instrument, and clinical diagnosis must be determined by a trained health care provider. EPDS has been translated and validated in many languages other than English. 7 Postpartum blues is mild and subsides spontaneously. It is temporary and self-limiting, it resolves on its own and requires no treatment other than validation, education, reassurance, and psychosocial support. However, patients with postpartum blues should be evaluated carefully to see if the diagnostic postpartum depression criteria are met. 11 Postpartum blues can occur within two weeks postpartum, while the intervention that can be done is to rest as much as possible, get help from family and friends, connect and share with other moms, set aside time to take care of yourself and avoid alcohol and drugs. The main thing of postpartum blues treatment is maximizing psychosocial and psychological intervention. Emotional support such as empathy, love, and trust from others, especially the husband as motivation. Providing information can help individuals to find an appropriate alternative to solve problems. Information support can be in the form of suggestions, advice, and directions from others so that individuals can solve problems. Appraisal support can be in the form of giving awards for the efforts that had been made, providing feedback on the results or achievements achieved, and strengthening and increasing feelings of self-esteem and self-confidence in individual abilities. Besides, the husband can work together with family members and closest friends to provide positive support so that the husband's support plays an important role in increasing the readiness of the mother. Creating comfortable conditions can help others develop their abilities. the intervention that has been given is expected to reduce the value of postpartum blues from positive postpartum blues to negative postpartum blues or normal. 4,14,15 CONCLUSION Postpartum blues is a mild symptom and resolves spontaneously, and it is not considered a psychiatric disorder. Interventions should be given to women with postpartum blues to avoid women who have more significant symptoms of postpartum depression and postpartum psychosis. The most commonly used screening instrument is EPDS. Early detection and appropriate intervention by an interprofessional process that enables health care providers to collaborate in reducing these interrelated risk factors will be most effective in reducing this rate of outcome. Health workers, especially midwives, can help new mothers overcome postpartum psychologic disorders and learn to enjoy their newborns and their lives.