Joey Wahler (Host): They can adversely affect new mothers, so we're discussing fourth trimester and postpartum depression, also called PPD. Our guest, Dr. Gamilah Pierre. She's an obstetrician-gynecologist with Silver Cross Hospital.

This is Silver Cross Hospital's IMatter Health podcast, where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Pierre. Welcome.

Dr. Gamilah Pierre: Good morning. Welcome. Thank you for having me.

Host: Absolutely. Great to have you aboard. And before we go any further, I have to tell those joining us that you are doing so from Hawaii. So, you get extra bonus points for making the appointment today for sure, yes?

Dr. Gamilah Pierre: Aloha. Yes, it's great to be here though.

Host: Beautiful, beautiful. Perfectly done. So first, what exactly do we mean by the fourth trimester?

Dr. Gamilah Pierre: Well, traditionally we think of a pregnancy as being three trimesters. First, second, and third. First, being very early, patients start coming into the office when they're maybe six to twelve weeks pregnant. The second trimester is when everybody feels good, moms feel well, they're glowing. And then, the third trimester is we're just trying to get through. Well now, we really recognize that we really should be using the term the fourth trimester, also more commonly known as postpartum. And really, it lasts for up to 12 weeks, even longer in some people's estimates. So, it's important that we recognize just because the baby is delivered, nothing just goes back to normal the next day.

Host: That's for sure. I can speak from personal experience not too long ago. So speaking of which, what are some of the symptoms of a woman experiencing fourth trimester issues?

Dr. Gamilah Pierre: So, fourth trimester, we just think of it as an actual term. However, the fourth trimester, we need to consider all of the different aspects. We need to consider how the infant is doing, how the mom is feeding the infant. We need to consider contraception, sexual function. mood and mental wellness, as well as comorbidities.

Some of our patients have had a significant amount of medical problems before they were pregnant, during their pregnancy, and how does that relate to them after? So, it actually encompasses many things, not just the mental. That's one that we are really focused on this day, because we are concerned about the rising rates of postpartum depression. But really, the fourth trimester encompasses all of the function of return to a pre-pregnant state after a baby's been born.

Host: Gotcha. So, how would you say fourth trimester problems compare with postpartum depression?

Dr. Gamilah Pierre: Well, really, we just need to focus on what's happening with the mom. They have obviously had a significant change in our life. And really, it takes a lot of questioning, discussions with the mom, and really interacting to understand how those changes are being received by them as well as their support team. So, when we see a mom who is not maybe bouncing back as well and say maybe the first two to four weeks, then we start to have some concerns.

So, it's really important that new moms really reach out to their primary care provider, mainly their obstetrician in this point, or it could be a certified nurse-midwife, very early in the postpartum stages to see how the baby blues are progressing. Baby blues are what we tend to recognize as being some hormonal changes and shifts back to a pre-pregnant state. But for the most part, we expect those blues, if you will, to really kind of correct themselves within about two to four weeks. However, we definitely see a percentage of patients where those blues really morph into something more significant and more serious and more concerning, such as postpartum depression and, even worse, postpartum psychosis.

Host: Gotcha. So, that would be the line, so to speak, between the two. When would you say, Doctor, that someone should seek help for either persistent signs of fourth trimester struggles or PPD?

Dr. Gamilah Pierre: Yes, very good question. I think making sure that the patients are aware who's their support team, because often it's their support team who recognizes the signs and the concerns before the patient actually does. So, we all recognize that having a newborn means that sleep is at a premium. However, if you are unable to get any rest or sleep or any help that makes it very difficult to function. When our bodies don't get sleep and don't get to rest and recover, we don't have as much resiliency. So, it's very difficult to deal with anxiety that could be normal, but we just don't have the resiliency because our bodies are exhausted.

So if a mother recognizes that they really are having some difficulty even getting sleep when the baby's sleeping, then that's opportunity to call out to us. If they are concerned that they're having thoughts which seem scary to them, then that's another time to call us. It doesn't mean that there's something bad or wrong with the mother, but when you have that concern, it's an opportunity to have a conversation with your caregiver. And most times, we'll recognize that those thoughts are actually completely normal. And a lot of times, once the mother recognizes that some of the thoughts and the process of this mental changes are normal and common, it's actually reassuring to them. If you're not able to have any ability to have some downtime. You have to be able to have someone to help you just for 10 minutes a day, an hour a day, be able to walk away and take a shower.

I mean, new moms struggle. They get some food. So, how are you eating? How are you resting? How do you feel the bonding is going with the baby? That's an actually very important question. But the support team, the family support, they're very in tuned, even more so sometimes in patients of how the interaction is, how's your interaction with your significant other. I mean, it's new for everybody, even if it's not your first baby. But how is that interaction going? And sometimes the other person is able to recognize signs and symptoms quicker than the patient themselves because they're so focused on being primary caregiver for that newborn.

Host: So having said that, Doctor, do all women experience these things shortly after giving birth? Just how common is this? Because I would guess very, right?

Dr. Gamilah Pierre: So, this is extremely common. Certain groups of people are at higher risk for more significant problems. So, number one, anybody who has a history of anxiety, depression, or any type of mental health concerns in the past is at a higher risk for the postpartum depression continuing past that two to four weeks and even becoming more significant. People who've been medicated in the past, people who've had a history in the past of postpartum depression. However, there are other groups that are equal risk. So, if you don't have a strong support system, that can put you at risk, or if you've had any type of recent trauma in the family, if you had a traumatic birth experience even if your baby's fine, but you had a traumatic birth experience, that could put you at a risk for kind of past the blues, if you will. If you've had a significant loss in your family, I have people who've lost loved ones during their pregnancy, and we know that that puts them at significant risk. There can be issues with socioeconomic and not having an opportunity to reach out to a caregiver. So, the baseline risk may be the same, but the problem is if the patient doesn't feel that they have a caregiver to reach out to or they're not in a position to reach out to their caregiver, nobody can preemptively act on that. So then, their risk of discontinuing and growing even deeper despair grows. So, it's just important that people are aware that postpartum depression exists. It's relatively common. The blues is extremely common. And now, some of the blues, if you will, is just related to some hormonal changes. Obviously, a woman's body goes through significant hormonal changes after a baby's born. Completely normal to have crying episodes and moments of feeling inadequate caring for a newborn. Completely normal. However, if those thoughts seem to be overtaking you, then that's where it becomes, maybe this isn't normal, or maybe I just need help. So, it's not so much of is it normal or not, but can I get some help? And that's where it comes into talking to your obstetrician, your midwife, or your caregiver, and then using that family support to really kind of see.

We also use an actual tool. We do have a screening tool, and it's been well validated to help us to identify patients who say everything is fine, but actually everything may not be fine. So, using that validated screening tool often is a way to get us to understand who's at risk. And we actually give the patient that screening tool every time they come to their appointment. And in fact, it's such an important screening tool that the ideal setting is any postpartum patient gets the tool. So even if they're at the pediatrician's office, who actually has very little to do with the mom's health, but the pediatricians now recognize, well, they're seeing these postpartum patients sometimes more frequently than we are because they're checking the baby. And so now, they've been educated to give that tool. It's just a little quick five-minute, 10-question tool, and then if there is a question, then the pediatricians have really been helpful saying, hey, you need to talk to your obstetrician, or they can even pick up the phone and say, "Hey, Dr. Pierre, I saw Ms. Jones today with the baby, but I'm actually concerned about her." So, those are ways to kind of help us to identify people who are at risk and the risk is significant that require medication or even hospitalization.

Host: A few other things. How about, Doctor, the importance of a new mother keeping in contact proactively with her doctor soon after birth? Since often, from what I understand, new moms lose touch when the baby is born because of being overwhelmed with many of the things you've touched on, right?

Dr. Gamilah Pierre: Yeah, that's a great question. Traditionally, it's always been the six week postpartum visit. Well, we finally recognized that that's just too far out. So, several patients with certain types of medical problems, we actually see them within three days of leaving the hospital, and they're surprised. They're like, "I have to come back so soon?" We're like, "Yes." So, in this day and age, we have really tried to move towards seeing our postpartum patients earlier and a little bit more often. Again, making it a true fourth trimester. So, for the average patient with no medical problems, no complications, we really try to encourage them to come back in about two weeks. For a complicated patient, they really may be back in three to four days.

Now, you say, "Well, that's great, but I have a newborn. How am I going to manage all these doctor's appointments?" So, actually, I think it's worthwhile to consider some of these visits as telehealth. And there's some pros and cons to telehealth. But I think with a newborn, especially just trying to assess, how does the mother look? Is she completely disheveled? Is she able to get a quick shower and comb her hair? Just things that sound like they may not be important, but even on a telehealth call, so we may just in the general OB community start using that telehealth so that it's not so onerous of mom to actually get herself to the doctor, but has that telehealth appointment maybe in two weeks, and then another appointment maybe in four to six weeks, and then maybe one additional one depending on what complications or comorbidities that particular patient had.

Host: And then finally, in summary here, Doctor, generally speaking, what would you tell new moms or new moms to be joining us about the chances that when they're hit with some of these challenges post birth, that they can be successfully addressed. Because I would think one of the keys, and again, I'm speaking from personal experience with my wife and myself as well, we have a two-year-old. A lot of it, I think, is a mindset of just knowing that almost everyone is going through the same things. It's normal, right?

Dr. Gamilah Pierre: I think the most important thing is what you just said. It's really to make sure that patients realize this is normal. It is overwhelming to have a baby. That's the most overwhelming change in your life for anybody. So, it's important for patients to recognize it's not all roses and sunshine. This is hard work. These babies don't sleep. They are demanding. They need a lot. Your body's changing. You're having just so many changes. So, the earlier we're able to see patients back postpartum and actually discuss it with them in the third trimester and reminding them that you may have feelings of inadequacy, or you may feel like you're not bonding with your baby. It doesn't mean you're a bad mother. You're not a bad parent. This is normal. And the important thing is to stay in touch with us so that we can work through how you feel and make sure that it's staying on the continuum of what we think is normal. And in those rare cases, because there are cases where the depression is so bad, and I'm talking beyond medication. I mean, where patients need to be hospitalized. In those cases, when we're really involved and in touch, we can get involved very soon, and we can get moms hospitalized who need to be hospitalized and also so they don't feel the stigma, that there's something wrong with them, that they're not good mothers, but that we're just working through another medical condition as if you had hypertension or if you had diabetes. So, I think just making it so that patients understand that the mental changes are very common, and we have ways of dealing with it, and we do therapy. I have several counselors that I refer patients to. Some patients will require medication, especially if they had a history of needing medication in the past, and very, very rarely a patient may need something more aggressive like hospitalization. But nonetheless, we can work through this and most women will be successful and be fine and go on to have additional children if that's part of their birthing plan.

Host: All the above sound great to hear indeed. Well, folks, we trust you're now more familiar with fourth trimester and PPD and some of the differences between the two. Dr. Gamilah Pierre, a pleasure. Thanks so much again. And before we let you go, may I ask what is on the agenda today for you in beautiful Hawaii? Is this business or pleasure or a combination of the two?

Dr. Gamilah Pierre: This is a hundred percent vacation. So, we're getting out to the beach and hopefully snorkeling. We just got here late last night. So, I'm excited to get my swimsuit, my wetsuit on and get out to that beach and snorkel.

Host: Snorkeling is great. I've only been once, but the clarity of the water alone is worth going down there, right?

Dr. Gamilah Pierre: It's worth the eight-hour flight. So, it's good.

Host: Absolutely. And for more information, folks, please visit silvercross.org/mother-baby. Now, if you found this podcast helpful, please do share it on your social media and thanks so much again for being part of Silver Cross Hospitals' IMatter Health podcast.

Dr. Gamilah Pierre: And thank you again for inviting me to speak on this very important topic. Thank you.

Host: Absolutely. Doctor, you have yourself a great trip. I'm sure everyone joining us joins me in being very, very jealous.

Dr. Gamilah Pierre: Thank you.

Host: Thank you.