The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Prevention
Recommendation 1.0
Nurses provide individualized, flexible postpartum care based on the identification of depressive symptoms and maternal preference.
(Level of Evidence = Ia)
Recommendation 2.0
Nurses initiate preventive strategies in the early postpartum period.
(Level of Evidence = Ia)
Confirming Depressive Symptoms
Recommendation 3.0
The Edinburgh Postnatal Depression Scale (EPDS) is the recommended self-report tool to confirm depressive symptoms in postpartum mothers.
(Level of Evidence = III)
Recommendation 4.0
The EPDS can be administered anytime throughout the postpartum period (birth to 12 months) to confirm depressive symptoms.
(Level of Evidence = III)
Recommendation 5.0
Nurses encourage postpartum mothers to complete the EPDS by themselves in privacy.
(Level of Evidence = III)
Recommendation 6.0
An EPDS cut-off score greater than 12 may be used to determine depressive symptoms among English-speaking women in the postpartum period. This cut-off criterion should be interpreted cautiously with mothers who 1) are non-English speaking; 2) use English as a second language, and/or 3) are from diverse cultures.
(Level of Evidence = III)
Recommendation 7.0
The EPDS must be interpreted in combination with clinical judgment to confirm postpartum mothers with depressive symptoms.
(Level of Evidence = III)
Recommendation 8.0
Nurses should provide immediate assessment for self harm ideation/behaviour when a mother scores positive (e.g., from 1 to 3) on the EPDS self-harm item number 10.
(Level of Evidence = IV)
Treatment
Recommendation 9.0
Nurses provide supportive weekly interactions and ongoing assessment focusing on mental health needs of postpartum mothers experiencing depressive symptoms.
(Level of Evidence = Ib)
Recommendation 10.0
Nurses facilitate opportunities for the provision of peer support for postpartum mothers with depressive symptoms.
(Level of Evidence = IIb)
General
Recommendation 11.0
Nurses facilitate the involvement of partners and family members in the provision of care for postpartum mothers experiencing depressive symptoms, as appropriate.
(Level of Evidence = Ib)
Recommendation 12.0
Nurses promote self-care activities among new mothers to assist in alleviating depressive symptoms during the postpartum period.
(Level of Evidence = IV)
Recommendation 13.0
Nurses consult appropriate resources for current and accurate information before educating mothers with depressive symptoms about psychotropic medications.
(Level of Evidence = IV)
Education Recommendations
Recommendation 14.0
Nurses providing care to new mothers should receive education on postpartum depression to assist with the confirmation of depressive symptoms and prevention and treatment interventions.
(Level of Evidence = III)
Organization and Policy Recommendations
Recommendation 15.0
Practice settings establish local care pathways and protocols to guide practice and to ensure postpartum mothers with depressive symptoms have access to safe and effective treatment.
(Level of Evidence = III)
Recommendation 16.0
Practice settings provide orientation and continuing education related to the care of postpartum mothers experiencing depressive symptoms.
(Level of Evidence = IV)
Recommendation 17.0
Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to education.
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
- Dedication of a qualified individual to provide the support needed for the education and implementation process.
- Ongoing opportunities for discussion and education to reinforce the importance of best practices.
- Opportunities for reflection on personal and organizational experience in implementing guidelines.
In this regard, Registered Nurses Association of Ontario (RNAO) (through a panel of nurses, researchers, and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the Registered Nurses Association of Ontario guideline Interventions for Postpartum Depression.
(Level of Evidence = IV)
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
