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Mother and Baby: Intertwined

Published:November 03, 2014DOI:https://doi.org/10.1016/j.acap.2014.09.013
      Henry was a wanted, planned, loved baby. By the world's standards, we were exceptionally well-qualified parents. Markus and I had been married 4 years, had already succeeded at parenting an infant once, and—both in the midst of pediatric residency—were professionally trained to care for children even in their sickest and most fragile states. Despite the rigors of my intern year, I was energetic, happy to be pregnant, and eagerly anticipating the birth of our second son.
      Toward the end of intern year and during my second trimester, I was examining a young girl with neck swelling and dysphagia. As I had done hundreds of times before, I used a tongue depressor to look at her posterior pharynx. She involuntarily gagged, and a droplet of her saliva landed in my eye. I was surprised but unconcerned.
      Three days later, my senior resident called me at home. Test results had come back on the patient, she said, and the child had been diagnosed with cytomegalovirus (CMV). As a pediatrician in training, I was well acquainted with the potential consequences of congenital CMV for my baby: intrauterine growth restriction, microcephaly, intracerebral calcifications, retinitis, sensorineural hearing loss, and developmental delays. But these symptoms had previously only been as real to me as the textbook pages they were printed on. Suddenly, they had become tangible and frightening. Suddenly, my unborn son was the patient.
      I was treated with a dose of intravenous CMV immunoglobulin and took acyclovir 5 times a day for the rest of my pregnancy. We had ultrasounds every 3 weeks to track Henry's growth, to look at his brain, and to reassure ourselves that everything was okay.
      Despite all that, my husband, Markus, and I were terrified. It is hard to describe the conflicting senses of responsibility and helplessness that I felt toward my unborn child. Before Henry was even born, I felt that I had already failed him. I knew, intellectually, that it wasn't my fault, and that with all the treatments we had completed, it was unlikely that he would be profoundly affected by this virus. But the fear of the unknown was tremendous.
      Henry was born after 9 hours of natural labor. He was 8 pounds, 5 ounces and beautiful. Those first moments with him were filled with joy, relief, and thankfulness, but in the back of my mind, they were poisoned by reservation and fear. He was a few hours old when we sent off the blood tests, and it was less than 48 hours before we learned that he did indeed have the virus in his bloodstream. I was bitter.
      Henry was healthy enough to go home with us, but he would have to take valganciclovir twice a day. I always asked Markus to give him the medicine; I simply could not do it. Every time I looked at my son, I saw visions of miniature, robotlike viral demons swimming through his veins. The medicine, as insignificant as it seemed to Henry and Markus, debilitated me.
      The medicine was not a benign one in terms of adverse effects. Within a month, Henry had a critically low neutrophil count. We decided to stop treating the virus because the risk of an immunocompromised state was the more imminent danger. Fortunately, all of his organs had developed appropriately, so the primary worry at that point was hearing loss. We were willing to accept the risk.
      Over the next 3 months, Henry continued to improve. I, however, was crumbling. It was simple enough to blame my circumstances. I was the mother of a newborn, the mother of a toddler, a pediatric resident, and the wife of a resident—and my family was 2000 miles away. I was exhausted and overwhelmed. I struggled through grueling days on the wards, pausing every 3 hours to pump milk. I survived long nights of Henry's inconsolable crying, trying but failing to get enough sleep. And every minute of it, I wished he had never been born.
      I knew what the textbooks said about postpartum depression. I dutifully screened for it among mothers at well-child visits. Yet although I knew something was amiss in my relationship with my son, my pride kept me from admitting that I was susceptible to such weakness.
      My chief resident explained it to me in the simplest of terms: “We all have trials, challenges, stressors, and fatigue. But we all have coping mechanisms, and supports, and reserves that we can rely on to get us through those times. Depression takes these supports away, robbing you of your ability to cope.”
      That last statement is what finally opened my ears. I knew that I was tired and sad; I spent hours each day crying. I knew that when I looked at my baby, in place of love, I felt regret, worry, guilt, and bitterness. He was losing weight, and he cried constantly when he was around me. I assumed that he was just a miserable baby until a good friend came over to offer me some respite. When she rang the doorbell, I picked Henry up, held him at arm's length (I rarely cradled him, as that was too intimate), walked briskly to the front door, and thrust my 3-month-old into her arms. I didn't make eye contact. I didn't say a word. I turned and walked back to my room and sobbed. Two minutes later, she was cooing at him on the floor, and he was cooing back. She called out from the living room, “Hannah! He is just the sweetest, happiest, most beautiful baby!”
      I knew there were 2 possibilities: either he was innately a happy baby and was only miserable around me because of my own misery, or he was innately a happy baby and I was blind to it. Either one was too painful to bear. The next day, I e-mailed my advisor, crying out for help.
      I will forever be grateful for the immediate and overwhelming support I received from my residency program. The program director, my advisor, and chief residents were there to listen to me, to encourage me, and most importantly, to force me to get the help I needed. Without robbing me of my autonomy, my program director guided me to accept what I had known for months to be true: I had postpartum depression. I could not work safely, but more importantly to her, I could not love my son.
      The next week, I flew home to the other side of the country to rest and heal. Markus stayed behind and worked the next 4 weeks for me, picking up my grueling 13-plus-hour shifts so that I did not have to. I wish I could say that freedom from work and a few weeks of good sleep (whatever that means when you are nursing every 3 hours) made me feel tremendously better. I was disappointed but not all that surprised to find that I still felt numb, hollow, tired, ashamed, and inadequate.
      And that is what depression does to you. It robs you of your joy. It robs you of a healthy perspective on the many beautiful gifts you have been given: a strong and tender husband, 2 precious children, a mind for science, a passion for medicine, a gift with others' children, an able body, an army of generous and loving family members.
      When I look back at pictures from that time, I see the emptiness in my eyes. I imagine most others saw my smile without knowing it was forced, saw my wonderful family, saw my successes, and had no idea. Postpartum depression is at once crippling and invisible.
      As a pediatrician, I now look for those invisible symptoms. Women suffering from postpartum depression are in a way blinded by it,
      • Whitton A.
      • Warner R.
      • Appleby L.
      The pathway to care in post-natal depression: women’s attitudes to post-natal depression and its treatment.
      and they desperately need their loved ones and health care providers to recognize it, to reach out, and to seek help on the mother's behalf. My screening for postpartum depression at well-child visits has completely changed. I acknowledge the fatigue, the transition period for the family, and the natural worries of a new mother; these are all to be expected. But I ask them specifically about their ability to cope. Often the nonverbal response to this question provides greater insight than the mother's words. Most mothers feel compelled to portray the blissful competence that society expects, regardless of how dark their reality may be. It is our duty as pediatricians to see past this. Babies and mothers are intricately intertwined, and when one suffers, so does the other.
      This is not to minimize the role of fathers; I learned firsthand how dramatically postpartum depression can affect fathers as well. For too many months, my husband lost his wife, his partner, his best friend. His household tasks and his parenting responsibilities multiplied. The emotional burden of loving me, nurturing me through my fragility and weakness, was perhaps an even greater task. Several months later, I was back at work, feeling energetic and capable, and Henry was thriving. I told Markus that I felt like my normal self again. He meekly stated that he was still scared that he could not count on me as an equal in our household, fearful that too much pressure would cause me to crumble. It had been so painful for him to witness that he would do anything to keep it from happening again. I knew then that I was not the only one who needed to heal.
      Today, Henry is a healthy, boisterous, cheerful, adventurous, fearless 2-year-old. He is also a big brother, and I am so grateful to have been free from the darkness of postpartum depression after our youngest son's birth. As a mother, I am whole again. As a pediatrician, I am all the more equipped to serve my patients and their families.

      Reference

        • Whitton A.
        • Warner R.
        • Appleby L.
        The pathway to care in post-natal depression: women’s attitudes to post-natal depression and its treatment.
        Br J Gen Pract. 1996; 46: 427-428