Postpartum Mental Health P1

Series: Beyond the Baby Blues: A Postpartum Mental Health Series

Intro to series:

At BESST Transitions, we explore the turning points that shape health and wellbeing. Few transitions are as profound as the shift into parenthood.  This post is part of Beyond the Baby Blues: A Postpartum Mental Health Series, which explores the emotional realities of the “fourth trimester.” This is a time of immense physical, emotional, and social change. In this series on postpartum mental health, we’ll follow this journey through its many layers: from the early adjustment beyond the baby blues, to the realities of anxiety and depression, to strategies for support and advocacy. Each post is an invitation to recognize the challenges of this transition, and to imagine more supportive pathways forward. Two other series will follow.  These will explore postpartum mental health across the lifespan and postpartum mental health in marginalized communities.

Posts in this Series:

1. Postpartum Mental Health: Beyond the Baby Blues

2. Postpartum Anxiety: The Silent Partner of New Motherhood

3. Postpartum Depression: Understanding the Shadows Beyond the Smile

4. Partners & Family: The Ripple Effects of Postpartum Mental Health

5. Self-Care and Coping Strategies for New Parents

6. Navigating Professional Support: From Pregnancy to Postpartum as a First-Time Parent

7. From Advocacy to Action: Canada Joins the Global Push for Perinatal Mental Health

Postpartum Mental Health: Beyond the Baby Blues

The body, the mind, and the silent struggles of the “fourth trimester”

In the days after birth, many women expect to feel joy, awe, and perhaps some exhaustion. What often comes instead is a mix of tears, cramps, leaking breasts, sleepless nights, and a rollercoaster of emotions. Some mothers wonder if this is normal, others worry they’re already failing, and almost everyone feels blindsided by something nobody warned them about. This is the reality of the postpartum period, not just cuddles and milestones, but a complex physiological and psychological recovery that deserves honest conversation.

Baby Blues vs. Postpartum Mental Health Conditions

• Baby Blues: Up to 76% of new mothers experience mood swings, irritability, tearfulness, and overwhelm in the first few days after birth (Rezaie-Keikhaie et al., 2020). Symptoms peak around day 4 and usually resolve within two weeks (Government of Alberta, 2024).

  
  

• Postpartum Depression (PPD): Lasts longer, interferes with daily functioning, includes persistent low mood, loss of interest, guilt, or hopelessness. Prevalence is ~17% worldwide (Wang et al., 2021).

  
  

• Postpartum Anxiety (PPA): Often overlooked, marked by excessive worry, intrusive thoughts, panic, or hypervigilance. Prevalence estimates range from 12–20% (Fawcett et al., 2019).

  
  

Other Conditions:

• Postpartum Obsessive–Compulsive Disorder (OCD): Intrusive, often frightening thoughts about harm coming to the baby, coupled with compulsive behaviors (e.g., repeated checking) (Nakic Rados et al., 2025).

  
  

• Postpartum PTSD: Can arise after traumatic birth experiences, emergency interventions, or feeling unsupported during labor (Reynolds, 1997; Ayers, 2017).

  
  

• Postpartum Bipolar Disorder (PPBD): Sometimes overlooked, bipolar disorder can first emerge or recur postpartum, with episodes of mania, hypomania, or depression. Misdiagnosis as “just depression” is common, which can lead to inappropriate treatment (Sharma et al., 2017). Careful assessment is crucial, especially if symptoms include racing thoughts, decreased need for sleep, impulsivity, or periods of elevated mood alongside depression.

  
  

Key distinction: Baby blues fade within approximately two weeks. If distress persists, worsens, or interferes with functioning, it may signal a clinical condition requiring support.

The Physiology of Postpartum Recovery

The postpartum period is sometimes called the “fourth trimester”; it is a phase of immense biological change as the body transitions from pregnancy to recovery. Yet how many parents are truly prepared for all that this stage entails before the baby arrives? And even then, can anyone fully understand it without having lived it? You’d think that as an older first-time mother, surrounded by people who had already gone through it, I would have known what to expect. I thought I did. But what I wasn’t prepared for was the intensity…the hormonal swings that felt like another tidal wave, the weeks of painful recovery, the hemorrhoids that made sitting to nurse a painful negotiation, the bouts of incontinence, and even the trapped gas that had me doubled over while I was still heavily bleeding -  no one had warned me about all of these. Perhaps it feels like too much information, but these are the realities of postpartum life for many women. And they deserve to be talked about.  Here, we look at some of the often-overlooked realities of this transformative time. Some of these clearly appear in peer-reviewed research yet others are more anecdotal and don’t necessarily appear in the postpartum literature, even though they are very common.

1. Hormonal Whiplash

• Estrogen and progesterone plummet after delivery (Dukic et al., 2024), contributing to mood swings and fatigue.

  
  

• Oxytocin and prolactin rise with breastfeeding, supporting bonding and milk production but also heightening emotional sensitivity (Pillay and Davis, 2023).

  
  

• Cortisol and the HPA axis recalibrate (as these are significantly altered during various stages of pregnancy), affecting stress response and vulnerability to depression/anxiety (Duthie and Reynolds, 2013).

  
  

2. The Uterus and Bleeding

• The uterus contracts (involution), causing afterpains that can be surprisingly intense, especially during breastfeeding.

  
  

• Lochia (postpartum bleeding) can last up to six weeks. Many women are startled by its volume or duration (Cleveland Clinic, 2025).

  
  

3. Vaginal Birth Realities

• Perineal trauma: tearing or episiotomy can cause pain, stinging with urination, and long-term pelvic floor weakness (Mayo Clinic, 2022).

  
  

• Hemorrhoids: common from pushing, often painful, and rarely discussed openly (Bužinskiene et al., 2022).

  
  

• Incontinence: leakage with coughing/sneezing (stress incontinence) is frequent and distressing.

  
  

4. C-section Recovery

• Abdominal incision pain limits mobility.

  
  

• Infection risk is higher (Cleveland Clinic, 2022).

  
  

• Core muscle healing complicates lifting, posture, and even breastfeeding positions.

  
  

• Some mothers feel grief or disappointment if birth didn’t go as planned (Zanardo et al., 2016).

  
  

5. Breasts and Feeding

• Engorgement: hot, swollen, painful breasts when milk first comes in (Zakarija-Grkovic

and Stewart, 2020).

• Nipple trauma: cracks, bleeding, or pain with latch.

  
  

• Mastitis: flu-like illness with breast pain and fever (La Leche League Canada, 2022).

  
  

• Non-breastfeeding mothers: also face engorgement and discomfort as milk suppresses.

  
  

6. The Silent Companions

• Night sweats from hormonal shifts.

  
  

• Hair loss around 3–6 months postpartum.

  
  

• Constipation (worsened by pain meds or C-section).

  
  

• Chronic sleep deprivation, which intensifies both physical and mental struggles.

  
  

Why these matter: These physical challenges directly affect mood, coping, and identity. When women aren’t told to expect hemorrhoids, night sweats, or months of leaking, they may feel broken, when in fact they are experiencing normal recovery.

Linking Physical to Psychological

The mind and body are inseparable in postpartum recovery.

• Pain, bleeding, and mobility restrictions limit independence and fuel frustration.

• Breastfeeding stress can erode confidence and increase guilt.

• Sleep deprivation alone is one of the strongest contributors to mood and anxiety symptoms (Iranpour et al., 2016).

• Hormonal and immune changes prime vulnerability. Whether this translates into depression or anxiety depends on psychosocial context: support, relationships, socioeconomic pressures, and prior trauma (Yim et al., 2015).

  
  

This is the biopsychosocial model in action: biological vulnerability, psychological traits, and social environment combine to shape postpartum wellbeing.

Red Flags: When to Seek Help

• Symptoms lasting more than two weeks.

• Distress interfering with daily life, bonding, or self-care.

• Persistent anxiety, panic, or intrusive thoughts.

• Feelings of hopelessness, worthlessness, or thoughts of harm.

  
  

Help may include support groups, counseling (especially CBT), medication when indicated, and above all, reassurance that these conditions are common and treatable. In a future post we’ll also look at how current technology, such as social media, apps, and online platforms, can play a role in supporting new parents who have grown up with these tools.

Closing Thoughts

Postpartum recovery is raw, messy, and profound. The baby blues are normal, but when distress lingers, it may signal a deeper issue. By talking openly about the gory details, the hemorrhoids, the night sweats, the incision pain, the cracked nipples, we normalize what women endure. And by linking physical recovery with psychological vulnerability, we remind mothers (and those who support them) that mental health is just as real a part of postpartum healing as any stitches or scars.

In my next post, I’ll focus specifically on postpartum anxiety: the silent partner of new motherhood, why it’s so common, why it’s missed, and what can be done to support women through it.

--Anne TM Konkle, PhD

References

Ayers S. Birth trauma and post-traumatic stress disorder: the importance of risk and resilience. Journal of Reproductive Infant Psychology. 2017 Nov;35(5):427-430. doi: 10.1080/02646838.2017.1386874.

Bužinskienė D, Sabonytė-Balšaitienė Ž, Poškus T. Perianal Diseases in Pregnancy and After Childbirth: Frequency, Risk Factors, Impact on Women's Quality of Life and Treatment Methods. Frontiers in Surgery. 2022 Feb 18;9:788823. doi: 10.3389/fsurg.2022.788823.

Cleveland Clinic. (2022, August 14). C-Section (Cesarean Birth): Procedure, Risks & Recovery. Cleveland Clinic Health Library. https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section

Cleveland Clinic. (2025, April 29). Lochia (postpartum bleeding): How long, stages, smell & color. Cleveland Clinic Health Library. https://my.clevelandclinic.org/health/body/22485-lochia

Dukic J, Johann A, Henninger M, Ehlert U. Estradiol and progesterone from pregnancy to postpartum: a longitudinal latent class analysis. Frontiers in Global Womens Health. 2024 Oct 9;5:1428494. doi: 10.3389/fgwh.2024.1428494.

Duthie L, Reynolds RM. Changes in the maternal hypothalamic-pituitary-adrenal axis in pregnancy and postpartum: influences on maternal and fetal outcomes. Neuroendocrinology. 2013;98(2):106-15. doi: 10.1159/000354702. Epub 2013 Sep 19.

Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. The Prevalence of Anxiety Disorders During Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis. Journal of Clinical Psychiatry. 2019 Jul 23;80(4):18r12527. doi: 10.4088/JCP.18r12527.

Government of Alberta. (2024, April 30). Baby Blues [Health information page]. Accessed Sept 11, 2025. MyHealth.Alberta.ca. https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=tn7417

Iranpour S, Kheirabadi GR, Esmaillzadeh A, Heidari-Beni M, Maracy MR. Association between sleep quality and postpartum depression. Journal of Research in Medical Sciences. 2016 Nov 7;21:110. doi: 10.4103/1735-1995.193500.

La Leche League Canada. (2022). Mastitis — A Matter of Inflammation [PDF]. La Leche League Canada. https://www.lllc.ca/sites/default/files/Mastitispdf.pdf

Mayo Clinic Staff. (2022, August 2). Episiotomy: When it’s needed, when it’s not. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/episiotomy/art-20047282

Nakić Radoš S, Brekalo M, Matijaš M, Žutić M. Obsessive-compulsive disorder (OCD) symptoms during pregnancy and postpartum: prevalence, stability, predictors, and comorbidity with peripartum depression symptoms. BMC Pregnancy Childbirth. 2025 Feb 17;25(1):176. doi: 10.1186/s12884-025-07302-y.

Pillay J, Davis TJ. Physiology, Lactation. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499981/ 

Reynolds JL. Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth. Canadian Medical Association Journal. 1997 Mar 15;156(6):831-5.

Rezaie-Keikhaie K, Arbabshastan ME, Rafiemanesh H, Amirshahi M, Ostadkelayeh SM, Arbabisarjou A. Systematic Review and Meta-Analysis of the Prevalence of the Maternity Blues in the Postpartum Period. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2020 Mar;49(2):127-136. doi: 10.1016/j.jogn.2020.01.001. Epub 2020 Feb 7.

Sharma V, Doobay M, Baczynski C. Bipolar postpartum depression: An update and recommendations. Journal of Affective Disorders. 2017 Sep;219:105-111. doi: 10.1016/j.jad.2017.05.014. Epub 2017 May 11.

Wang Z, Liu J, Shuai H, Cai Z, Fu X, Liu Y, Xiao X, Zhang W, Krabbendam E, Liu S, Liu Z, Li Z, Yang BX. Mapping global prevalence of depression among postpartum women. Translational Psychiatry. 2021 Oct 20;11(1):543. doi: 10.1038/s41398-021-01663-6. Erratum in: Translational Psychiatry. 2021 Dec 20;11(1):640. doi: 10.1038/s41398-021-01692-1.

Yim IS, Tanner Stapleton LR, Guardino CM, Hahn-Holbrook J, Dunkel Schetter C. Biological and psychosocial predictors of postpartum depression: systematic review and call for integration. Annual Review of Clinical Psychology. 2015;11:99-137. doi: 10.1146/annurev-clinpsy-101414-020426.

Zakarija-Grkovic I, Stewart F. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev. 2020 Sep 18;9(9):CD006946. doi: 10.1002/14651858.CD006946.pub4.

Zanardo V, Soldera G, Volpe F, Giliberti L, Parotto M, Giustardi A, Straface G. Influence of elective and emergency cesarean delivery on mother emotions and bonding. Early Human Development. 2016 Aug;99:17-20. doi: 10.1016/j.earlhumdev.2016.05.006. Epub 2016 Jul 2.