Alexis Totaro, MSN, on assessing distress and executing a warm handoff in postpartum care

Responding effectively to a struggling postpartum patient requires clinicians to ask directly what “struggling” means, conduct a careful nonjudgmental assessment, and execute a clinician-to-clinician warm handoff when escalation is needed, according to Alexis Totaro, MSN, RN, WHNP-c, CARN-AP, Vice President, Mental Health Operations, and Chief Nurse Executive, Christian Health.

Asking potentially tough questions to avoid assumptions

“We can't make assumptions as to what we think struggling means, and I would be remiss if I didn't note that that can vary by culture, what they have experienced in their family before, and what their life was before,” she said, recommending clinicians ask patients directly what struggling looks like for them.

That conversation, she said, must include difficult but specific questions.

“You do have to get into those tough questions of, ‘How are you sleeping? What is your support system looking like, or is there none? Are you thinking of hurting yourself? Are you thinking of hurting the baby or other people in your home?’” she said, adding that clinicians should also gauge whether a patient simply needs practical support, such as someone to allow them a daily nap or shower.

Totaro emphasized observing the patient directly, whether in person or by televisit.

“Are they engaging? Are they looking at the infant if they're holding the infant or the infant is with them? Are they making eye contact with you? So this really requires a very careful assessment,” she said, stressing that the exchange must occur in a judgment-free environment with reassurance that recovery is possible.

What is a warm handoff?

Turning to escalation, Totaro identified the warm handoff as a frequently missed step.

“We tend to pick up the phone or have someone in the office pick up the phone and arrange, let's just say, transportation to the local emergency department for evaluation, or we make a direct admission call for the patient without giving a full report,” she said.

A proper handoff, she said, is clinician-to-clinician and comprehensive.

“A warm handoff would be clinician-to-clinician, the treating clinician talking to the receiving clinician on the other end, giving a full account of the patient's history, including the mental health history and medical history, which is often left out,” Totaro said, adding that this should include a full medication list and prior psychiatric medications, some of which may have been discontinued.

She also stressed preparing the patient for what comes next.

“It's very scary for a patient to go from their treating ob-gyn’s office to an unknown environment in a hospital, likely a psychiatric unit of a hospital, without any preparation,” she said, noting families should be reassured about who will greet them on arrival.