Antenatal and Postnatal Mental Health

Antenatal and Postnatal Mental Health

Between 2010 and 2012, 16 women (0.67 per 100 000) were reported as dying from a

psychiatric cause. In UK, suicide affects about 1 pregnancy in 100 000- It is a leading cause of maternal death.

Risk Assessment-

At the booking visit- Women should be asked about-

  1. previous or current major mental illness, particularly schizophrenia,bipolar disorder, other serious affective disorder, previous psychotic illness in the postnatal period or severe depression in the postnatal period.
  2. previous treatment by mental health services, including periods of inpatient care.
  3. family history of bipolar disorder and of early postpartum major mental illness

(puerperal psychosis).

  1. current treatment with psychotropic medication.
  2. Sensitively ask about- intimate partner violence, sexual abuse or assault, use of illegal drugs, self-harm and lack of social support

At each antenatal visit– ask about- current mental health.

Direct questioning is advised at every encounter

The most commonly suggested questions are the Whooley’s questions- ( check this link)

  1. â–  During the past month, have you often been bothered by feeling down, depressed or hopeless?
  2. â–  During the past month, have you often been bothered by having little interest or pleasure in doing things?

If yes to any of the above- ask- Is this something you feel you need or want help with?

Suggested treatment pathways-

  1. Current mild to moderate illness, and those with previous depressive/ anxiety disorders treated only in primary care- Refer to GP.
  2. Women who develop mild/moderate depression or anxiety during pregnancy → refer to GP. Consider self-help strategies (guided self-help, computerised cognitive behavioural therapy or exercise).
  3. Women who develop serious illness ( symptoms of psychosis, suicidal ideation, self-neglect, evidence of harm to others, significant interference with daily functioning, psychotic disorders, severe anxiety or depression, obsessive–compulsive disorder and eating disorders) → refer to perinatal mental health / psychiatry.
  4. Women with addiction- refer to addiction services.

Intrapartum care–

● Agreed care plan should be in place describing the place of delivery, roles of different care workers, midwives (one-to-one care), obstetrician, anaesthetist and neonatologist/paediatrician, care during late pregnancy and early puerperium, who to contact if problems arise, together with

their contact details, out of hours contact numbers. With her consent, this plan should be placed in her handheld notes.

● Clear advice on whether to take their prescribed psychotropic medicines during labour – the anaesthetist and neonatologist should be made aware of it.

● The RCOG Clinical Governance Advice Obtaining Valid Consent should be used for obtaining consent for various procedures during labour. Consider the possibility of advance directive.

History of mental health issues should be entered in the handheld records after taking permission from the woman.

Postnatal care-

  1. If the woman has been identified to be at high risk of early postpartum mental illness( Puerperal psychosis) – manage according to the plan ( which has already been devised by perinatal mental health psychiatry service).
  2. If the woman has psychotropic medications during pregnancy- monitor the neonate for signs of neonatal adaptation syndrome. If they occur- neonatal should be assessed.
  3. Information sharing with community midwives, health visitors and the GP is important.
  4. Any change in mental state → urgent discussion with specialised perinatal mental health services/ psychiatry should be done.

Child safeguarding services may need to be involved ( Mental illness per se is not an indication for involving Child Safeguarding) .

Each organisation should have local support groups.

References- 1. Management of Women with Mental Health Issues during

Pregnancy and the Postnatal Period Good Practice No.14 June 2011.

2. Perinatal mental health: how to ask and how to help. The Obstetrician &

Gynaecologist. 2017;19:147–53. DOI: 10.1111/tog.12376

3. Postpartum psychosis. The Obstetrician & Gynaecologist 2013;15:145–50.

Link to the NICE guideline – Antenatal and postnatal mental health: clinical management and service guidance Clinical guideline [CG192]

( I will try to write a summary of this guideline as soon a possible)

To read about Postpartum Mood Disorders click here Postpartum Mood Disorders

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