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Oxfordshire Integrated Maternal Mental Health Care Pathway
Integrated Antenatal Mental Health Care Pathway for HV Guidance
Much of the care given to pregnant women with mental health problems will follow the care pathway for healthy pregnant women developed in accordance with the NICE
guidance. This additional pathway supplements the routine pathway and should be used in conjunction with individual professional groups guidelines
MW/GP at 1st contact or booking use the Whooley questions to ask all women about their current mental health, past mental health and family
history of serious mental illness. Give all women the leaflet ‘Antenatal and Postnatal Depression’ It is essential that there is liaison between
MW/GP/HV to ensure all relevant information is made available.
No history of mental health problems
Mild/moderate mental health problems
Continue with routine antenatal care with
ongoing assessment of mental health.
Discussion on PND at antenatal classes and
provide information on support e.g. EI
HUB*. Revisit PND leaflet at 36wks.
Mental health problems treated with
support/counselling or antidepressants
from GP or facilitate self-referral to TS.
Discuss support networks offer referral
to EI HUB*. Ensure ongoing
communication between GP/MW/HV.
28-34 weeks all parents offered Ante-natal Health
Review HV Contact using Promotional Guide
Framework. Whooley Question and GAD 2 to be
asked and EPDS done if indicated.
If significant low mood or anxiety identified refer to GP. General low mood/anxiety facilitate
self-referral to Talking Space (can be stepped up to step 4 PTS where appropriate). If relating
to pregnancy or motherhood consult with IPPS. Ensure ongoing communication between all
services involved on A/N and P/N care plan. Offer CAF process and additional support (see
supporting notes to care pathway).
Significant/severe previous or current mental health problems
GP/AMHT to refer to MW pregnant women on caseload or
previously on caseload . GP/MW refer to specialised antenatal
clinic for Consultant Obstetric care and to AMHT (see list) for
assessment and initiation of pre-birth planning meeting as
appropriate. A copy of the agreed care plan needs to be
documented in client’s maternity electronic record.
HV and MW to discuss care plan during liaison meetings and
AMHT contact numbers. Ensure ongoing communication
between AMHT with GP/MW/HV. Consider Social Care
referral and CAF process. AMHT to invite MW/HV all
involved parties to CPA. Visit as needed and ensure family
have 24 hour contact numbers. AMHT to consider referral to
Step 4 PTS where appropriate. If HV unclear of care plan can
contact Public Health Midwives on 01865220113.
If HV unclear of
For sudden onset emergency (if unknown to AMH) please
contact the GP, if out of hours ring 111. You can contact your
locality AMHT for advise, they are available 7am – 9pm.
There is a Night Assessment team available for out of hours
on 01865 901 100. If physical harm has occurred refer to A&E.
All professionals need to liaise and agree a plan of care accessible to all which must be documented in the woman’s maternity record.
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Oxfordshire Integrated Maternal Mental Health Care Pathway
Integrated Postnatal Mental Health Care Pathway From Birth to One Year for HV Guidance
All Postnatal Women are assessed, using the Whooley questions, by HV during the P/N period about their feelings and mood.
No or only Mild concerns about mental health
Continue routine P/N care ensuring
effective communication between
maternity and Primary Care
Services at transfer of care.
HV to ask Whooley and GAD 2 questions at
core Healthy Child Programme contacts
EPDS assessment to be used if the client:
 Is taking medication for mental
health or anxiety
 Has an open referral to adult
mental health
 Has a history of mental health
problems
Universal contacts with parents
New birth Review
6-8 week Review
3-4 month Review
8-12 month Review
Whooley questions asked at:
6-8 weeks - GP post-natal examination
3-4 months - Practice nurse at
immunisation
Moderate concerns about mental
health. Anxious or low mood identified
Ongoing assessment from community MW
and effective handover to HV team. Ensure
ongoing communication between
GP/MW/HV and involved partner agencies.
 Health visitors offer up to 6 active
listening visits/therapeutic listening
visits
 Referral to local therapeutic PND
Wellbeing Group programme
 Consider additional support from
partner agencies – EI HUB*,
HomeStart…
 All families with parental mental
health problems to be offered CAF
 EPDS where indicated and review
Significant low mood or anxiety from birth to
1year: refer to GP and consider either IPPS or TS
or PND group (HV) and ensure ongoing
communication between GP/MW/HV on care
plan. Problems bonding with baby: inform GP
and consider referral to IPPS. Offer CAF process
and additional support e.g. EI HUB*
Significant/severe postnatal depression or
presence of psychotic symptoms
Maternity Inpatient:
Call OUH Psychiatrist for
sudden onset
urgent/emergency
assessment or out of hours
Community
If Unknown to Mental Health. Urgent referral to GP
( or 111 if out of hours), inform HV/community MW.
GP will refer to AMHT where appropriate for
urgent/emergency or Mental Health Act Assessment.
Further advice if needed is available from locality
AMHT. Continual HV assessment of family health
needs. Multi-professional care plan. HV to consider
CAF, safeguarding concerns. Safeguarding SOP and
individual health plan for each child to be in place.
If Known to Mental Health. Refer to local AMHT for
urgent/emergency assessment or Mental Health Act
Assessment. Care overseen by Consultant
Psychiatrist and Care Coordinator. If necessary,
admission should be to MBU, consider available
alternatives if not possible.
If physical harm has occurred send straight to A&E
All professionals need to liaise and agree a plan of care which must be documented on the client’s record
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Oxfordshire Integrated Maternal Mental Health Care Pathway
AMH
Adult Mental Health services
AMHT
Adult Mental Health Team (formerly known as Community Mental Health Team):
Provides mental health assessments within 4 hours for emergency cases, 7 days for urgent and 28 days for routine. Teams are
comprised of assessment and treatment functions. Where appropriate, assessment function can provide up to four assessments and
treatment function can provide treatment and care coordination.
CAF
Common Assessment Framework:
Early intervention tool for children who appear to need multi-agency involvement, helps to avoid children and families having to tell
their stories to multiple agencies and develop a shared understanding of a child's needs with the family and other agencies to meet them
more effectively.
EI HUB
Early Intervention Hub (* Children Centres til Sept 2016)
EDPS
Emergency Department Psychiatric Services
EPDS
Edinburgh Postnatal Depression Score
FASS
Family Assessment and Safe-guarding Service:
Specialist multi-disciplinary service which provides mental health assessment and treatment to enable safeguarding. Provides child and
parenting assessments in families with high risk of severe parenting problems, high risk of major parent/child relationship difficulties
and/or attachment disorder.
HV
Health Visitor
IPPS
Infant Parent Perinatal Service:
Offers treatments to women who are experiencing or at risk of moderate mental health difficulties (parent-infant relationship difficulties,
depression and low mood, anxiety and panic attacks, PTSD, OCD, eating disorders).
MBU
MW
Mother-baby Unit:
Inpatient psychiatric facility for mother and baby. Beds MBUs are funded by NHS England.
Mid-wife
PH
Public Health
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Oxfordshire Integrated Maternal Mental Health Care Pathway
H&S score
Health and Social Care assessment (also known as “assessment of need”):
Assesses individual needs such as healthcare, equipment, home-help in order to create a package of care. Would be provided by
midwifery department at OUH.
PND
Post-natal depression
PTS
Psychological Therapies Service (comprised of Talking Space and Step 4 Psychological Interventions)
Step 4 PTS
Psychological interventions for individuals with severe or complex mental illness or psychological distress.
TS
Talking Space:
For mild/moderate depression or anxiety disorders. Offers Step 2 treatments (guided self-help by phone, psycho-education classes,
computerised CBT) and Step 3 Treatments (individual and group treatments - CBT, IPT, Mindfulness).
Adult Mental Health Team Contact Details.
Please note: These numbers are for use if the women is an existing patient of the adult mental health team and not for new referrals.
Please contact switch on 01865 901 000 if you need to speak with the Service Manager for AMHTs or experience any difficulty in getting through to the
relevant AMHT.
North AMHT
City and NE Oxford AMHT
South Oxon AMHT
Team Manager: Tasmin Irving
Community Lead: Angela Brown
Team Manager: Catherine Sage
Community Lead: Chris Morton
Team Manager: Debbie Walton
Community Lead: Julie Belfield
Elms Centre
Banbury
Tel: 01865 902 563
Warneford Hospital
Oxford
Tel: 01865 902 200
Wallingford Community Hospital
Wallingford
Tel: 01865 904191
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Oxfordshire Integrated Maternal Mental Health Care Pathway
Can provide
assessment of
Mental Health?
Sees baby?
Baby older Countywide?
than 12
months?
✔
IPPS
✔
✔
Talking
Space
Step 4
✔
-
✔
✔
✔
-
✔
Adult
Mental
Health
✔
-
Mother &
Baby Unit
Family
Assessment
& Safeguarding
services
✔
✔
Complex
case/history of
MH illness?
✔
High risk?
Child
Protection
Plan?
✔
-
Some
cases
-
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Referral out
of county
✔
✔
✔
✔
✔
✔
✔
Other?
-
Can provide advice on
preventative treatment
and management to
GPs/MWs/HVs
✔
Support Groups and Helplines for clients and their family
Local Children Centre’s
Association for Postnatal Illness: http://www.apni.org
Fathers Reaching Out: Web: www.fathersreachingout.uk
MIND: Tel 02085192122 or mind infoline0845
www.mind.org.uk
Netmums: Web: www.netmums.com
Twitter - @PNDandMe #pndhour
Twitter @dadsmatteruk
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Web:
Dads Matter UK www.dadsmatteruk.org
Oxpip : 01865 778034 or www.oxpip.org.uk
Relate: 0845 456 1310 Web www.relate.org.uk
Rethink: advice line: 020 8974 6814, tel. 0845 456 0455 web: www.rethink.org
Samaritans: helpline: 08457 90 90 90, textphone: 08457 90 91 92 web:
www.samaritans.org
Saneline : helpline : 0845 7678000