Download Antenatal and Perinatal Mental Health Pathway

Antenatal & Perinatal
Mental Health Pathway
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Population covered by this pathway
Women who are pregnant with mental health problems during pregnancy and the postnatal period (up to 1
year after childbirth) and women with mental health problems who are planning a pregnancy. A child under
the age of 18 who is pregnant should also be considered under this pathway.
This pathway is underpinned by the expected clinical practice within the NICE Guideline for Antenatal and
Postnatal Mental Health that lies within the NICE Pathway for antenatal and postnatal mental health.
These should be referred to in conjunction with this pathway.
Overall considerations
 Healthcare professionals working in universal services and those caring for women in mental health
services should:
o assess the level of contact and support needed by women with a mental health problem
(current or past) and those at risk of developing one
o agree the level of contact and support with each woman, including those who are not having
treatment for a mental health problem
o monitor regularly for symptoms throughout pregnancy and the postnatal period, particularly
in the first few weeks after childbirth
 All healthcare professionals referring a woman to a maternity service should ensure that
communications with that service (including those relating to initial referral) share information on any
past and present mental health problem.
 If a woman has any past or present severe mental illness (especially bipolar 1 disorder or
psychosis) or there is a family history of severe perinatal mental illness in a first-degree relative, be
alert for possible symptoms of postpartum psychosis in the first 2 weeks after childbirth.
These women should have daily contact with a healthcare professional (in partnership with
all agencies) for 2 weeks after childbirth.
 Always consider whether the woman or pregnant child has capacity
Assessment and diagnosis of a suspected mental health problem in pregnancy and the postnatal
period should include:
 The woman's attitude towards the pregnancy, including denial of pregnancy/concealed pregnancy
and late presentation
 The woman's experience of pregnancy and any problems experienced by her, the foetus or the
baby
 The mother–baby relationship during and after pregnancy
 Safeguarding considerations of the baby and any other children in the household
 Discussion and planning as to how symptoms will be monitored (for example, by potentially using
validated self-report questionnaires, such as the Edinburgh Postnatal Depression Scale [EPDS],
Patient Health Questionnaire [PHQ-9] or the 7-item Generalized Anxiety Disorder scale [GAD-7]).
 Recognition that some women with a mental health problem may experience difficulties with the
mother–baby relationship. Assess the nature of this relationship, including verbal interaction,
emotional sensitivity and physical care, at all postnatal contacts. Discuss any concerns that the
woman has about her relationship with her baby and provide information and treatment for the
mental health problem.
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Thresholds
 The threshold for assessment, treatment, CPA, home treatment and admission should be lower in
this population. Assessment of / intervention for suicide risk should always have a lower threshold
due to the increased risk of death through violent suicide at this time
 Specialist inpatient care should be considered for all women in the post natal period who are
suffering from a post-partum psychosis or who are expressing suicidal ideas. The risk of harm to
the child should always be assessed, especially in those who are severely unwell
 Post-partum (Puerperal) psychosis should be dealt with as a psychiatric emergency
Medication
 NOTE: Women of childbearing potential are not prescribed valproate to treat a mental health
problem
 If a woman is planning a pregnancy or once pregnant, psychiatric medication should be overseen
by a Consultant Psychiatrist, with careful consideration given to continued prescription and to
potential risk / benefits to the woman and the baby of either continuing or ceasing.
 After childbirth, review and assess the need for starting, restarting or adjusting psychotropic
medication as soon as a woman with a past or present severe mental illness is medically stable.
At all times, staff should communicate between Mental Health, IAPT, Midwifery / Health Visiting,
Primary and Obstetric care as appropriate, with flexible movement between the levels of care
dependant on the woman’s needs.
Level 1
Recognition,
Referral &
Assessment
Women are asked about their emotional wellbeing at each routine antenatal and postnatal
contact (QS115) [primary care / midwifery].
Discuss with all women of childbearing potential who have a new, existing or past
mental health problem:
•
the use of contraception and any plans for a pregnancy
•
how pregnancy and childbirth might affect a mental health problem, including the
risk of relapse
•
how a mental health problem and its treatment might affect the woman, the foetus
and baby
•
how a mental health problem and its treatment might affect parenting (QS115)
If a woman has any past or present severe mental illness or there is a family history of
severe perinatal mental illness in a first-degree relative, be alert for possible symptoms of
postpartum psychosis in the first 2 weeks after childbirth (NICE CG192)
Referral to:
 IAPT / Turning Point Talking Therapies / Insight Healthcare (from now on in this
document called IAPT)
 SWYT Single Point of Access
 SWYT Intensive Home Based Treatment Team
 Mental Health Liaison service
(depending on severity of presentation and presence of concerns about risk to self or
others)
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Triage by SPA Practitioner - discussion with referrer, completion of referral
documents, risk information, review of past mental health problems and
vulnerability factors
Referral accepted into services without challenge. Clarity obtained about severity
of presenting problems, risks, stage of pregnancy / age of baby, and names and
dates of birth of all children in the house
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Co-ordinated
care
An integrated care plan will be developed for a woman with a mental health problem in
pregnancy and the postnatal period that sets out:
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Level 2
Mild
Disorder
Provisional assessment of severity - discuss with a senior colleague and if in doubt
be cautious
Where there is a history of severe mental illness (bipolar disorder, schizoaffective
disorder, schizophrenia, puerperal psychosis, severe depressive episode or
postnatal depression requiring hospital secondary care) but the individual is
currently well and is seeking pre-conceptual advice or is pregnant, refer to
Community Team/Sector Consultant Psychiatrist for advisory assessment. All
women with a history of Severe Mental Illness should be accepted into
secondary care services. Further referral to a Mother & Baby Outreach
Service should also be considered.
If mental disorder is present proceed as outlined below according to severity
When a woman with a known or suspected mental health problem is referred in
pregnancy or the postnatal period, assess for treatment within 2 weeks of referral
and provide psychological interventions within 1 month of initial assessment (NICE
CG192)
Women with a suspected mental health problem in pregnancy or the postnatal
period receive a comprehensive mental health assessment (QS115). This will be
offered as a matter of urgency. Women who are planning a pregnancy will be
offered a routine appointment
All prescribed medications should be discussed and considered in relation to
potential harm to the unborn baby and the potential risk / benefits to the mother
NOTE: Women of childbearing potential are not prescribed Valproate to treat
mental health problems. Valproate can harm unborn babies when taken during
pregnancy. Babies exposed to valproate in the womb are at high risk of serious
developmental disorders (approximately 30-40% of babies) and congenital
malformations (approximately 10%of babies).
The care and treatment for the mental health problem
The roles of all healthcare professionals, including who is responsible for
coordinating the integrated care plan, the schedule of monitoring, providing the
interventions and agreeing the outcomes with the woman or pregnant child
(CG192)
The integrated care plan should be completed between 28 and 32 weeks of the
pregnancy
Issues regarding the starting and stopping of medications and the associated risks /
benefits should be considered within the care plan
As part of the preparedness for the birth, the care coordinator should inform the
woman or pregnant child that it is usual practice that professionals will want to see
the baby with the mother when they visit
Consider discussion with a mother and baby in-patient unit or other specialist prior
to the birth, depending on the level of risk
Be aware that the woman might have self-referred to a local mental health provider
without the midwife’s knowledge, therefore contact should be made with other
health care professionals providing care whilst developing the plan
Depression or anxiety with no suicidality (Mental Health Cluster Tool score likely to be 1 or
2)
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Refer to IAPT for Perinatal Pathway Assessment
Following IAPT assessment, may offer low intensity interventions, high intensity
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interventions or may step up to SWYT input via SPA if assessment reveals
moderate or severe presentation with complications requiring CPA
Level 3
Moderate
Disorder
Depression or anxiety with no suicidality. MHCT likely to be 3.
If no suicidality or previous mental health presentations, refer to IAPT for Perinatal
Pathway High Intensity Assessment. Following assessment, may offer high intensity
intervention alone plus review and medical treatment supplied from medical colleagues
within SWYT (but not on CPA) if necessary.
If prior mental health presentations reported and vulnerability factors present e.g.
pregnant/baby born in last 6 weeks/perceived lack of social support and /or concurrent
social adversity/ life events such as bereavement and / or underlying concern that some
more serious mental illness may be developing, refer to SPA if psychological treatment
required as part of package of care.
Level 4
Severe
Disorder
Severe or psychotic disorder, with accompanying risks to self or child / others, or when the
person’s mental health is deteriorating rapidly.
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Discuss with Consultant Psychiatrist colleague, with urgent assessment of mental
health and potential risks by senior practitioner / joint with medical practitioner
Assess suitability for IHBTT and refer as appropriate
Discuss with Community Team Leader (or deputy) and refer to Community Team,
including if psychological treatment required as part of package of care
Daily visits for the first two weeks after the birth, by any of the professionals
involved, with a plan for clear communication between all involved
Consider suitability for admission to hospital, a mother and baby unit where
possible if after the birth. This might particularly be considered if family support is
unavailable. Women who need inpatient care for a mental health problem within 12
months of childbirth should normally be admitted to a specialist mother and baby
unit, unless there are specific reasons for not doing so (CG192)
It might be that local inpatient care needs to be considered. If the patient is
admitted to a local unit then there should be ongoing consideration of assessment
for transfer to a specialist mother and baby unit
Key
IAPT Improving Access to Psychological Therapies
mental health
SPA
Single Point of Access
postnatal mental health
IHBTT Intensive Home Based Treatment Team
Foundation Trust
CPA
Care Programme Approach
CG192 NICE Guideline for antenatal and post-natal
QS115 NICE Quality Standard Antenatal and
SWYT South West Yorkshire Partnership NHS
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Appendix: 1 Sample Pregnancy and Early Post-Natal Care Plan (to be completed between 28 and 32
weeks of pregnancy)
Pregnancy and Early Post-Natal Care Plan (to be completed between 28 and 32 weeks of
pregnancy)
Name:
DOB:
EDD:
Address:
NHS no:
Date of plan:
Care Co-ordinator:
Contact info:
Health Visitor:
Contact info:
Midwife:
Contact info:
Child and Families Social worker:
Contact info:
Obstetrician:
Contact info:
Psychiatrist:
Contact info:
GP:
Contact info:
Other Professional:
Contact info:
Family member/named person:
Contact info:
Emergency Out of Hours Mental
Health Contact:
Contact info:
Leeds MBU: 0113 855 5505
0113 855 5509
Risk of illness: consider previous personal or family history of psychosis,
bipolar disorder or post natal mental illness
1.
2.
Early warning signs of relapse:
1.
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2.
Current Management
1.
2.
3.
Planned antenatal changes
Special instructions in labour
1.
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2.
2.
Safeguarding
1. Does a pre-birth assessment need to be made?
2. Is there a history of previous safeguarding concerns?
Immediate postnatal plan
Intention to breastfeed
YES/NO
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2.
3.
Action to be taken in case of relapse:
Advance statement completed YES/NO
Sign/print name (Care Co-ordinator)
Date
Sign/print name (Patient)
Date
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