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The role of the Maternity Services in

Perinatal Mental Health (PMH)

Mr Raja Gangopadhyay MBBS MRCOG DFFP Cert Med Ed

Consultant Obstetrician and PMH Lead


West Hertfordshire Hospitals NHS Trust

24/02/2016
Role of Maternity Services: Maternal
perspective
PMH: two components perinatal and mental

health

Early diagnosis and treatment

Prevention: maternal death and suffering


Women are at higher risk of experiencing new onset
severe mental illness in the early postpartum
period than at any other time in their lives
(Kendell, Chalmers et al. 1987)
Role of Maternity Services: Babys
perspective
Direct:
- premature delivery
- intrauterine growth restriction
- increased infant mortality
- cognitive and neurodevelopmental impairment
(low IQ, special need, violent behaviour)
- early-onset MH problems
Indirect:
- Bonding and attachment
- Social/financial/family
Ref. Prevention in Mind: all babies count (NSPCC)
Role of Maternity Services: Patient
safety
Good communication is critical (MBRRACE 2015)
Role of Maternity Services: broader
perspective
Patient awareness: pregnancy perspective

stigma/fear/denial
Effective MBU services

Effective use of MH services

Training
Who needs MH care during
pregnancy?
Women with known MH conditions
Substance misuse/ socially deprived
High risk situations: eg. Traumatic birth/
pregnancy loss/ NICU admission
Women even without risk factor/s
Just as the body changes in pregnancy, so can the
mind (MBRRACE - UK 2015)
Preventative role of Maternity Services
The patient journey: good practice
Pre-pregnancy care
Screening/ Risk Assessment: Booking visit
a current or past history of full range of mental health
issues- not just depression (MBRRACE 2015)
Triage: Clearly defined Care Pathway
Combined Obs-Psych Antenatal Clinic
Care Planning
Labour
Post-partum care
RCOG (2011): Management of women with mental health issues
during pregnancy and postnatal period
Approach to care: family rather than
patient only
Infrastructure of the PMH Service
The multidisciplinary team
Job description
Communication
MDT meetings
Measuring outcomes
Training
Clinical Governance
Roles and responsibilities
Lead Obstetrician
Specialist Midwife
Neonatologist
Safeguarding MW
Community MW
Psychiatrist/ Counsellor/ Psych Liaison Team
HV
Good practice
Patient information
Contact details: Crisis Team
Co-ordination of care: ensuring on-going
care
Point of contact for the mums (and dads)
Working in partnership with mums
Patients first and foremost
Kind, compassionate care
Listen
Non-judgmental approach
Communication: wordings
Avoid wrong information
Patient Education
Signs to be aware of red flag symptoms
Its OK to tell
Its OK to ask - MBBRACE 2015

Myths surrounding social services:


NOT all mums with PMH are referred to
Social Services
NOT all babies are taken into care
PMH Network
Local/ Regional/ National

Access to specialist expert advice

Should include Addiction Services

Clear pathways of communication

- NICE CG 192 (2014)/ MBRRACE (2015)


Care Planning
Meeting held at 32 weeks of pregnancy

Attended by :
- Woman
- Her Partner/significant other(s)
- All professionals involved in her care (eg. Obstetrician,
Midwife, Health Visitor, Social Worker, Family Support
Worker, Mental health worker(s), Neonatologist,

Particularly helpful in Safeguarding cases

Courtesy: Jo Luckie, London Perinatal Mental Health Network Co-


ordinator
Care Plan
Schizophrenia; Schizoaffective disorder; BPAD

Severe Depression ; Severe Eating disorder; Dual


Diagnosis ; Severe Personality Disorder; Current
Psychotic Depression

MH problems & complex Safeguarding concerns

Psychiatric Admission during pregnancy

Courtesy: Jo Luckie, London Perinatal Mental Health Network Co-


ordinator
Care Plan
Integrated care plan:
Treatment for the mental health problem
Roles and responsibilities for:
- Coordinating the plan
- The schedule of monitoring
providing the interventions and agreeing the outcomes
There is effective sharing of information with all services involved and
with the woman herself
NICE
CG192 (2014)
Care Plan
Arrange the meeting well in advance
Send written invitation to the woman
Cc the invitation to all professionals involved in her care
Allow an hour
Book Interpreter if required
The Care Plan should be recorded in all versions of the
woman's notes (her own records and maternity, primary
care and mental health notes) and a copy given to the
woman and all involved professionals (preferably at the
end of the meeting)

Courtesy: Jo Luckie, London Perinatal Mental Health


Network Co-ordinator
Care Plan
1. Time/ mode of delivery
2. Medication (existing & new)
3. Breastfeeding
4. Baby monitoring
5. Any risks or relapse indicators
6. Psych review on the Ward prior to discharge
and/or extended stay
7. Postnatal follow up
8. Safeguarding Pre-discharge planning
meeting arrangements
Courtesy: Jo Luckie, London Perinatal Mental Health
Network Co-ordinator
Supportive Care
Pregnancy complications
Pregnancy loss (miscarriage/ still birth)
Babies admitted to the NICU
Traumatic birth experience
Tocophobia
Universal Support and Care
Sleep
Feeding
Information and awareness
Peer Support
Increased monitoring
NICE (CG 192, 2014)/SIGN (2012)
Challenges
Communication - Mind the Gap
Continuity of care
Time
Access to care
Ownership
Let us do something..
Training
Antenatal education
Patient information
Local Alliance
Escalate
Safety principles of practice
Always rule out serious medical conditions
Always consider: co-morbidities/complex
social conditions/ substance misuse/domestic
abuse
Always remember: its everyone's business
Always individualise care
Always put mums and their families at the
centre of care
Happy moments
Charlotte Bevan Inquest: Chain of failures led
to Gorge fall death
Further information and
support
On-line training:
http://www.maternalmentalhealth.org.uk/resources/
http://www.beatingbipolar.org/perinataltraining/
http://www.e-lfh.org.uk/programmes/perinatal-mental
-health-for-health-visitors/open-access-sessions/
Recommended resources:
Prevention in Mind: All babies count (NSPCC)
NICE Guideline
SIGN Guideline
Contact details:

Mr Raja Gangopadhyay

Department of Obstetrics and Gynaecology


West Hertfordshire Hospitals NHS Trust
Vicarage Road
Watford
WD18 0HB

Email: r.gangopadhyay@nhs.net
Twitter: @RajaGangopadhyay3
Secretary: 01923217212