/ CHHS15/115

Canberra Hospital and Health Services

Clinical Guideline

Perinatal Emotional Wellbeing

Assessment and Management of Perinatal Mental Health

Contents

Contents

Introduction

Scope

Background

Summary of Perinatal Mental Health (PMH)

Section 1 – Perinatal Mental Health Screening

Who to screen

When to screen

Screening tools

How to use EPDS and PPSA screening tool

Interpret the results/identify risk and protective factors

Section 2 – Management Strategies

Section 3 – Postpartum Psychosis

Background

Management

1.Management of the infant

2.Medication and treatment management options

3.Non-pharmacological treatments: psycho-socio-cultural considerations

4.Managing the risk of suicide

5.Follow up

Implementation

Related Policies, Procedures, Guidelines and Legislation

References

Definition of Terms

Search Terms

Attachments

Attachment 1: Edinburgh Postnatal Depression Scale Scoring Guide

Attachment 2: Edinburgh Postnatal Depression Scale Flow Chart

Attachment 3: Perinatal Mental Health Integrated Care Pathway

Attachment 4: Referral Reference Guide

Introduction

The purpose of this document is to provide early identification, prevention and support to women and their families who are at risk of or have postnatal depression/anxiety or other mood issues. Adjusting to life as a mother is a major life change and for some woman this, or factors associated with the perinatal period, can adversely affect their emotional wellbeing leading to depression, anxiety or other mental health conditions.

Health professionals providing clinical care for women in the perinatal period will routinely screen for emotional wellbeing utilising the following screening tools the Edinburgh Postnatal Depression Scale (EPDS) and the Perinatal PsychoSocial Assessment (PPSA).

The use of evidence-based screening tools will facilitate the identification ofearly signs and symptoms of maternal anxiety and/or depression in the perinatal period. This practice issupported by the Clinical Practice Guidelines[1]

Scope

This document applies to:

  • Nurses, Midwives and Maternal and Child Health Nurse (MACH) who are working within their scope of practice (Refer to Midwifery and Nursing Continuing Competence Policy)
  • Medical staff working within their scope of practice
  • Student working under direct supervision
  • Allied health working within their scope of practice

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Background

Perinatal emotional wellbeing can present in a variety of forms ranging from mild to severe and include:

Baby Blues

  • Usually occurs in the first week after giving birth, feeling emotionally labile which peaks around the 3rd to 5th day and usually disappears without treatment
  • 25% to 80% of woman experience the baby blues following birth
  • The baby blues are characterised by mild mood swings and are usually transient in nature. These symptons can manifest as, irritability, periods of crying, exhaustion, feeling overwhelmed and/or experiencing sleep disturbance

However, if these feelings continue for more than 2 weeks, and interfere with daily life, this could mean that the woman may be developing postnatal depression and/or anxiety.

Perinatal Anxiety

  • Feeling uncertain in pregnancy and worrying about adapting to parenthood are normal
  • An anxiety disorder may be diagnosed if these feelings interfere with everyday functioning, activities and, the ability to enjoy pregnancy and parenthood
  • There are several types of anxiety disorders including Generalized Anxiety Disorder (GAD), Posttraumatic Stress Disorder (PTSD), Tocophobia (fear of birth) and Obsessive-Compulsive Disorder (OCD)
  • Maternal symptoms can include:
  • overwhelming worry
  • panic or fear that is difficult to control
  • feeling irritable, restless or on edge
  • unrealistic fears
  • muscle tension, tightness in the chest, breathlessness

Antenatal Depression

  • 6-16% of women meet the diagnostic criteria for major depression during their pregnancy
  • Common experiences of pregnancy can mimic those of depression or anxiety, such as, changes in eating and sleeping patterns and loss of libido and energy
  • Some medical conditions occurring in pregnancy also need to be consideredas they can also mimic a depressive illness, such as anaemia, gestational diabetes and thyroid dysfunction

Postnatal Depression(PND)

  • PND affects 5-20% of women occurring at any time in the first year postpartum
  • Correct diagnosis and appropriate interventions can be delayed as women frequently present to health care workers with other presenting issues, such as, relationship issues, sleep disturbance or over-concerns for their baby rather than low mood
  • At times fatigue, distress and normal adjustment issues are misdiagnosed as depression

Postpartum Psychosis (refer to Section 2 page 8 for more detailed information including management strategies).

  • It is a rare severe mental illness that occurs in 1 to 2 mothers in every 1000 after they give birth
  • Onset is within hours or up to weeks following birth
  • It is characterised by a significant change/shift in ‘usual’ behaviour. Signs and symptoms can include:
  • euphoria
  • decreased sleep requirement
  • rapid and pressured speech
  • irritability
  • paranoia
  • delusions
  • severe depression with delusions and auditory hallucinations

Alert: This is a psychiatric emergency. You need to refer the woman to psychiatric/psychological services immediately.

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Summary of Perinatal Mental Health (PMH)

Factors associated with perinatal mental health conditions

  • personal or family history of mental health problem/s
  • current personal mental health disorder/s
  • current alcohol and/or drug problems
  • current or past history of abuse (e.g. Physical, sexual, psychological)
  • negative or stressful life events (e.g. previous loss of baby, stillbirth, loss of job, relationship issues, moving house)

Outlined below is an overall summary of Perinatal Mental Health conditions and management plan.

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Section 1 –Perinatal Mental Health Screening

Who to screen

Screening for both the Perinatal PsychoSocial Assessment (PPSA) and the Edinburgh Postnatal Depression Scale (EPDS) should be offered to all antenatal and postnatal women at the first contact with a health professional either at a home or clinic visit.

When to screen

Health professionalswill use the following screening schedule to apply the screening tools to help indentify mother and families vulnerability factors that may influence maternal emotional wellbeing:

  1. Edinburgh Postnatal Depression Scale (EPDS)

The EPDS screening tool is administered routinely to mothers once in pregnancy at pre-admission clinic and at their 6-8 week postnatal check or when appropriate. The EPDS scoringtemplate is used to score the tool.Repeat EPDS can be conducted at any time during pregnancy, postnatal period or when clinically indicated.

  1. Perinatal PsychoSocial Assessments (PPSA)

The PPSA screening tool is administered routinely to all mothersonce in pregnancy and postnatally at the first initial contact either at home or clinic visit.

Note: If time is insufficient to completion screening at the first visit then screening assessments can be offered at the next visit.

Screening tools

Screening Tool / Resources/ Tools
Edinburgh Postnatal Depression Scale (EPDS) /
  • Edinburgh Postnatal Depression Scale
  • EPDS Scoring Template (Attachment 1)
  • EPDS Management Response Flowchart (Attachment 2)
  • Resources link

Perinatal Psychosocial Assessments (PPSA) /
  • Perinatal PsychoSocial Assessment(PPSA)screening tool
  • Perinatal MentalHealth Integrated Care Pathway(Attachment 3)
  • Referral Reference Guide (Attachment 4)

How to use EPDS and PPSA screening tool

Complete the e-learning package on capabiliti–here

  1. Administering the EPDS

Introduce the EPDS screening tool using supportive and reflective listening skills and open communication strategies such as, “as you are about to or have recently had a baby, how you are feeling is important”.

Avoid saying, ‘I need your permission to administer the EPDS’ or ‘You don’t have to do this if you don’t want to’. These statements may create a negative or fearful reaction in the women.

Note: Remember that the EPDS asks about their mood in the past seven days.

Important considerations:

  1. Have the correct form/s ready
  2. The EPDS screening tool is to be completed in the presence of the health professional
  3. Briefly explain the EPDS, providing clear instruction about the screening tool to the woman, answer any questions they have making no assumptions about their literacy or ability to complete the form on their own
  4. If the woman wants you to go through the EPDS with them, work through the 10 questions. Do not change or reword the questions
  5. Score the questionnaire using the EPDS scoring template
  6. In discussingand communicating the outcome of the tool try to keep any discussion until after the woman has finished the screening tool.
  7. Inform the woman of the score and discuss any issues the screening tool has highlighted for the woman. In discussion with the mother suggest that the results indicate that they may be experiencing some depressive/anxious symptoms and further investigation of these symptoms may be of benefit.
  8. The woman’s overall score of the EPDS may be below the cut-off point indicative of significant difficulties, but some issues may still be important to the respondent.

ALERT: EPDS QUESTION 10
If a woman scores 1, 2 or 3 the health professional must gather further information in order to ensure the woman’s safety. This information should include whether she has a current plan of self-harm, she can ensure her safety in the immediate future, she has attempted self-harm before or if she has the resources to carry out the plan.
  1. Administering the Perinatal PsychoSocial Assessments (PPSA)

Follow the same procedure as for the EPDS, including introducing the PPSA screening tool to the woman.Usesupportive and reflective listening skills and open communication strategies such as, “this is a routine questionnaire that helps us look at what may impact you as a new parent ensuring the best outcomes are achieved for you, your baby and family”.

  • The PPSA screening tool is given to the woman to completein the presence of the health professional with explanatory comments and support as required
  • The PPSA provides a good way to start a conversation focusing on the key issues concerning the woman. This allows the women the opportunity to recognise her readiness to seek further support

Interpret the results/identify risk and protective factors

The health professional is toutilise their clinical judgement concerning additional support and/or referral, in conjunction with the woman. The referral is to includeresponses to the PPSA, as appropriate, the score derived from the EPDS, as well as other medical or social relevant history that may impact the women’s emotional wellbeing. This promotes continuity of care as women may see a number of health professionals during pregnancy and early parenthood.

NOTE: It is important to remember the PPSA and the EPDS are screening tools and not used for diagnosis. They will help identify vulnerability factors for women at risk of perinatal mental health issues.

Section 2 – Management Strategies

The score obtained from screening using the EPDS or PPSA will guide which management strategies is most suitable. For example:

  • ‘Watchful waiting’: a woman with mild distress, anxiety or depression may need extra practical support regarding normalizing adjusting to parenting.
  • Utilize the support documents for current best practice referral pathway ie:
  • EPDS Management Response Flowchart
  • Perinatal Mental Health Integrated Care Pathways
  • Referral Reference Guide for referral options
  • Provide the woman with information regarding possible support services e. g. GP, Post and Ante Natal Depression Support and Information (PANDSI), New Parent Groups, Social Worker, Access to Allied Psychological Services(ATAPS) program – Medicare Local or private psychologists
  • Refer the woman to the beyondblue booklet ‘Emotional Health During Pregnancy and Early Parenthood’
  • If referral is required ensure the woman is aware of the service being referred to and has given her consent for referral
  • Document consent for referral in the woman’s relevant clinical notes.

For further professional support and guidance speak to your CMC/CNC

Further comprehensive assessment and management plans may be required by General Practitioners or mental health professionals.

URGENT referral:

Mental Health Crisis and Assessment Team (CATT) - 1800 629 354

NON-URGENT referral:

Fax or email Perinatal Mental Health Referral Form[2]to Perinatal Mental Health Consultation Service ph: 6205 2627email:

and/or refer clients to their General Practitioner.

Section 3 – Postpartum Psychosis

Background

Postpartum psychosis is indicated by changes in a woman's usual behaviour. These changes usually start within 48 hours to two weeks after giving birth, but may develop up to 12 weeks after the birth. They can be extremely distressing for both the woman and her family.

Early changes in usual behaviour include:

  • finding it hard to sleep
  • feeling full of energy or restless and irritable
  • feeling strong, powerful, unbeatable
  • having strange beliefs (e.g. people are trying to harm the baby)
  • seeing, hearing, smelling, tasting or feeling something that doesn’t exist

This may be followed by a combination of manic or depressive symptoms including:

  • manic symptoms (e.g. high energy, hearing voices or seeing things that aren't there (hallucinations), believing things that are not based on reality (delusions), talking quickly)
  • depressed symptoms (e.g. low energy, not sleeping or eating, having thoughts of harming herself or the baby, feeling hopeless or helpless as a mother).

Note: The hallucinations arenot just associated with the manic symptoms (can be manic without psychosis and can be psychotic/hallucinating while depressed)*

The woman may seem confused and forgetful,she may experience rapid fluctuation in mood and have difficulty concentrating. Women who experience the symptoms of postpartum psychosis can become very confused and disconnected from reality, thusmay be at risk of harming themselves or others (including their baby).

Management

Urgent mental health assessment, ensuring an appropriate understanding of and attention to safety issues for mother and infant but also others in the immediate environment, and level of symptoms is required urgently.

Admission to a specialized psychiatric facility that has some capacity for rooming in for babies less than 6months, such as at Calvary Hospital is generally appropriate, however at times mothers may be treated within the community. Wherever safety considerations permit,it is very important to tryto keep the mother and infant together to help establish good attachment relationships and breastfeeding.. Some medications may be contraindicated in breastfeeding, thus lactation support may be considered in conjunction with the medical team.

For an inpatient the O&G Registrar is required to contact the Psychiatric Services Register from the Psychiatric Consultation Liaison ph: 6244 3204.

For the communitycontact the Crisis Assessment Team (CATT (SOP: Crisis Assessment and Treatment Team – Mental Health Services Triage) also GP or Perinatal Mental Health Consultation Services (PMHCS.)

Safety/risk considerations for mother and infant must be considered as some psychotic illnesses at this time are florid, with delusionsand hallucinations producing unpredictable behaviours

The highest risk time for occurrence/recurrence of a postpartum psychosis is in the first 28 days postpartum.

The woman’s health care team is recommended to involve:

  • General Practitioner
  • Obstetrician
  • Midwife- continuity of care
  • Perinatal mental health, or preferred psychiatrist
  • Maternal and Child Health nurse (MACH)
  • Psychiatric Consultation Liaison (while an inpatient)
  • Social Worker

1.Management of the infant

While the mother remains acutely unwell, she may find complete care of her infant very difficult as her ability to concentrate may make it difficult for her to complete tasks such as feeding her baby. Continuing to breastfeed may be manageable but can sometimes be difficult and consultation with a lactation consultant and with her treating psychiatric team regarding medicationis advisable.

Keeping the infant separate, or observed at all times, when with their mother, may be necessary until safety can be assured.

2.Medication and treatment management options

Preventative measures, including anti depressants, mood stabilizers, antipsychotics and benzodiazepines for sedation can be introduced immediately if labour is concluded. Some women may prefer to take the (unknown) risks of using medication in late pregnancy. Type of medication and doses will vary depending on the woman’s obstetric presentation, previous history, responsiveness to treatment and risk of relapse and women should be advised to seek the guidance of a medical professional prior to making any changes to their medication.

3.Non-pharmacological treatments: psycho-socio-cultural considerations

Good management of all psychotic illnesses in pregnancy, and ideally pre-pregnancy planning if the woman has a history of PND or bipolar, and postpartum will include:

  • Psycho-education, with provision of both written and verbal information to the woman and her immediate family
  • Counselling support
  • Practical support for other children in the family
  • Information providing a low stimulus environment through restricted visiting, single room accommodation, accommodation provided for partner or significant other to support in care of woman and newborn baby
  • Extended hospital stay if indicated is recommended.
  • Comprehensive discharge planning across a number of agencies including mental health and MACH services
  • Specific Cognitive Behavioural Therapyintervention once the acute symptoms have subsided

All management plans should be undertaken in consultation with the woman or significant other and they are provided with all the relevant contact support numbers.

Safety/risk considerations for mother and infant can be paramount initially as some psychotic illnesses at this time are florid, with delusions producing unpredictable behaviours and Care and Protection involvement should be considered.

4.Managing the risk of suicide

Evidence has shown that the first weeks following discharge from psychiatric in-patient care is a most critical time in terms of suicide risk, particularly for people initially admitted following a suicide attempt; suicidal ideation; and/or depression. The increased contact that health professionals have with clients during this time provides an opportunity for closer monitoring of suicidality.