Perinatal Emotional Wellbeing - | Health



Canberra Hospital and Health ServicesClinical GuidelinePerinatal Emotional WellbeingAssessment and Management of Perinatal Mental HealthContents TOC \o "1-3" \h \z \u Contents PAGEREF _Toc418170969 \h 1Introduction PAGEREF _Toc418170970 \h 3Scope PAGEREF _Toc418170971 \h 3Background PAGEREF _Toc418170972 \h 3Summary of Perinatal Mental Health (PMH) PAGEREF _Toc418170973 \h 5Section 1 – Perinatal Mental Health Screening PAGEREF _Toc418170974 \h 6Who to screen PAGEREF _Toc418170975 \h 6When to screen PAGEREF _Toc418170976 \h 6Screening tools PAGEREF _Toc418170977 \h 7How to use EPDS and PPSA screening tool PAGEREF _Toc418170978 \h 7Interpret the results/identify risk and protective factors PAGEREF _Toc418170979 \h 8Section 2 – Management Strategies PAGEREF _Toc418170980 \h 9Section 3 – Postpartum Psychosis PAGEREF _Toc418170981 \h 9Background PAGEREF _Toc418170982 \h 9Management PAGEREF _Toc418170983 \h 101.Management of the infant PAGEREF _Toc418170984 \h 112.Medication and treatment management options PAGEREF _Toc418170985 \h 113.Non-pharmacological treatments: psycho-socio-cultural considerations PAGEREF _Toc418170986 \h 114.Managing the risk of suicide PAGEREF _Toc418170987 \h 125.Follow up PAGEREF _Toc418170988 \h 12Implementation PAGEREF _Toc418170989 \h 13Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc418170990 \h 13References PAGEREF _Toc418170991 \h 14Definition of Terms PAGEREF _Toc418170992 \h 15Search Terms PAGEREF _Toc418170993 \h 15Attachments PAGEREF _Toc418170994 \h 15Attachment 1: Edinburgh Postnatal Depression Scale Scoring Guide PAGEREF _Toc418170995 \h 16Attachment 2: Edinburgh Postnatal Depression Scale Flow Chart PAGEREF _Toc418170996 \h 18Attachment 3: Perinatal Mental Health Integrated Care Pathway PAGEREF _Toc418170997 \h 19Attachment 4: Referral Reference Guide PAGEREF _Toc418170998 \h 21IntroductionThe 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 of early signs and symptoms of maternal anxiety and/or depression in the perinatal period. This practice is supported by the Clinical Practice Guidelines ScopeThis 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 supervisionAllied health working within their scope of practiceBack to Table of ContentsBackgroundPerinatal emotional wellbeing can present in a variety of forms ranging from mild to severe and include:Baby BluesUsually occurs in the first week after giving birth, feeling emotionally labile which peaks around the 3rd to 5th day and usually disappears without treatment25% to 80% of woman experience the baby blues following birthThe 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 disturbanceHowever, 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 AnxietyFeeling uncertain in pregnancy and worrying about adapting to parenthood are normalAn anxiety disorder may be diagnosed if these feelings interfere with everyday functioning, activities and, the ability to enjoy pregnancy and parenthoodThere 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 fearsmuscle tension, tightness in the chest, breathlessness ?Antenatal Depression 6-16% of women meet the diagnostic criteria for major depression during their pregnancyCommon 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 considered as they can also mimic a depressive illness, such as anaemia, gestational diabetes and thyroid dysfunctionPostnatal Depression (PND)PND affects 5-20% of women occurring at any time in the first year postpartumCorrect 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 moodAt 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 birthOnset is within hours or up to weeks following birthIt is characterised by a significant change/shift in ‘usual’ behaviour. Signs and symptoms can include: euphoriadecreased sleep requirementrapid and pressured speech irritabilityparanoiadelusionssevere depression with delusions and auditory hallucinationsAlert: This is a psychiatric emergency. You need to refer the woman to psychiatric/psychological services immediately.Back to Table of ContentsSummary of Perinatal Mental Health (PMH)Factors associated with perinatal mental health conditions personal or family history of mental health problem/scurrent personal mental health disorder/scurrent alcohol and/or drug problemscurrent 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.Back to Table of ContentsSection 1 – Perinatal Mental Health Screening Who to screenScreening 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 professionals will use the following screening schedule to apply the screening tools to help indentify mother and families vulnerability factors that may influence maternal emotional wellbeing: 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 scoring template is used to score the tool. Repeat EPDS can be conducted at any time during pregnancy, postnatal period or when clinically indicated.Perinatal PsychoSocial Assessments (PPSA)The PPSA screening tool is administered routinely to all mothers once 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 toolsScreening Tool Resources/ ToolsEdinburgh Postnatal Depression Scale (EPDS)Edinburgh Postnatal Depression ScaleEPDS Scoring Template (Attachment 1)EPDS Management Response Flowchart (Attachment 2)Resources link .auPerinatal Psychosocial Assessments (PPSA)Perinatal PsychoSocial Assessment (PPSA) screening toolPerinatal Mental Health 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 – hereAdministering the EPDSIntroduce 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: Have the correct form/s readyThe EPDS screening tool is to be completed in the presence of the health professionalBriefly 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 ownIf the woman wants you to go through the EPDS with them, work through the 10 questions. Do not change or reword the questionsScore the questionnaire using the EPDS scoring templateIn discussing and communicating the outcome of the tool try to keep any discussion until after the woman has finished the screening rm 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. 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 10If 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.Administering the Perinatal PsychoSocial Assessments (PPSA)Follow the same procedure as for the EPDS, including introducing the PPSA screening tool to the woman. Use supportive 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 complete in the presence of the health professional with explanatory comments and support as requiredThe 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 factorsThe health professional is to utilise their clinical judgement concerning additional support and/or referral, in conjunction with the woman. The referral is to include responses 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 optionsProvide 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 referralDocument 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 354NON-URGENT referral: Fax or email Perinatal Mental Health Referral Form to Perinatal Mental Health Consultation Service ph: 6205 2627 email: perinatalmhcs@.au and/or refer clients to their General Practitioner.Section 3 – Postpartum Psychosis BackgroundPostpartum 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 sleepfeeling full of energy or restless and irritablefeeling strong, powerful, unbeatablehaving strange beliefs (e.g. people are trying to harm the baby)seeing, hearing, smelling, tasting or feeling something that doesn’t existThis 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 are not 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, thus may be at risk of harming themselves or others (including their baby). ManagementUrgent 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 try to 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 community contact 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 delusions and 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 PractitionerObstetricianMidwife- continuity of carePerinatal mental health, or preferred psychiatristMaternal and Child Health nurse (MACH)Psychiatric Consultation Liaison (while an inpatient)Social WorkerManagement 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 medication is advisable.Keeping the infant separate, or observed at all times, when with their mother, may be necessary until safety can be assured. Medication and treatment management optionsPreventative 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. 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 babyExtended hospital stay if indicated is prehensive discharge planning across a number of agencies including mental health and MACH services Specific Cognitive Behavioural Therapy intervention once the acute symptoms have subsidedAll 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. Managing the risk of suicideEvidence 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. Risk factors for suicide include:A personal or family history of suicide or self harmPlan, intent and access to meansPrevious suicide attemptHopelessness about the futureRelationship issuesDrug or alcohol abuse or misuseGamblingTrouble with family or friendsFinancial stressTrouble with the lawInability to cope with the current stresses, crisis or lossPoor physical healthUntreated mental illness or recent discharge from an inpatient psychiatric admissionCurrent or previous experience of domestic violence, family violence or abuseThe presence of children or a pregnancy is not necessarily a protective factor.Follow up Long term mental health/parenting support follow up is likely to be appropriate and referral to the most relevant adult mental health community team should be facilitated. A multidisciplinary approach for long term care is generally necessary. This could include family and professional support from a wide range of practitioners. Eg: Maternal & Child Health Child and Family Health CentresGeneral PractitionerPerinatal Mental Health Consultation ServicePsychologistSocial workerIMPACT programPANDSI Implementation Implemented professional development education sessionsIncorporated with the PMH e-learning education package for ACT HealthPresented at team, Maternity Leaders, MACH Leaders MeetingTabled at Senior Division Women, Youth and Children (WYC) Management MeetingsTier 3 WYC Divisional Quality and Safety MeetingDivisional Tier 3 Risk Meeting Policy Register ACT HealthBack to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationLegislationMental Health Act 2015 Practice GuidelinesDepression and related disorder anxiety, bipolar and puerperal psychosis- in the perinatal period. A guideline for primary health care professionals February 2011, beyondblueClinical Practice GuidelinesPoliciesACT Mental Health, Justice Health and Alcohol and Drug Services Policy: MHACT Triage Category of Response Mental Health, Justice Health and Alcohol and Drug Services Policy: Suicidal Behaviour: Treatment and Care of Consumers with Suicidal Behaviour Mental Health, Justice Health and Alcohol and Drug Services: Clinical Processes and Documentation Resource Package- 3rd Edition Mental Health Justice Health Alcohol and Drug Services (MHJHADS), Standard Operating Procedure: Crisis Assessment and Treatment Team – Mental Health Services TriageRelated DocumentsEdinburgh Postnatal Depression (EPDS) Screening ToolEPDS Scoring templateMACH Nurses Management Response Flow ChartPerinatal Mental Health Integrated Care PathwayReference referral guide Perinatal PsychoSocial Assessment (PPSA)Perinatal Mental Health Referral FormNational Perinatal Depression Initiative (NPDI) Steering Committee includes:Perinatal Mental Health Consultation ServiceGP liaisonMACH Managers and representativeMaternity Manager and representativeMedicare localCommunity and Hospital Social workerQE11Calvary Maternity Services Calvary John James Maternity Unit NPDI Project OfficerBack to Table of ContentsReferencesClinical Practice Guidelines Depression and related disorder anxiety, bipolar and puerperal psychosis- in the perinatal period. A guideline for primary health care professionals February 2011, beyondblueCentre for Mental Health Research. (2001). Mental Health First Aid, A Participants Manual. Australian National University, Canberra.Cox, J.L., Holden, J.M. & Sagosvsky, R.(1987). Detection of postnatal depression development of the 10item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786Hickey, A.R., Boyce, P.M., Ellwood, D., Morris - Yates, A. (1997). Early Discharge and Risk for Postnatal Depression. MJA, 167: 244-247.NHMRC. (1999). Informational Paper Postnatal Depression - A systematic review of published scientific literature to 1999. Pp 82 - 86. National Health and Medical Research Council. Commonwealth of Australia.Back to Table of ContentsDefinition of Terms Perinatal period - the period covering pregnancy and the following year. (Clinical Practice Guidelines: beyondblue 2011)Psychosocial – refers to the various psychological and social factors that may have an impact on the health and wellbeing in the perinatal period. (Clinical Practice Guidelines; beyondblue 2011)Health professional – refers to nurses, midwives, MACH nurses, medical staff and allied health professionalsSearch Terms Perinatal Mental HealthEdinburghPostnatalDepressionAnxietyBabybluesPsychosisScreening toolsPsychosocial AntenatalbeyondblueAttachments Attachment 1: Edinburgh Postnatal Depression Scale Scoring GuideAttachment 1: Edinburgh Postnatal Depression Scale Flow ChartAttachment 3: Perinatal Mental Health Integrated Care PathwayAttachment 4: Referral Reference GuideDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC ChairAttachment 1: Edinburgh Postnatal Depression Scale Scoring GuideAttachment 2: Edinburgh Postnatal Depression Scale Flow ChartAttachment 3: Perinatal Mental Health Integrated Care PathwayAttachment 4: Referral Reference Guide ................
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