1. 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

2. 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)

3. Role of Maternity Services: Baby’s 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)

4. Role of Maternity Services: Patient safety Good communication is critical (MBRRACE 2015) Primary care MH Services Maternity

5. Role of Maternity Services: broader perspective Patient awareness: pregnancy perspective – stigma/fear/denial Effective MBU services Effective use of MH services Training

6. 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)

7. Preventative role of Maternity Services

8. Kendal et al 1987

9. 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

10. Pre - pregnanc y Booking Antenata l Labour Early postpart um Late postpart um

11. Approach to care: ‘family’ rather than ‘patient only’

12. Infrastructure of the PMH Service The multidisciplinary team Job description Communication MDT meetings Measuring outcomes Training Clinical Governance PMH Servic e Team Pathway / Guidelin e Commun i-cation MDT meeting s Audit/ Surveys/ Clinical Governa nce Training

13. Roles and responsibilities Lead Obstetrician Specialist Midwife Neonatologist Safeguarding MW Community MW Psychiatrist/ Counsellor/ Psych Liaison Team HV

14. 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

15. Patients first and foremost Kind, compassionate care Listen Non-judgmental approach Communication: wordings Avoid wrong information

16. Patient Education Signs to be aware of – red flag symptoms It’s OK to tell It’s 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

17. PMH Network Local/ Regional/ National Access to specialist expert advice Should include Addiction Services Clear pathways of communication - NICE CG 192 (2014)/ MBRRACE (2015)

18. 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

19. 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

20. 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)

21. 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

22. 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

23. Supportive Care Pregnancy complications Pregnancy loss (miscarriage/ still birth) Babies admitted to the NICU Traumatic birth experience Tocophobia

24. Universal Support and Care Sleep Feeding Information and awareness Peer Support Increased monitoring NICE (CG 192, 2014)/SIGN (2012)

25. Challenges Communication - Mind the Gap Continuity of care Time Access to care Ownership

26. Let us do something….. Training Antenatal education Patient information Local Alliance Escalate

27. Safety principles of practice Always rule out serious medical conditions Always consider: co-morbidities/complex social conditions/ substance misuse/domestic abuse Always remember: it’s ‘everyone's business’ Always individualise care Always put mums and their families at the centre of care

28. Happy moments…

29. Charlotte Bevan Inquest: ‘Chain of failures’ led to Gorge fall death…

30. 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/ 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

31. Contact details: Mr Raja Gangopadhyay Department of Obstetrics and Gynaecology West Hertfordshire Hospitals NHS Trust Vicarage Road Watford WD18 0HB Email: r.gangopadhyay@nhs.netr.gangopadhyay@nhs.net Twitter: @RajaGangopadhyay3 Secretary: 01923217212