perinatal mental health guideline (gl1131)...perinatal mental health guideline (gl1131) june 2019...

Author: L Perkins Date: June 2019

Job Title: Consultant Midwife Review Date: February 2021

Policy Lead: Group Director Urgent Care Version: V1.1 June 2019 V1.0 ratified 1/2/19

Location: Policy hub/ Clinical/ Maternity/ Social Issues & Public Health/ GL1131

This document is valid only on last printed 26/06/2019 12:40:00 of 23

Perinatal Mental Health Guideline (GL1131)

Approval and Authorisation

Approved by Job Title or Chair of Committee

Date

Maternity & Children’s Services Clinical Governance Committee

Chair, Maternity Clinical Governance Committee

1st February 2019

Change History

Version Date Author Reason

1.0 Jan 2019 L Perkins (Consultant MW)

Full review and re-write of Emotional Wellbeing protocol

1.1 June 2019 L Perkins (Consultant MW)

Live change to update pg 19 Appendix 3 Inclusion/Exclusion criteria






Perinatal mental health guideline (GL1131) June 2019

Contents 1.0 Purpose ......................................................................................................... 3

2.0 Function ......................................................................................................... 3

3.0 Protocol content ........................................................................................... 3

4.0 In the Antenatal Period ................................................................................. 3

5.0 Referral .......................................................................................................... 5

5.1 A quick look guide to mental health services for referral or self-referral 5

5.2 Consultant Obstetrician Referral ................................................................. 8

6.0 Medication ..................................................................................................... 9

6.1 Reviewing Medication on Admission ........................................................ 10

6.2 Psychotropic Medication and Intrapartum Care ...................................... 10

6.3 Psychotropic Medication and Postnatal Care .......................................... 11

7.0 Mental Health Crises................................................................................... 12

7.1 Recognising Mental Health Crises ............................................................ 12

7.2 Initial Management of Mental Health Crises on Maternity Units ............. 13

7.2.1 Preventing patients at risk from leaving ................................................... 13

7.2.2 Medication for acute behavioural disturbance ......................................... 13

8.0 References .................................................................................................. 15

9.0 Dissemination and circulation ................................................................... 15

10.0 NICE Quality Standards - Antenatal and postnatal mental health QS115 .. ...................................................................................................................... 15

Appendix 1 - Where to Refer in Mental Health .................................................... 16

Appendix 2 Referral to the Berkshire Maternity Mental health clinic ................ 17

APPENDIX 3 - BERKSHIRE SPECIALIST PERINATAL MENTAL HEALTH SERVICE – INCLUSION / EXCLUSION CRITERIA ............................................... 19

APPENDIX 4 - Referral pathways for Women with Birth Trauma or Significant Fear of Birth ........................................................................................................... 21

APPENDIX 5 – CHALLENGING BEHAVIOUR RISK ASSESSMENT TOOL ........ 22







1.0 Purpose

To provide guidance, underpinned by evidence based practice, and to facilitate collaboration between members of the Obstetric and Mental Health Teams to enable seamless effective care for women with emotional wellbeing problems 2.0 Function

This guidance sets out the processes for and referral of women at risk of, or suffering from, emotional wellbeing disorders in the antenatal, intrapartum and postnatal period. 3.0 Protocol content

Mental health problems during pregnancy and the postnatal period are common and

span from mild problems with low mood and anxiety to severe depression and

psychosis. All pregnant women are potentially at risk of developing these problems

and women with pre-existing mental health problems are particularly at risk. The

potential associated risks can be significant and wide-ranging. On an individual level

they include the risks of self-harm, self-neglect, or attempted suicide. There are also

potential risks to others including the antenatal and postnatal development of the

child, potential physical harm to the child, and effects on the emotional wellbeing of

child and wider family. Early identification and proactive treatment leads to better

outcomes.

Cases of new onset psychosis in the postnatal period occur in women with no

history of mental illness at a rate of approximately 2 per 1000 births. In addition, a

severe depressive illness will occur at a rate of around 30 per 1000 births. Mild or

moderate depression and anxiety disorders together around affect 1 in 10 women

postnatally. Problems with distress or adjustment are also common. In total 15-20%

of women will experience some degree of mental health problem in the postnatal

period.

For women with pre-existing mental health problems, pregnancy and the postnatal

period bring an increased risk of relapse or exacerbation of the problems. This is

particularly true of the first week following delivery, particularly for those with a

history of psychotic illness (Bipolar disorder, schizophrenia, schizoaffective disorder,

psychotic depression).

4.0 In the Antenatal Period

All women should be given an appointment to be seen by a midwife, usually between 8-11 weeks of pregnancy where a detailed history should be taken, to include medical, obstetric, emotional and social factors.







It is the midwives responsibility to check the woman’s mental health history.

During this antenatal history taking, all women should have an assessment of their mental health undertaken by ascertaining the following:

Previous history or current presentation of major mental health disorders particularly bi-polar disorder, schizophrenia, previous psychotic illness or severe post natal depression, anxiety depression and phobias (i.e. needle) and Post Traumatic Stress Disorder.

Family history of bipolar disorder or psychosis (including, but not limited to, puerperal psychosis)

Current prescribed medication for any of the above or for any other mental illness.

Previous treatment by mental health services, including IAPT (e.g. Talking Therapies) or the Community Mental Health Team.

Any history of domestic violence, sexual abuse, female genital mutilation, assault, use of illegal drugs, self-harms or lack of social support.

Significant Fear of Birth (e.g. tocophobia) or previous traumatic birth

At the booking visit the women should be asked the ‘Whooley’ questions, as part of a general discussion about her mental health and wellbeing. .

During the past month, have you often been bothered by feeling down, depressed or hopeless?

During the past month, have you often been bothered by having little interest or pleasure in doing things?

A third question should be considered if the women’s answer is ‘yes’ to either of the initial questions

Is this something you feel you need or want help with?

The Whooley Questions can be used as part of a meaningful conversation about the woman’s mental health and wellbeing which should happen at each included at each antenatal and postnatal contact, and the mental health and wellbeing assessment documented in the woman’s handheld maternity notes.

At any point of contact the woman may disclose a past history or recent onset of symptoms and this should be managed following the referral process.







5.0 Referral

5.1 A quick look guide to mental health services for referral or self-referral

Se

veri

ty o

f m

en

tal

illn

es

s

Where is the woman?

Community based services e.g. Antenatal clinic

In-patient services e.g. Wards/DS/Rushey

Scheduled care

Mild-moderate mental illness e.g. mild-moderate anxiety/depression

GP And/or Talking Therapies

Plus: 3

rd sector

support e.g. PANDAS support group

Usual midwifery care, with additional focus on woman’s mental wellbeing, and clear handover to HV

GP/Talking Therapies/ HV Liaison/ Midwifery support

Moderate-severe mental illness e.g. women requiring secondary level services who are vulnerable due to their mental health and at risk of deterioration

Berkshire Perinatal Mental Health Service via CPE

OR: Existing Community Mental Health team (CMHT)

Psychological Medicines Services (PMS)

Poppy Team Midwifery care Specialist perinatal mental health support e.g. Berkshire Perinatal service or CMHT Consultant Obstetrician Care via the Berkshire Maternity Mental Health Clinic at RBH, with joint appointments with a perinatal clinician.

Urgent Crisis Team Samaritans Psychological Medicines Services

Emergency Call 999 Security PMS







The local 3rd sector organisations may be of use to some women or for advice for professionals:

Organisation Purpose Contact details

Reading Lifeline

Reading Lifeline offers counselling and support for those affected by infertility, miscarriage, termination, stillbirth or neonatal death.

https://readinglifeline.co.uk/

Karma Nirvana Support for victims of honour-based violence or forced marriage. Support for victims, those at risk and professionals.

UK Helpline: 0800 5999 247 Monday - Friday: 9am - 5pm. Email: [email protected]

If women are in immediate danger, they should call 999.

Launchpad Housing support for the homeless or the insecurely housed

www.launchpadreading.org.uk

Drop-in is open Mon/Weds/Fri from 10am to 2pm at The Stables, Merchants Place, Reading RG1 1DT (down the alley on Friar St at the side of Nando’s). Or call 0118 929 1111 or email [email protected] Mon - Fri 9am to 5pm.

Alana House Reading based centre, serving women throughout Reading and West Berks, with complex needs. Supporting women with:

Accommodation Attitudes, thinking and

behaviour Children, families and

relationships Domestic abuse,

violence and rape Drugs and alcohol Education, training and

employment Finance, benefits and

debt Health and well-being Sex working/prostitution

Call 0118 9217640

Email [email protected]

Drop-in sessions – see Contact us for a map and What's on page for the times and days of for drop-ins

- Fill in a Referral form and they will make contact to make a private appointment with one of our support workers

Trust House Reading

Support centre for those affected by rape or sexual abuse, either recently or in the past.

www.trusthousereading.org

Call 0118 958 4033

For emotional support, information and advice on accessing other services, email [email protected]

Rose Clinic A specialist monthly drop in clinic for women affected by female genital mutilation (FGM), where they can receive

Drop-in held on the1st Friday of every month, 9:30am-12:30pm, at Oxford Road Community Centre (old Battle Hospital site).

mailto:[email protected]

http://www.launchpadreading.org.uk/



https://www.pactcharity.org/community-projects/alana-house/contact

https://www.pactcharity.org/community-projects/alana-house/what%E2%80%99s

https://www.pactcharity.org/community-projects/alana-house/referrals








specialist advice from a doctor and peer support from women in their community.

Contact Victoria on 07903675676.

RAHAB The Rahab Project is dedicated to identifying and supporting those who are or have been affected by any form of exploitation through raising awareness, offering support and empowerment, including but not limited to - o Sexual Exploitation o Modern Slavery o Financial Exploitation o Criminal Exploitation

[email protected]

0118 956 7000

Helpline

07443 456598 or 07825 331262

Facebook

www.facebook.com/rahab.reading

Website

www.themustardtree.org/rahab

Homestart Free and face-to-face support to local families who are under stress, help prevent family crisis and help parents grow in confidence, strengthen their relationships with their children and widen their links with the local community, which helps give their children the best possible start in life.

www.home-start-reading.org.uk 0118 956 0050

Recovery College – (West Berkshire & Reading)

Delivers free mental health courses to any adults living in West Berkshire who experience mental health challenges. The courses are designed to increase knowledge and understanding, and to improve confidence in self-managing personal mental health and wellbeing. Courses are led by Peer trainers who have personal experience of mental health challenges and mental health professionals from Berkshire Healthcare NHS Trust.

http://www.recoveryinmind2016.com [email protected]


https://www.facebook.com/rahab.reading

http://www.themustardtree.org/rahab

http://www.home-start-reading.org.uk/

http://www.recoveryinmind2016.com/







National organisations

Organisation Purpose Contact details

PANDAS National support organisation for antenatal and postnatal depression and anxiety, as well as other perinatal mental illnesses

http://www.pandasfoundation.org.uk

Telephone helpline, email support, social media peer support groups.

Local support groups in Reading and Didcot.

MIND National mental health charity www.mind.org.uk

Telephone and web support available. Excellent source of information about a variety of perinatal mental illnesses.

Birth Trauma Association

Support for women with birth trauma/PTSD after birth

https://birthtraumaassociation.org.uk

Facebook support group

Maternal Mental Health Alliance

Education, awareness, support Links to other support organisations - https://maternalmentalhealthalliance.org/resources/mums-and-families/

5.2 Consultant Obstetrician Referral

All women should be referred for Consultant (Obstetric) care if they:

Are identified to have a history of moderate to severe mental illness (see table below)

Are prescribed long term psychotropic medication for mental illness such as antipsychotics, mood stabilisers (including lithium or anti-epileptic medication such as Valproate)

Women primarily requiring Consultant Obstetrician care for mental illness will be seen at the Royal Berkshire ANC in the Berkshire Maternity Mental Health Clinic,

Included conditions under ‘moderate to severe mental illness’

History of psychosis or puerperal psychosis

Schizophrenia or schizoaffective disorder

Severe depression

Severe phobias (needle, hospital, tocophobia or other)

Personality disorder and open to CMHT or already under the care of the Perinatal Mental Health Service WITH additional physical health complications, ACE events or receiving treatment with medication e.g. Mood Stabilisers

First presentation of OCD in perinatal period, or severe recurrent OCD

PTSD, on-going symptoms with trauma which may impact perinatal period e.g. PTSD relating to birth trauma, medical trauma, childhood sexual abuse, sex trafficking.

A significant deterioration in a woman’s mental health status during the perinatal period, prior to diagnosis of any of the above conditions

http://www.pandasfoundation.org.uk/

http://www.mind.org.uk/

https://birthtraumaassociation.org.uk/

https://maternalmentalhealthalliance.org/resources/mums-and-families/

https://maternalmentalhealthalliance.org/resources/mums-and-families/







which is a joint clinic run by Ms Sengupta (Consultant Obstetrician) and a clinician from the Berkshire Perinatal Mental Health service.

Women should be referred for Consultant Obstetric care using the Berkshire Maternity Mental Health Clinic referral form. If the woman requires midwifery care from the Poppy Team, the completed referral form should also be emailed to them, in lieu of a separate Poppy Referral form. (See Appendix 1, Referral to the BMMHC)

If the woman meets the inclusion criteria for the Berkshire Perinatal Service (see Appendix 2) please email a fully completed referral form, including your contact details, to [email protected]

If you would like to discuss any potential referrals or seek further advice,

please phone Berkshire Perinatal Mental Health Service (9am-5pm

Mon-Fri) via the Common Point of Entry (CPE) on 0300 365 0300 (8am-

8pm Mon-Fri)

6.0 Medication

Women and healthcare professionals should understand that it is not possible

to guarantee the safety of any medication taken during pregnancy or whilst

breastfeeding however an individual assessment of potential risks and

benefits can help to guide treatment decisions. The risks associated with

untreated or deteriorating maternal mental illness should be weighed against

the risks associated with exposing a foetus / baby to medication. The mother

(and if the mother agrees, the partner / carer) must always be involved in the

decision-making process where possible.

Switching or discontinuing medication during the perinatal period carries a

risk of relapse and / or deterioration in mental state but also exposes the

foetus / baby to more drugs; careful consideration of potential risks should be

undertaken before a change in treatment is commenced. The lowest effective

dose should be prescribed as sub-optimal treatment exposes the foetus /

baby to medication yet the risks associated with on-going / deteriorating

maternal mental illness may continue.

Medication taken during pregnancy or whilst breastfeeding should be checked

to confirm appropriateness and safety; this includes inhalers, creams, ‘over

the counter remedies’, herbal products*, complimentary medicines* and

homeopathic treatments*.

Consider referring the woman back to her prescriber for review if

necessary

these treatments are not usually regulated and are therefore not

recommended during pregnancy and whilst breastfeeding







A recent review of SSRI antidepressant use during pregnancy and

breastfeeding suggests they do not appear to significantly increase the risk of

foetal cardiac malformation or persistent pulmonary hypertension of the

newborn (PPHN) once confounders (e.g. smoking) are taken into account; no

additional monitoring is recommended.

For information about psychotropic (or other medication) in pregnancy and

breastfeeding, use the following resources, in order according to complexity

of need:

1. BUMPS website. http://www.medicinesinpregnancy.org/ (Resources for women and professionals)

2. Royal College of Psychiatrists, information leaflets on perinatal mental health, including medicines management: https://www.rcpsych.ac.uk/members/your-faculties/perinatal-psychiatry/news-and-resources

3. LactMed. https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm (In-depth information for professionals on medicines and lactation. Available as an app.)

4. Medicines Information at Royal Berkshire NHS FT. For RBH patients and professionals. Telephone: (0118) 322 7803 (Mon-Fri, 11am-4pm) Email: [email protected]

5. Perinatal Pharmacist, Beki Inglis at the Berkshire Perinatal Mental Health Service Provides in-depth and individualised discussions with patients and healthcare professionals making decisions about psychotropic medication in the perinatal period. Tues, Weds, Thurs, 09:30-16:15. Phone: 03003650300 (via CPE)

6.1 Reviewing Medication on Admission

Antenatally and at the point of any admission, in pregnancy, during labour, or

postnatally, a woman should have a discussion about any prescribed or ‘Over

the Counter medicines she may be taking. This includes herbal or

homeopathic remedies.

6.2 Psychotropic Medication and Intrapartum Care

Women taking lithium in pregnancy require intrapartum care on Delivery

Suite; an Obstetrician should oversee monitoring of fluid balance and serum

lithium levels. There is no other psychotropic medication or mental illness

which requires specific management of labour.

Women with no obstetric or medical complications beyond their mental health

should be supported to birth in the place of their choosing, whether this is in a

Midwifery Led birth centre setting or at home.

http://www.medicinesinpregnancy.org/

https://www.rcpsych.ac.uk/members/your-faculties/perinatal-psychiatry/news-and-resources

https://www.rcpsych.ac.uk/members/your-faculties/perinatal-psychiatry/news-and-resources

https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm








6.3 Psychotropic Medication and Postnatal Care

Early skin to skin contact should be encouraged as this is known to promote

infant mother relationships, infant growth and autoimmune system function

Early establishment of breastfeeding should be encouraged, in accordance

with the mother’s wishes.

Psychotropic medication cautioned or contraindicated with lactation include:

Lithium

Clozapine

Lamotrogine

Infants of mothers taking psychotropic medication during pregnancy may

require additional monitoring, as could the mothers themselves; details of

relevant monitoring should be outlined by the woman’s mental health team in

her maternity planning document. Medication requiring additional infant

monitoring include lithium and antipsychotics (more detailed guidance is

currently in development).

Infants who have been exposed to lithium during pregnancy should be

observed for signs of lithium toxicity and managed accordingly. The MHRA

suggest all infants exposed to an antipsychotic during the third trimester are

monitored for discontinuation symptoms (including extrapyramidal effects)

and treated as necessary; up to 1 in 5 babies are thought to be affected.

Other causes should be excluded before attributing these symptoms to

medication.

SSRIs may increase the risk of post-partum haemorrhage. 1 in 3 babies are

thought to experience discontinuation effects associated with SSRI

antidepressants; symptoms are usually temporary (often subsiding within 48

hours), mild and do not require treatment. Other causes should be excluded

before attributing these symptoms to medication.

Women who have already been identified as being at high risk of early

postpartum mental illness (e.g. puerperal psychosis) should be managed

according to the plan put in place by their relevant team, e.g. CMHT or the

Berkshire Perinatal Mental Health Service

Relevant information pertinent to the woman’s mental health should be

shared with the community midwives and the GP.

Any change in the woman’s mental health in the postnatal period should be

assessed and a referral made according to the pathway, as appropriate. If

you have urgent concerns about a woman’s mental health, advice should be

sought from PMS (if the woman is an inpatient) or from the Berkshire







Perinatal Service via the Common Point of Entry (if the woman is an

outpatient).

Clear plans of care for a woman’s mental health should be formulated and

documented within the woman’s hospital and hand-held notes, as well as

shared with GPs and Health Visitors.

Depression in the postnatal period may be reduced by the following

strategies, which are important for all women:

promoting both the relationship between mother and child and

relationships within the family.

encouraging appropriate diet and rest

ensuring that women are aware of the support available to them (cf.

reference table with 3rd sector support organisations, e.g. Homestart)

Clear communication to women at every stage of their care

7.0 Mental Health Crises

7.1 Recognising Mental Health Crises

The first 14 days after birth is the most high risk period for the development of

a severe mental illness. The presentation will differ between women. There

may be a number of distinctive features. These include:

Acute onset (e.g. within hours of birth)

Fluctuating severity of symptoms

Significant degree of emotional fluctuation

Rapid deterioration

A history of previous significant mental illness, such as psychosis, bi-polar disorder, and schizophrenia or schizoaffective disorder, significantly increases the risk of relapse in the perinatal period.

If a woman presents with any of the following, consider an urgent referral to

PMS (if an inpatient) or to the Berkshire Perinatal Service (if an outpatient).

Any recent change or deterioration in the woman’s mental state

Thoughts of violent self-harm

Thoughts of maternal incompetence and guilt

Feelings of estrangement from the baby







7.2 Initial Management of Mental Health Crises on Maternity Units

If it is felt that a woman admitted to the maternity unit is suffering from a

mental health crisis it is important that they receive urgent specialist

assessment. At the Royal Berkshire Hospital a referral by phone should be

made to the Psychological Medicine Service (PMS) to facilitate first-line

psychiatric assessment and management.

PMS offer a 4 hour response for any woman developing a potential

psychosis.

Physical health and organic causes should be excluded alongside psychiatric

causes for changes in a woman’s behaviour.

7.2.1 Preventing patients at risk from leaving

There may be situations in which a patient on the maternity unit who is felt to

be suffering from an acute mental health crisis wishes to leave the ward. In

these circumstances they should be reviewed by the team looking after the

patient on the maternity unit before leaving and their capacity to make this

decision assessed. If it is felt that they lack the capacity to make this decision,

and that remaining on the ward is in their best interests, then they can be

prevented from leaving in accordance with the Mental Capacity Act to allow

further psychiatric assessment.

In preventing the patient from leaving the least restrictive approach should be

used. It may be appropriate to physically prevent the patient from leaving,

requesting security to assist if required. Use of medication in this situation, as

outlined below, would also be covered by the Mental Capacity Act. After

psychiatric assessment use of the Mental Health Act (such as the use of

section 5(2)) may be considered, but decisions regarding this should be led

by the psychiatric team.

If a woman in hospital is at risk of suicide or self-harm An Adapted Australian

Triage Tool (Purple Mental Health folder in all areas) should be completed,

the purpose is to risk assess the situation and condition and to put safety

measures in place. After completion a copy of the tool should be sent to the

Safe Guarding Team on Level 6.

7.2.2 Medication for acute behavioural disturbance

If a patient presents with acute agitation or aggression in the context of a

presumed mental health crisis then attempts at verbal de-escalation should

be tried first. If it is felt that the woman requires medication to control acute

agitation or aggression then a short acting benzodiazepine would be the most







appropriate first line medication. An oral dose of Lorazepam, 1 to 2mg, should

be offered first. If this is refused, but the patient is still felt to require

medication for severe agitation and lacks capacity to refuse, then a dose of

Lorazepam, 1 to 2mg, can be given via the IM route. Further medication may

be required but specialist advice should be sought from a psychiatrist through

PMS before it is prescribed. Further details are covered in the Rapid

Tranquilisation Protocol (GL104). If Lorazepam is given antenatally, it very

unlikely that there would be respiratory depression of the neonate unless a

very large dose was given, very close to delivery. This should be obvious at

the time of birth; therefore routine observations on baby are not necessary.

If Lorazepam is given antenatally, it very unlikely that there would be

respiratory depression of the neonate unless a very large dose was given,

very close to delivery. This should be obvious at the time of birth; therefore

routine observations on baby are not necessary.

Lorazepam is excreted into breast milk in small amounts. Whilst there is only

limited data available, there is no evidence that Lorazepam used in

breastfeeding women would have any acute adverse effect on the child being

fed. Midwives need to have awareness that there may be a very small risk of

drowsiness and respiratory suppression. Routine observations are not

required.

Medication Dose Route Indication Impact on breastfeeding

Who can administer medication?

Lorazepam 1 to 2mg PO Agitation Can continue to breastfeed. See above

Lorazepam 1 to 2 mg IM Severe agitation or aggression when refusing oral medication and lacking capacity

Can continue to breastfeed. See above







8.0 References

8.1 Antenatal and postnatal mental health: Clinical management and service guidance. London NICE updated April 2018 https://www.nice.org.uk/guidance/cg192

9.0 Dissemination and circulation

This guideline is ratified by the maternity clinical governance committee. It is circulated to Manager for Trust Perinatal Mental Health Services, Lead Pharmacist for Maternity & Mental Health Co-ordinator, Safeguarding.

10.0 NICE Quality Standards - Antenatal and postnatal mental health QS115

Statement 1. Women of childbearing potential are not prescribed valproate to treat a mental health problem.

Statement 2. Women of childbearing potential with a severe mental health problem are given information at their annual review about how their mental health problem and its treatment might affect them or their baby if they become pregnant.

Statement 3. Pregnant women with a previous severe mental health problem or any current mental health problem are given information at their booking appointment about how their mental health problem and its treatment might affect them or their baby.

Statement 4. Women are asked about their emotional wellbeing at each routine antenatal and postnatal contact.

Statement 5. Women with a suspected mental health problem in pregnancy or the postnatal period receive a comprehensive mental health assessment.

Statement 6. Women referred for psychological interventions in pregnancy or the postnatal period start treatment within 6 weeks of referral.

Statement 7 (developmental). Specialist multidisciplinary perinatal community services and inpatient psychiatric mother and baby units are available to support women with a mental health problem in pregnancy or the postnatal period.

https://www.nice.org.uk/guidance/cg192

https://www.nice.org.uk/guidance/qs115/chapter/quality-statement-1-valproate#quality-statement-1-valproate

https://www.nice.org.uk/guidance/qs115/chapter/quality-statement-2-preconception-information#quality-statement-2-preconception-information

https://www.nice.org.uk/guidance/qs115/chapter/quality-statement-3-information-for-pregnant-women#quality-statement-3-information-for-pregnant-women

https://www.nice.org.uk/guidance/qs115/chapter/quality-statement-4-asking-about-mental-health-and-wellbeing#quality-statement-4-asking-about-mental-health-and-wellbeing

https://www.nice.org.uk/guidance/qs115/chapter/quality-statement-5-comprehensive-mental-health-assessment#quality-statement-5-comprehensive-mental-health-assessment

https://www.nice.org.uk/guidance/qs115/chapter/quality-statement-6-psychological-interventions#quality-statement-6-psychological-interventions

https://www.nice.org.uk/guidance/qs115/chapter/quality-statement-7-developmental-specialist-multidisciplinary-perinatal-mental-health-services#quality-statement-7-developmental-specialist-multidisciplinary-perinatal-mental-health-services







Appendix 1 - Where to Refer in Mental Health

Contact Times

Indication for referral

Contact Details

Talking Therapies

Normal office hours Some late evenings

Mild to moderate low risk common mental health e.g. mild to moderate anxiety/depression. See referral pathway

T: 0300 365 2000 F: 01344 415926 Email: [email protected]

Berkshire Perinatal Mental Health Service via Common Point Of Entry (CPE)

8am – 8pm Monday to Friday excluding bank holidays

Moderate to severe mental health or higher risk/complex mental health issues See referral pathway

Tele: 0300 365 0300 Fax:0300 365 0200 Secure email: [email protected]

Crisis Response and Home Treatment Team (CRHTT)

24 hours X 365 days

Urgent referrals outside CPE hours

T: 0300 365 9999

Community Mental Health Team (CMHT)

Normal office hours

Clients already open to mental health services

Bracknell 01344 823333 WAM 01628 640200 Slough 01753 690950 Newbury 01635 292020 Reading 01189 605612 Wokingham 01189 890707

Poppy Team Monday to Friday Normal office hours

Moderate to severe or high risk/complex mental health issues. See referral pathway

Please contact T : 0118 3228499

Consultant Obstetrician via the Berkshire Maternity Mental Health Clinic

Normal office hours

Moderate to severe or high risk/complex mental health issues. A joint clinic with Consultant Obstetrician and Berkshire Perinatal mental health clinician,

Email: [email protected]

Named Midwife for Safeguarding

Monday to Friday Normal office hours

For advice or to inform of Children’s Services referral

Please contact Tele: 07768752529









Appendix 2 - Referral to the Berkshire Maternity Mental health clinic

Clinical criteria NB: If in doubt, please speak to a member of the Poppy team, Sunetra Sengupta or Louise Perkins for advice

□ History of psychosis or puerperal psychosis

□ Bi-Polar

□ Schizophrenia or schizoaffective disorder

□ Severe depression

□ Severe phobias (needle, hospital, tocophobia or other)

□ Personality disorder and open to CMHT or already under the care of the Perinatal Mental Health Service

WITH additional physical health complications, ACE events or receiving treatment with medication e.g. Mood Stabilisers

□ First presentation of OCD in perinatal period, or severe recurrent OCD

□ PTSD, on-going symptoms with trauma which may impact perinatal period e.g. PTSD relating to birth

trauma, medical trauma, childhood sexual abuse, sex trafficking.

□ A significant deterioration in a woman’s mental health status during the perinatal period, prior to diagnosis

of any of the above conditions

Introduction to the BMMH clinic The BMMH clinic has been established to ensure the quality of care for women in West Berkshire with significant mental illness in pregnancy. Women will be seen jointly in the clinic by a Consultant Obstetrician from RBHFT and a Perinatal Clinician from Berkshire Healthcare Trust, with additional psychiatrist input as necessary.

Women will be seen an average of twice in their pregnancies, for example, once to plan their

needs for care in pregnancy, and once to plan their needs for the birth of their babies and the

postnatal period.

The clinic will run twice per month, on a Wednesday afternoon, at the RBH antenatal clinic.

Women will have a 30 minute appointment. Their named community midwife will be welcome to

attend if they are able (this is most likely to be a Poppy team midwife)

Routine investigations and examination e.g. bloods, BP, urinalysis, will be undertaken by the MSW

for clinic on that day







1. Referral process AFTER Booking

For women who require an appointment within 2 weeks, referral can be made to the BMMH clinic directly by GPs, midwives or other healthcare professionals using the BMMHC referral form, which should be completed and sent directly to [email protected]

2. Referral process for community midwives AT Booking

Community midwife books woman who meets BMMHC clinic criteria.

No. There is no need to complete an additional Consultant Obstetrician referral. Include any additional risk factors requiring Consultant Obstetrician care on the BMMHC referral form.

No. There is no need to complete an additional Poppy team referral. If you are a generic community midwife, please email copy of the BMMHC referral to [email protected] and your referral to the Poppy team is also complete

Do I need to fill an additional Poppy Team referral form, if she requires Poppy team care?

Do I need to fill an additional Consultant Obstetrician referral?

Complete 1x BMHHC clinic referral form. Please email a copy of the BMMHC referral form to these 2 email addresses: [email protected] (as per Consultant referrals) and [email protected] (Plus [email protected] if required)

Email account reviewed and BMMHC team responsible for deciding on when woman needs seeing. Appt. requested by BMMHC team. If other significant co-morbidities e.g. T1 diabetes, cardiac conditions, in additional to significant mental health needs, appropriate care pathway should be requested by J Siddall when reviewing the Consultant referral forms sent













APPENDIX 3 - BERKSHIRE SPECIALIST PERINATAL MENTAL HEALTH SERVICE – INCLUSION / EXCLUSION CRITERIA





APPENDIX 4 - Referral pathways for Women with Birth Trauma or Significant Fear of Birth Significant Primary Fear of Birth e.g. tokophobia* (No previous history of traumatic birth)

- Preconception or during pregnancy

Significant Secondary Fear of Birth e.g. tocophobia (Fear of Birth & previous traumatic birth or other trauma event e.g. Adverse Childhood Events, abuse history, trafficking etc)

Recent Birth Trauma (e.g. 10-14 days postnatal and significantly struggling to come to terms with birth experience & impacting negatively on daily life)

Concerns re. difficult birth experience in the immediate postnatal period e.g. until discharge from postnatal wards or early PN home visits

Refer to Consultant Midwife ASAP, at Booking or after first disclosure, for support and birth planning.

Refer to Perinatal Mental Health team

Refer to Consultant Midwife ASAP, at Booking or after first disclosure, for support and birth planning and debrief, if appropriate, of previous birth.

Refer to Perinatal Mental Health team. Assessment for PTSD +/- recommendation treatment by the Berkshire Birth Trauma service will be made.

Consider referral to Perinatal Mental Health team.

Offer the woman the self-referral details for the Birth Reflections service. They will be contacted within 2 weeks for a phone triage, and referral to the appropriate service.

Handover to the Health Visitor for watchful waiting/review of the woman’s mental health

Take the opportunity to discuss the woman’s birth with her and to address any questions or concerns she has about events. On the wards it would be appropriate to go through her labour notes with her.

Give her information about normal emotional transitions in the first few days after birth.

Offer the woman the self-referral details for the Birth Reflections service. They will be contacted within 2 weeks for a phone triage, and referral to the appropriate service.

*Tocophobia

Significant Fear of Birth or ‘Tocophobia’ is defined as extreme and intense fear and anxiety (often associated with phobia symptoms such as panic attacks,

insomnia, and nightmares)

The presence of the following associated clinical conditions could mimic tocophobia or they may co-exist with the tocophobic state: 1) Blood-injection-Needle

phobia 2) Hospital phobia, 3) Vaginismus 4) Fear of vaginal examination 5) Social anxiety disorders (encounter with unfamiliar people during labour) 6) Panic

disorders

Causes for tocophobia can be complex, however; including vicarious trauma through family or friends, previous traumatic experience in the hospital or previous traumatic birth, a history of rape or sexual abuse, and lack of trust in the hospital staff.

Policy Lead: Group Director Urgent Care Version:

V1.1 June 2019 V1.0 ratified 1/2/19 Location: Policy hub/ Clinical/ Maternity/ Social Issues & Public Health/ GL1131



APPENDIX 5 – CHALLENGING BEHAVIOUR RISK ASSESSMENT TOOL

Policy Lead: Group Director Urgent Care Version:

V1.1 June 2019 V1.0 ratified 1/2/19 Location: Policy hub/ Clinical/ Maternity/ Social Issues & Public Health/ GL1131



perinatal mental health guideline (gl1131)...perinatal mental health guideline (gl1131) june 2019...

Documents