Women Who are Pregnant or Have Recently Given Birth

• Be kind and empathic.
• Think about the (unborn) baby as well as the mother.
• Ensure nutrition and other physical needs are met.
• Assess and manage risks promptly:
• Suicide
• Neglect or harm to the baby
• Risk from others (e.g. partner violence)
• Refer if needed. Review regularly.
• Consider the effect of medication on the (unborn) baby when prescribing in pregnancy and breastfeeding (see box)

1. Is there immediate risk to herself or the baby e.g. neglecting the child, suicidal ideas.
   • If YES, act quickly to keep mother and baby safe.
   • Use the de-escalation/rapid tranquilisation section (BUT take particular care in pregnancy: make sure you have lots of assistance; give lowest effective doses of medication; minimise any restraint.)
   • Assess and manage suicide risk.

3. Is she drowsy, confused (disorientated) and/or have physical signs/symptoms?
   • If YES, then DELIRIUM is likely. It may be caused by an obstetric condition (e.g. haemorrhage, infection) or another general medical illness. This is an emergency. See the section on Delirium for management.
4. Does she have hallucinations and delusions? Or mania? Or severe depression?
   • If YES, and she has recently delivered, the likely diagnosis is POSTPARTUM PSYCHOSIS. (If she is still pregnant, it may be relapse of a pre-existing disorder such as schizophrenia, bipolar disorder or recurrent depression.)
   • Carry out a full physical exam to exclude Delirium. See the section on Delirium for management.
   • Ensure safety (as above). Advise the family that the mother should not be left alone with the baby whilst she is unwell. A family member may need to look after the baby if the mother is very agitated and distressed. However, when she is more settled, she should be closely supervised to breastfeed and care for the baby.
   • Refer to hospital for further assessment and management.
5. Is there a clear history of a traumatic event such as her husband beating her?
   • If YES, her behaviour could be a REACTION TO TRAUMA.
     • Provide empathic care and reassurance
     • Ensure her safety – if she is at risk of harm consider contacting ONE STOP centre and/or Police.
     • Consider problem solving counselling.
     • Low dose short term chlorpromazine (25mg) may be helpful to manage immediate distress.
     • If not improving, reassess for other conditions and refer if needed.
6. Is she feeling persistently low in mood, or so worried that she is very distressed and/or not able to care for herself?
   • If YES, this could be DEPRESSION AND ANXIETY.
     • Assess and manage as per the Depression and Anxiety sections.
     • Review more regularly than usual and always ask about thoughts of suicide or harm to the baby.
     • Provide practical information in response to worries, and support in providing care and stimulation to the baby.
     • Offer lots of praise!

• NEVER prescribe sodium valproate in pregnancy (or to any woman of childbearing age).
• Use psychosocial treatments (e.g. problem solving) for mild/moderate depression/ anxiety.
• Do not leave a woman with severe mental illness untreated just because she is pregnant/breastfeeding.
• Most medications (except sodium valproate) can be prescribed with care.
• Keep to lowest effective dose. Avoid multiple medications.
• Avoid benzodiazapines (other than occasional doses)
• Don’t start depot antipsychotic in pregnancy. But if the person is already prescribed depot and is stable, don’t stop it.
• Monitor the breastfeeding baby for sedation or feeding difficulties.
• If it is not possible for the baby to breastfeed, make sure there is formula milk available.

All women attending for antenatal care should be asked if they have a history of mental illness (e.g. postpartum psychosis, schizophrenia, bipolar disorder or recurrent depression). If YES, refer them to the mental health clinic. DON’T stop psychiatric medication without getting advice first.

Advise all women that they should not drink alcohol whilst pregnant.

It can also be helpful to ask women attending for antenatal care simple questions about mental wellbeing e.g.

1. During the last month, have you often been bothered by feeling down, depressed or hopeless? (YES/NO)

2. During the last month, have you often been bothered by little interest or pleasure in doing things? (YES/NO)

If YES, set aside some time to ask in more detail. Assess for (and manage) mental health conditions and offer basic counselling (see section on problem solving).