Fundamentals of Midwifery: A Textbook for Students (119 page)

Rhythm method
Involves recognising the fertile and infertile times of the menstrual cycle to plan when to avoid sex and requires the monitoring of body temperature, cervical mucus and menstrual cycle length.
Sterilisation
Surgical intervention to prevent conception either by preventing passage of ova from the ovaries to the uterus (tubal ligation) or by preventing sperm travelling from the testes to the penis (vasectomy).
References
280Hall, J. (2005) Postnatal fertility control advice.
The Practising Midwife
8 (5), pp. 39–43.Hiller, J.E., Griffith, E., Jenner, F. (2002) Education for contraceptive use by women after childbirth.
The Cochrane Database of Systematic Reviews
3 (2).Jackson, K. (2005) Lactational amenorrhoea method as a contraceptive.
British Journal of Midwifery
13 (4), pp. 229–231.NICE (2006)
Routine postnatal care of women and their babies. CG37
. London: NICE.Norris, S. (2006) Is there a role for midwives in family planning?
British Journal of Midwifery
14 (12), p. 701. Queenan, J. (2004) Contraception and breastfeeding.
Clinical Obstetrics and Gynecology
47(3), pp.734–739.Srikanthan, A., Reid, R.L. (2008) Religious and cultural influences on contraception.
JOGC
February, pp.129–137.Szarewski, A., Guillebaud, J. (2000)
Contraception: A User’s Guide
. Oxford: Oxford University Press.Van der Wijden, C., Kleinen, J. (2003) Lactational amenorrhoea for family planning (Cochrane Review).
The Cochrane Library
Issue 4.
Chapter 13‌
Perinatal mental healthJulie Jomeen
University of Hull, Hull, UK
Nicky Clark
University of Hull, Hull, UK
Learning outcomesBy the end of this chapter the reader will be able to:

recognise why perinatal mental health is important for mother and baby as well as the wider family

explain the policy context and national guidance related to perinatal mental health

recognise the risk factors and consequences associated with perinatal mental illness

recognise and differentiate the signs and symptoms of normal versus abnormal emotionaladjustment across the perinatal period

explain how healthcare professionals should identify and assess women’s perinatal mentalhealth and some of the associated challenges

recognise why good pathways of care are essential to support women with perinatal mentalillness.
Introduction
Perinatal mental illness (PMI) was raised to public attention following the Confidential Enquiryin Maternal and Child Health report published in 2004; for the first time psychiatric illness was the largest cause of maternal deaths. This chapter will explore why healthcare practitioners need to understand and consider PMI. It will identify risk factors and the signs and symptoms of PMI and promote consideration of normal versus abnormal emotional adaptation of the mother across the perinatal period. It will identify the health professional’s role and responsibilities in identifying and assessing perinatal mental illness and offer considerations for appropriate man- agement and referral processes, with the aim of improving outcomes for childbearing women.
Fundamentals of Midwifery: A Textbook for Students
, First Edition. Edited by Louise Lewis.© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd. Companion website: www.wileyfundamentalseries.com/midwifery282‌‌‌
The importance of mental health in a maternity context
Mental health problems which are present during pregnancy and the postnatal period (perina-
tal mental health problems [PMHP]) are not uncommon and can have serious consequences. In high-income countries, 10% of pregnant women and 13% of mothers of infants have significant mental health problems, depression and anxiety being the most common (O’Hara and Swain 1996; Fisher et al. 2010). Considering that in England 700,000 women give birth each year, this suggests that approximately 70,000 women will be affected antenatally and 91,000 postnatally, with rates much higher in resource-constrained countries (Fisher et al. 2010). Whilst the focus within the literature is on depression, historically on postnatal depression (PND) and more recently, antenatal depression (AND), PMI is a spectrum of conditions, varying in severity from adjustment disorders and distress, through mild to moderate depressive illness and anxiety states, severe depressive illness and post-traumatic stress disorder, to chronic serious mental illness and postpartum psychosis. Specifically, these may include generalised anxiety disorder (GAD), panic disorder (PD) post-traumatic stress disorder (PTSD), phobias and obsessive com- pulsive disorder (OCD) as well as the more severe conditions such as bipolar disorder, schizo- phrenia and personality disorders.PMHP affect women from across the population and can have a significant impact upon the healthy functioning of the women and her long-term mental health, obstetric outcomes, her partner, the quality of family relationships, as well as on the wellbeing of the fetus and a child’s development in the short and the long term. The burden of PMI in individual, societal and economic terms must not be underestimated. Childbirth provides a clear window of opportu- nity for professionals who come into contact with women to make a positive impact on adverse obstetric and mental health outcomes related to PMI (Alderdice et al. 2013). This, however, requires awareness and understanding of common mental health problems, as well the confi- dence to make enquiries of women about their mental health status. This is an area that has been traditionally identified as problematic for midwives (Ross-Davie et al. 2006; Jomeen et al. 2009), health visitors (Morrell et al. 2009; Jomeen et al. 2013), as well as health professionals generally (NSPCC 2013). It is essential that practitioners effectively assess and recognise PMI to underpin appropriate and proactive referral and care decisions, which assure the necessary support that women and their families need.
Putting PMI into perspective
Maternal mortality and morbidity
Public attention on PMI followed the Confidential Enquiries in Maternal and Child Health (CEMACH) report published in 2004. For the first time deaths from psychiatric causes were reported and identified as the overall leading cause of maternal mortality in the years from 1998–2001 (CEMACH 2004). These maternal mortality reports lucidly highlighted PMI as an issue of concern and one requiring greater attention, catapulting PMI firmly onto the maternity public health agenda. Subsequent reports (CEMACH 2007; Centre for Maternal and Child Enquiries (CMACE) 2011), have continued to evidence psychiatric disorders as a significant cause of death in both pregnant and postnatal women and highlight no decrease in suicide rates in this group.
Maternal deaths
Maternal deaths from psychiatric causes are deaths arising directly from a psychiatric condition, suicide or accidental overdose of drugs misuse. Deaths from medical and other causes are
Table 13.1
Causes of death in the perinatal period, due to, or associated with, a psychiatric disorder
Cause of deaths reported
Suicide Substance misuse Violence AccidentsMedical conditions being aggravated by a psychiatric disorder
Main psychiatric diagnoses made on those who died
PsychosisSevere depressive illness Anxiety/depressive adjustment Alcohol dependenceDrug dependence Personality disorder
Medical conditions aggravated by a psychiatric disorder
Infection PancreatitisIncorrect diagnosis of a medical disorder delaying appropriate management Incorrect diagnosis of a psychiatric disorder delaying appropriate management283associated with psychiatric causes if they are the physical consequences of substance misuse. Delays in the diagnosis and treatment of other life-threatening conditions because of the pres- ence of a psychiatric illness are also included. In the years 2003–2005, a total of 104 women died due to, or associated with, a psychiatric disorder (CEMACH 2007) and between 2006 and 2008 a total of 79 women died (CMACE 2011) (see Table 13.1).Most psychiatric causes of maternal mortality are classed as indirect causes. Indirect causes are deaths that occur as a result of previously existing disease or disease that develops during pregnancy. This exacerbation or development of disease is not due to obstetric causes but by aggravation of the physiological effects of pregnancy.The development of a psychiatric disorder during pregnancy and following delivery is common. Pregnancy, until recently was thought to have a ‘protective effect’; unfortunately the rising suicide rate challenges this belief, with many deaths occurring in the antenatal period, or very shortly after. Additionally those women with pre-existing serious mental disorder evidence a heightened risk of relapse in pregnancy, yet paradoxically the risk of developing a serious mental disorder is significantly elevated following childbirth. This is particularly so in the first 3 months and furthermore a family history of bipolar disorder increases this risk to 50%.PMH is a potentially preventable cause of perinatal mortality (Department of Health (DH) 2002). Disturbingly, an important feature of many of these ‘indirect deaths’ was considered to be the lack of coordinated multidisciplinary care (CEMACH 2004; 2007; CMACE 2011). Recom- mendations from these reports strongly emphasise that all professionals involved with women throughout childbirth should be alert to the possibility of sudden deteriorations and escala- tions. Questions about mental ill-health (see Box 13.1) should be made routinely in antenatal clinics, with effective communication between services and professionals, particularly the psy- chiatric, maternity, mental health and child protection services and those working within them. CMACE is no longer commissioned to produce these reports, with MBRRACE-UK being the collaboration now appointed by the Healthcare Quality Improvement Partnership to continue with the Confidential Enquiry into Maternal Deaths (CEMD) as part of its programme of work. This work commenced on 1 January 2013. MBRRACE-UK is anxious to safeguard the continuity
Box 13.1 Identifying and assessing PMI
Prediction and detection questions (National Institute for Health and Care Excellence (NICE) 2007)
Prediction questions
At the woman’s first contact with services during pregnancy and the postnatal period, healthcare professionals (including midwives, obstetricians, health visitors and General Practitioners (GPs)), should ask about: