Module 9 Flashcards
antenatal psychiatric disorders
Most first-onset conditions are mild depressive and anxiety disorders and the cause is commonly psychosocial
* Relapses of the following disorders may occur: depressive and anxiety disorders, obsessive compulsive disorder, schizophrenia, bipolar disorder and substance misuse
* It is important to enquire for a previous history of serious mental illness at the booking visit
* Identifying women with a past or family history of bipolar disorder or puerperal psychosis is particularly important because of the high risk of postpartum relapse (one in two).
* Psychiatric medication should not automatically be discontinued once the woman becomes pregnant. This is a frequent cause of relapse.
* Mild to moderate disorders may be managed in primary care. Past or current severe illness should be referred to specialist psychiatric services, preferably to a perinatal psychiatric service
* Good communication between all health professionals both in primary and secondary services is crucial
complications antenatal psychiatric disorders
Poor attendance in antenatal clinic
* Smoking and substance misuse
* Poor general health and nutrition
* Deliberate self-harm and suicide
* Low birth weight and pre-term deliveries
* Problems with mother–infant attachment
* Neglect or harm to infant and other children; safeguarding issues
* Possible long-term developmental and behavioural problems in the child
* Mental health problems in the woman’s partner
preconception issues and care antenatal psychiatric disorders
- Risk of recurrence of mental illness in perinatal period
- Risks and benefits of medication in pregnancy
- Some psychiatric medications reduce fertility and should be changed if pregnancy is planned
- Avoid certain drugs (especially sodium valproate) due to high rates of birth defects
pregnancy issues antenatal psychiatric disorders
Fetal growth retardation
* Low birth weight
* Prematurity
* Long-term developmental and behavioural problems in the child Mental illness may be associated with other behaviours that could indirectly affect her health and that of the baby. These include:
* Smoking
* Alcohol and substance misuse * Poor dietary habits * Lack of exercise * Self-harming behaviour * Lack of engagement with services
medical management and care antenatal psychiatric disorders
- Mild to moderate depressive and anxiety symptoms are the most frequent psychiatric problems in pregnancy
- Psuchological therapies such as cognitive behaviour therapy, interpersonal therapy or self-help strategies
- Advice sorted from specialist psychiatric services
- All women with serious mental illness should be referred to specialist services
- Risk-benefit ratio of psychotropic medication is assessed and decisions regarding medication during pregnancy
midwifery management antenatal psychiatric disorders
- Booking in – screen for past or present serious mental health – refer to perinatal psych
- trusting relationship
- advice regarding smoking, diet, exercise, BF, birth prep and support services
labour issues antenatal psychiatric disorders
- neonatologists should be contacted if woman is on psychotropic meds
medical management - discuss methods of support for labour pain to reduce anxiety
- support in labour
- consent
midwifery management labour antenatal psychiatric disorders
- advice regarding continuation or discontinuing psychotropic meds prior to labour
- drugs should be used judiciously in view of possible effects on the baby
postpartum issues antenatal psychiatric disorders
- new symtpoms may emerge like
- increased anxiety and agitation
- low mood, excessive tearfulness or apathy
- poor handling or attachment to baby
- bizarre or unusual behaviour
- delusions and hallucinations
- thoughts or acts of harming herself or baby
medical management postpartum antenatal psychiatric disorders
- specialist perinatal psychiatry contacted
- approp. Treatment takes precedence over BF
- transfer to specialist psychiatric mother and baby unit
midwifery management postnatal antenatal psychiatric disorders
- observe mother and baby interaction
- discuss rest, diet and self-care, assess how mum is coping
- reassure if mood change is baby blues
- observe baby if BF
- assess risk to baby
postnatal psychiatric disorders
- baby blues
- PND
- postpartum psychosis
general symptoms PND
- Low mood, loss of interest and enjoyment, reduced energy
- Reduced concentration and self-esteem, ideas of guilt, hopelessness, thoughts or acts of self-harm or suicide and appetite disturbance
postpartum psychosis
- delusions and hallucinations. The onset is sudden, usually within the first 2 days postpartum.
- Mood changes – elation, depression or irritability
- Perplexity and confusion
- Agitation and abnormal behaviour
complications postpartum psychosis
- Self harm and suicide
- Neglect of baby
- Problems with mother-infant attachment and interaction
- Long-term emotional, behavioural and cognitive problems
- Relationship problems and breakdowns
- Social, occupational and financial complications
- Depression in the partner
pre-conception issues and cares postnatal psychiatric disorders
- Relapse rates in women that have had postpartum psychosis 50%
- Risk-benefit should be assessed
- Sodium valproate not prescribed (epilepsy)
- Discuss poor diet, smoking, substance/alcohol abuse, self-harming, relationship problems
pregnancy issues postnatal psychiatric disorders
Biological risk factors
- Past history of severe depression
- Past or family history of bipolar or postpartum psychosis
Psychosocial factors
- Lack of social support
- Recent stressful life events
- Longstanding difficulties in coping
- Sexual abuse
- DV
medical management pregnancy postnatal psychiatric disorders
- Talking therapies or antidepressants
- Psychotropic meds don’t discontinue
midwifery care pregnancy postnatal psychiatric disorders
- Communicate with other professionals
- Refer to OB
- Refer to perinatal service
- Trusting relo
- Any risk to baby, referral
labour issues postnatal psychiatric disorders medical management
- Psychotropic medication may be indicated
- Drugs should be used judiciously
labour issues postnatal psychiatric disorders midwifery management
- Discuss carefully
- Consent
- Psych and physical support
- Avoid interventions
- Encourage skin to skin
- Breast feeding encouraged
postpartum issues postnatal psychiatric disorders
- Depression usually presents within 12 weeks
- Postpartum psychosis within 2 days
- Suicide leading causes of mortality – early detection
medical management postpartum issues postnatal psychiatric disorders
- Risk assessment
- Admission to mother baby unit
midwifery management postnatal issues postnatal psychiatric disorders
- Observe interaction
- Discuss sleep, diet and self-care
- Reassure if baby blues
- EPDS
- Social services
eating disorders
- severe disturbances in eating behaviour
- In anorexia there is a deliberate attempt to lose weight whereas bulimia is characterised by repeated episodes of binge eating followed by compensatory behaviours (self-induced vomiting or purging)
anorexia nervosa
- Body weight maintained at least 15% below that expected, or BMI less than 17.5
- Weight loss, self-induced vomiting, purging, excessive exercisem appetite suppressants
- Body image distortion
- Endocrine disorder – hypothalamic-pituitary-gonadal axis causing amenorrhea
anorexia associated clinical features
- Amennhorrea, infertility, loss of sexual interest
- Lethargy, weakness, anaemia
- Hypotension, peripheral oedema, cardiac arrhythmia
- Constipation, abdo pain, enlarged salvary glands
- Dry skin, alopecia, lanuago hair, brittle nails, osteoporosis
- Tooth decay, erosion of dental enamel
bullimia nervosa
- Repeated bouts of overeating and excessive preoccupation with control of body weight leading to extreme measures to counteract effects of overeating
- Persistent preoccupation with eating, craving for food, eating large quantities in short time
- Counteracting the fattening effects of food by self-induced vomiting, purging, periods of starving or drugs
- Morbid dread of fatness
- Inappropriate low target weight
- Sometimes earlier episode of AN
bulimia associated clinical features
- Irregular periods
- Dependence on laxatives, diarrhoea and constipation
- Dehydration, fluid and electrolyte disturbances
- Tooth erosion, loss of dental enamel
- Enlarged salivary glands
eating disorders non-pregnancy treatment
- Psychotherapies such as cognitive, interpersonal, psychodynamic
- Meds
pre-conception care eating disorders
- Counselling and support
- Dietary and nutritional assessment
- Polycystic ovaries
pregnancy issues eating disorders
- ED detected early
- Maternal worries about change in weight
- Self-induced vomiting
- IUGR
- Poor weight gain
- Stillbirth and miscarriage
- Premature labour
- Depression/self-harm
medical management eating disorders in pregnancy
- Multidisciplinary team
- Monitor weight and IUGR
- Serial scans
- Expected weight gain
- Assess vitamin and mineral deficiencies
- Check for cardiac complications
- Liaise closely with GP and ED service
midwifery management eating disorders in pregnancy
- Check womans weight and BMI
- Discuss complications in pregnancy
- Monitor weight regularly
- Screen for other MH
- Give support
- Dietary advice
- Antenatal prep
labour issues eating disorders
- Proceed as normal
- Higher risk of LSCS
medical and midwifery management labour eating disorders
- Advice psychotropic medication
Midwifery - Methods of support for labour pain to reduce anxiety
postpartum issues eating disorders
- Relapse of worsening can occur
- Preoccupation with weight gain
- Exaggerated weight loss after birth
- Excessive exercise
- Depression
- Self-harm, alcohol
- Mother-infant attachment
medical management postpartum eating disorders
- Watch for signs of relapse
- Assess risks
- Monitor baby if woman on psychotropic meds
midwifery mangement postpartum eating disorders
- Observe mood and interaction with baby
- Monitor weight
- Assess nutritional advice
- Observe attachment and caring for infant
- Relapse – refer to ED service
PTSD
- Delayed or protracted response to a stressful event of an exceptionally threatening or catastrophic nature affecting individuals at any age or time of life
- Previous PTSD may be exacerbated during pregnancy – 3-7.7% experience after birth
- Avoidance of situations similar to the stressful event
- Inability to recall the event
- Increased arousal or hyper-vigilance
- Sleep problems
- Irritability and/or anger outburst
- Poor concentration
- Exaggerated startle response
- Disassociating or emotional numbing
Risk factors for PTSD in childbirth
- Miscarriage and stillbirth
- Emergency problems such as cord prolapse
- Complicated deliveries and LSCS
- Catheterisation
- Intimate clinical procedures e.g VE
- Attitude of healthcare professionals
- Survivor of disaster or accident
complications PTSD
- Develop low self-esteem, anxiety, depression
- Employment problems, relationship breakdown, social isolation
- 1/3 report self-harm
- Ptsd can occur after
- Rape, sexual assault, childhood sexual abuse
- Victim of violent crime or DV
- Victim of torture, war, disaster or accident
- Refugee or asylum seeker
- Previous FGM
- Occupation
consequences of PTSD
- Depression, anxiety, self-harm, suicide
- Avoidance of intimate and sexual relationships
- Impaired mother-infant attachment
- Fear and avoidance of future pregnancies
- Avoidance of VEs
- Termination
- Requests for LSCS
- Requests for sterilisation
preconception care PTSD
- Detection of PTSD symptoms
- Identification of complications
- Discussion of plans for pregnancy
- Referral for psychological therapies
- Medication
pregnancy issues PTSD
- Birth plan with specific wishes
- Failure to detect symptoms may result in poor attendance to appointments, exacerbation of symptoms, use of drugs and alcohol, self-harm
medical management PTSD in pregnancy
- Medication
- Trauma-focused CBT and EMDR
midwifery management PTSD in pregnancy
- Booking in history important
- Appropriate referrals
- Reassurance
- Desensitisation by arranging visits to birth unit
- Include fears and wishes in birth plan
- Communicate
labour issues PTSD
- Continuity of care
- Familiarisation with staff
- Empathic and sensitive care
medical and midwifery management PTSD labour
- Shared OB and midwifery care
Midwifery - Birth plan written early
- Know triggers
- Discuss analgesia
- Arrange meeting with anaesthetist
- Birth support
postpartum issues PTSD
- Escalation of anxiety
- Attachment with baby
- Depression or irritability
- Self-harm
- Alcohol or illicit drug use
- Social, relationship and work problems
midwifery care postpartum PTSD
- Identify any abnormal mood changes
- Observe attachment
- Discuss rest, diet and self-care
- Be prepared for BF difficulties
- Discuss how mum is feeling
