7- Normal pregnancy and labour (Antenatal care con: Safeguarding and mothers mental health)

Question 1

vulnerable women in pregnancy include

Answer 1

o Women aged 19 or under at booking
o Disclosure of substance misuse
o Disclosure of domestic violence
o Learning disabilities
o Recent migrants, asylum seekers and refugees

Question 2

when should relevant vulnerabilites be identified

Answer 2

first contact- i.e. booking appointment

Question 3

what sort of questions should be asked in regard to safeguarding concerns

Answer 3

• age
• substance misuse
• domestic violence
• residency status
• domestic violence
• learning disability

Question 4

pregnancy in women <19

Answer 4

Women giving birth in their teenage years are at higher risk of adverse birth outcomes
including:
- stillbirth
- perinatal death
- neonatal death

Young parents are disproportionately more likely to have
experienced poverty, poor housing and educational under-achievement.

Question 5

substance abuse in pregnancy

Answer 5

greater risk of
- maternal death
- miscarriage
- stillbirth
- malformations
- neurokogical damage

There is a direct adverse impact on the physical, mental and emotional development of the children of parents with addictions. Women
with addictions will face many barriers to accessing care and may have additional needs including being at risk of exploitation, poor
sexual health and homelessness.

Question 6

support for pregnant women <19

Answer 6

• Specialist nurses
• Social support i.e. housing and debt

Question 7

support for pregnant women with substance misuse problems

Answer 7

• drug and alcohol change services

Question 8

define domestic abuse

Answer 8

“Any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional)
between adults who are or have been intimate partners or family members, regardless of gender or sexuality”

Question 9

Domestic abuse in pregnancy

Answer 9

• increases in pregnancy

can cause
- infections
- premature birth
- miscarriage
- injury
- dethas
- stress and anxiety

Question 10

support for pregnant women experience DV

Answer 10

• advice
• contact numbers
• safe places
• social services

Question 11

pregnancy and migrants, asylum seekers and refuggees

Answer 11

Women who are recent migrants, asylum seekers or refugees are at a higher risk of poor birth outcomes, particularly when there are
language barriers. Key issues for these women can include poor physical and mental health, medical conditions, FGM, trauma, fears
about immigration status, exploitation and language difficulties (NICE 2010). Women who are new to this country and in difficult
circumstances, may have poor understanding of the healthcare system and how to access care and services.

Question 12

learning disabilities in pregnancy

Answer 12

• Women with learning disabilities can parent successfully and confidently with the right support; care should be planned to enable them to
  have an equal chance to do so.
• Barriers to women with learning disabilities receiving care equal to that of women without include
  inadequate diagnosis and identification of learning needs, and a lack of effective multidisciplinary working (Malouf et al 2017b). Women
  with learning disabilities feel less confidence in maternity staff and perceive that their concerns will be taken less seriously compared to
  women without a learning disability; a comprehensive assessment of needs early in pregnancy is needed (Malouf et al 2017a).
• Women with learning disabilities are more likely to have their child taken into care, usually due to other social complexities, however there
  is no clear evidence linking intellectual ability with parenting competence, and there is evidence that robust support can lead to positive
  parenting outcomes for these women.

Question 13

female genital mutiltation and prgenancy

Answer 13

Should be asked about on booking

Some women with FGM may find it difficult to become pregnant, and those who do conceive can have problems in childbirth.

Question 14

what is FGM

Answer 14

All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons

Question 15

why does FGM happen

Answer 15

o Mistaken religious practice
o Culture- purification
o Social acceptance, family honour- esp for marriage
o Fear of exclusion

Question 16

types of FGM

Answer 16

Question 17

Consequences and complications of FGM

Answer 17

• Infection
• Pain (can be chronic)
• Childbirth problems
• Acute haemorrhage
• Sexual difficulties – fertility issues
• Obstetric
• Psychological

Question 18

is FGM legal in the UK

Question 19

how can FGM affect birth

Answer 19

• increased risk of caesarean section
• episiotomy
• post-partum haemorrhage
• extended hospital stay

Question 20

perinatal mental health def

Answer 20

refers to a womens mental health during pregnancya nd the first year after giving brith
- includes pre-existing and new mental health problems relating to the oregnancy

Question 21

perinatal mental health disorders

Answer 21

• anxiety
• depression (inc postnatal dep)
• puerperal psychosis
• PTSD
• pre-existing illness

Question 22

impact/importance of perinatal mental health

Answer 22

Question 23

why is perinatal mental health poorly detected: patient factors

Answer 23

• Stigma
• Putting on a brave face
• Fear of being considered a ‘bad’ mother
• Fear the baby might be taken away
• Not knowing what is normal
• Not knowing if treatment will help
  *

Question 24

why is perinatal mental health poorly detected: health professional factors

Answer 24

• Not asking
• Time constraints
• Not recognising risk factors or red flags
• Normalising or dismissing symptoms
• Lack of training or confidence
• Lack of access to specialist services
  *

Question 25

perinatal mental health history

Answer 25

briefly screen for depression - during the pasdt month have you been bothered ny feeling down, depressed or hopeless? - during the past month have you often been bothered by having little interest or pleasure in doing things? - is there soemthing you feel you need help with? briefly screeen for anxiety (GAD2) - during the pasdt month ahve you been feeling nervous, anxious or on the edge? - during the past month have you not been able to stop or control worrying?

Question 26

perinatal mental health risk factors

Answer 26

Prior diagnosis of mental health illness Family history (first degree relative) of severe perinatal health illness History of childhood abuse and neglect Domestic violence. Interpersonal conflict Inadequate social support Substance misuse Migration status, language and cultural barriers Unplanned or unwanted pregnancy Pregnancy complications or traumatic birth Fetal or neonatal loss

Question 27

perinatal red flags for mental health proble ms

Answer 27

Question 28

chronic mental health problems which can continue in the perinatal period

Answer 28

Anxiety Disorder Bipolar Disorder Depression Eating Disorder Schizophrenia Substance Misuse Personality Disorder Psychosis, other

Question 29

simple lifestyle advice for mild low mood and anxiety

Answer 29

Question 30

services to support perinatal mental health

Answer 30

Question 31

perinatal mental health: pre-conceptual counselling

Answer 31

* Women on psychotropic medications should be advised NOT to discontinue treatment if they find themselves pregnant without consultation with health care professional * Contraception use and pregnancy plans * Implications of pregnancy and childbirth for mental illness and risk of relapse * Implications of and treatment in pregnancy- maternal, fetal and neonatal effects * Risks of no treatment or poor compliance with treatment * Psychiatric review- options of switching to safer treatments of treatment combinations * Option of discontinuing treatment safely

Question 32

the problem with drug treatment for perinatal mental illness

Answer 32

- limited safety data for many psychotropic medications - some are teratogenic - none are of 'proven' safety - risk and beenfits of medications

Question 33

Sodium valproate for the treatment of bipolar disorder in pregnancy

Answer 33

- contraindicated in women of childbearing age for psychiatric indications - increase risk of neural tube defects and neurodevelopmental issues

Question 34

carbamazepine

Question 35

carbamazepine for the treatment of bipolar disorder in pregnancy

Answer 35

associated with cleft lip

Question 36

lamotrigine for the treatment of bipolar disorder in pregnancy

Answer 36

increased risk of steven johnson syndrome

Question 37

Lithiumfor the treatment of bipolar disorder in pregnancy

Answer 37

mother must be able to comply with strict montioring Can cause: - fetal hypotonia - poor reflexes - arrhthmia - Ebsteins anomaly - neonatal goitre (thyroid)

Question 38

olanazepine for the treatment of schizophrenia and bipolar disorders in pregnancy

Answer 38

associated with fetal macrosomnia and GDM

Question 39

SSRIs for the treatment of anxiety and depression in pregnancy

Answer 39

- **Possible birth defects.** There is evidence that taking SSRIs early in pregnancy slightly increases the risk of your baby developing heart defects, spina bifida or cleft lip. -** Increased risk of miscarriage and premature birth.** - **Slightly increased risk of blood loss after childbirth.** If you take SSRI or SNRI antidepressants in the month before giving birth, there is a small increase in your risk of heavy bleeding in the first 24 hours after birth (known as postpartum haemorrhage). - **Withdrawal symptoms in your newborn baby.** Taking any antidepressant in late pregnancy has the risk that your newborn baby will experience withdrawal symptoms. -** If you are breastfeeding, antidepressants can be passed to your baby through your breast milk. **

Question 40

SSRI withdrawal in newborns

Answer 40

**`Neonatal abstinence syndrome** These symptoms include: - With SSRIs and SNRIs: jitteriness, poor muscle tone, not being able to cry loudly, difficulty breathing, low blood sugar (which can cause fits), and high blood pressure in the lungs Management: observation period of 48hrs - Withdrawal symptoms are usually self-limiting and generally occur within 24 – 48 hours (longer for fluoxetine) and typically last 1 -2 days - In almost all cases minimal or no treatment is needed and breastfeeding should continue unless symptoms persist

Question 41

which SSRI causes the majoriy of withdrawal symptoms in neonates

Answer 41

Paroxetine

Question 42

important discussion points with pregnant mother when discussion medication for mental health conditions

Answer 42

1) Risk benefit consideration 2) importance of using drugs whcih are effectuve 3) importance of compliance 4) Neontal syndroems/withdrawa; 5) may not be able to breastfeed with some drugs

Question 43

post natal mental health conditions

Answer 43

- postnatal blues - postnatal depression - postnatal anxiety disorders - puerperal psychosis

Question 44

presentation of post-natal blues or 'baby blues'

Answer 44

* Affects more than half of women after giving birth * Starts within 3 or 4 days, self limiting by around 14 days * Tearfulness, low mood, irritability, feeling anxious, over-reacting

Question 45

cause of baby blues

Answer 45

* Significant hormonal changes * Recovery from birth * Fatigue and sleep deprivation * The responsibility of caring for the neonate * Establishing feeding * All the other changes and events around this time

Question 46

management of baby blues

Answer 46

Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.

Question 47

postnatal depression

Answer 47

* Affects 15% of women * Starts within one or two month of giving birth * Usual depression symptoms * Depending on severity, may struggle to care for baby * Difficulty bonding with baby * Feeling inadequate as a mother * Thoughts about harm coming to baby

Question 48

postnatal depression presentation

Answer 48

Low mood Anhedonia (lack of pleasure in activities) Low energy

Question 49

screening tool for postnatal depression

Answer 49

The **Edinburgh postnatal depression scale** can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression. There are ten questions, with a total score out of 30 points. **A score of 10 or more suggests postnatal depression.**

Question 50

management of mild postnatal depression

Answer 50

- additional support - self-helo - follow up with GP

Question 51

management of moderate postnatal depression

Answer 51

- antidepressant medications (e.g. SSRIs) - cognitive behavioural therapy

Question 52

management of severe postnatal depression

Answer 52

- specialist psychiatry sevrices - ratley inpatient care on mother and baby unit

Question 53

mother and baby unit

Answer 53

The mother and baby unit is a specialist unit for pregnant women and women that have given birth in the past 12 months. They are designed so that the mother and baby can remain together and continue to bond. Mothers are supported to continue caring for their baby while they get specialist treatment.

Question 54

presentation of puerperal psychosis

Answer 54

Puerperal Psychosis Puerperal psychosis is a rare but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as: * Delusions * Hallucinations * Depression * Mania * Confusion * Thought disorder

Question 55

management of puerperal psychosis

Answer 55

Women with puerperal psychosis need urgent assessment and input from specialist mental health services. Treatment is directed by specialist services, and may involve: * Admission to the mother and baby unit * Cognitive behavioural therapy * Medications (antidepressants, antipsychotics or mood stabilisers) * Electroconvulsive therapy (ECT)