The British Journal of Midwifery's September editorial, ‘perinatal mental health support in the UK’ (Allkins, 2023), highlighted the need to support women with mental health problems during pregnancy. This article focuses on a collaborative approach to supporting a woman with a pre-existing mental health condition.
The development of perinatal mental health services in Ireland is guided by their counterparts internationally, particularly in the NHS. The National Institute for Health and Care Excellence (NICE, 2020) stated that the population risk for bipolar affective disorder is approximately 1%. Nevertheless, for women who have a diagnosis of bipolar affective disorder, there can be significant impact on both the individual and their family. The condition is characterised by periods of depression and periods of hypomania or mania; in some instances there can be features of both depression and mania during the one episode. Common symptoms associated with these mood changes are listed in Table 1.
Table 1. Symptoms of bipolar affective disorder
| Depression | Mania |
|---|---|
| Feeling sad, hopeless or Irritable most of the time | Feeling very happy, elated or overjoyed |
| Poor energy | Speaking very quickly |
| Difficulty sleeping or sleeping too much | Increased energy |
| Difficulty concentrating and remembering things | Feeling self-important |
| Loss of interest in everyday activities | Feeling full of great new ideas and having important plans (grandiosity) |
| Feelings of emptiness or worthlessness | Being easily distracted |
| Changes to appetite, lack of interest in food or over eating | Being easily irritated or agitated |
| Feelings of guilt and despair | Reduced need for sleep |
| Feeling pessimistic about everything | Being delusional, having hallucinations and disturbed or Illogical thinking |
| Delusional, having hallucinations and disturbed or illogical thinking | Reduced appetite |
| Early morning wakening | Saying things that are out of character, often risky or harmful |
| Suicidal thoughts or thoughts of self harm | Behaving in a way that is very out of character |
Source: NICE, 2020
A systematic review by Wesseloo et al (2016) established that for women with a diagnosis of bipolar affective disorder, there was a relapse risk for 1 in 3 women in the postpartum period. These women were more likely to require inpatient psychiatric admission than women with any other psychiatric diagnosis, including schizophrenia. Ireland has no mother and baby unit (National Mental Health Division, 2017). Therefore, unfortunately, for women with bipolar affective disorder who require inpatient treatment, there is a possibility that they may be admitted to a general adult psychiatry ward, most likely without their baby.
Women with bipolar affective disorder are at increased risk of developing postpartum psychosis, a severe and potentially life-threatening condition for both mother and baby. Approximately 5% of women affected by postpartum psychosis end their life by suicide and 4% commit infanticide (Spinelli, 2009). As a result of the severity of postpartum psychosis and the increased risk to the life of the mother and her baby, all healthcare professionals need to be aware of the symptoms of the condition, in order to identify women who are more at risk of developing it. An estimated 134 women in Ireland experience postpartum psychosis each year, although it is thought this number under-represents the true incidence rates, because of challenges around how diagnoses are reported and recorded in different areas. (National Mental Health Division, 2017).
Interdisciplinary working in perinatal mental health
Given the statistics related to women with bipolar affective disorder, promoting interdisciplinary mental health services is critical across the perinatal period (Knight et al, 2022). The specialist perinatal mental health services, and specifically the clinical nurse specialist, have key roles and responsibilities in the care of women with bipolar affective disorder, which often require them to provide and co-ordinate shared care. The clinical nurse specialist's responsibilities include patient focus, patient advocacy, education and training. The principles of care for pregnant women with bipolar affective disorder include co-ordination across services, with clear responsibilities for each distinct time period outlined (NICE, 2020).
As registered advanced nurse practitioners are introduced to perinatal mental health services in Ireland, it is anticipated that leading and co-ordinating episodes of care for such vulnerable women falls in the remit of registered advanced nurse practitioner. Clinical case reviews have proved valuable in nursing; researchers such as Huang et al (2012) found that they can inform nurses’ decision-making skills during episodes of complex care. Raising midwives’ awareness of risk factors and presentations for mental illness enhances confidence when caring for these women (Noonan et al, 2018). This approach requires healthcare professionals to work in close collaboration and is illustrated though Kathleen's journey, organised around a clinical case study framework (Box 1). Permission was sought from the women involved in this case review, and ‘Kathleen’ is a pseudonym.
Box 1.Case and backgroundKathleen (pseudonym) is a 33-year-old woman, recently married and in her first pregnancy. She lives with her husband and parents, and works 30 hours/week in the family business. She has a diagnosis of bipolar affective disorder, type 1, since the age of 19 years. She has experienced depressive episodes, which featured significant and life-threatening self-harm episodes. During other episodes of depression, she has experienced psychotic symptoms. She has experienced several episodes of hypomania and one episode of mania. Kathleen has been hospitalised for her safety on eight occasions, with one of these admissions being on an involuntary basis. The duration of the admissions ranged from 2 weeks to 4 months. Her last admission was 7 years ago. In the past 7 years, she has remained stable on a pharmacological regime, including lithium 1000mg/day. She planned a pregnancy with her husband but did not discuss this with her adult mental health team and was not offered the pre-conception assessment service from the local specialist perinatal mental health team. Physically, her pregnancy was uncomplicated until approximately 28/40 weeks, when she developed gestational diabetes, which was managed with diet and lifestyle moderations.
Kathleen's journey demonstrating interdisciplinary working
Prior to becoming pregnant, Kathleen was actively engaged with a community mental health team, with attendance every 3 months for review and monitoring of lithium plasma levels. She had not been offered or requested any preconception mental health assessment. When Kathleen became pregnant (discovered at 5/40 weeks) and informed her community mental health team, they immediately linked with the specialist perinatal mental health team to arrange an urgent pharmacological regime review.
Midwifery and obstetric care was under the consultant obstetrician who leads care for women with severe and enduring mental illness. A joint clinic is run with the specialist perinatal mental health team and Kathleen attended both clinics within 3 days of initial contact.
Kathleen was initially assessed by the perinatal consultant psychiatrist and a full history was taken. Specific attention was given to her prescription of lithium (1000 mg/day). This was a long-term prescription since her acute episodes of mania and depression. Once stabilised on this medication 7 years ago, with good quality of life, she experienced no readmissions or relapses, returned to work, started a relationship and became pregnant. However, some studies have associated lithium with a slight increase in birth defects, most commonly cardiac defects, so careful consideration of this medication was needed. Munk-Olsen et al (2018) reported no association between lithium and birth defects. Pharmacological decisions during pregnancy are guided by the British Association for Psychopharmacology's (McAllister-Williams et al, 2017) consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum. These guidelines highlight the need to balance the risks to the fetus versus the potential risks/benefits of the medication for the mother, and to consider the risks associated with relapse or untreated perinatal mental illness (Table 2). It was decided that reducing Kathleen's lithium dose could potentially lead to relapse and the risk factors associated with managing an acute episode while pregnant were considered.
Table 2. Balancing risks of treatment vs discontinuation of psychotropic medication
| Risk of continuation | Risk of discontinuation |
|---|---|
| Rare congenital malformation, thought to occur in 1 in 20000 live births, anomaly scan and additional scans recommended | Risk of relapse for women with bipolar affective disorder increased two fold during pregnancy, especially for women with history of depression or affective psychosis |
| Increased risk of lithium toxicity in third trimester so increased monitoring is recommended | Risk of factors associated with untreated Illness including increase In smoking, drinking, substance use, poor self-care, neglect and poor nutrition |
| Risk of postpartum relapse 23% | Risk of postpartum relapse 66% |
Adapted from: McAllister-Williams et al (2017)
Kathleen was advised that her lithium levels would be reviewed or monitored monthly for the first and second trimester, as plasma levels tend to decrease from as early as 6/40 weeks, which could potentially result in sub-therapeutic plasma levels, most likely requiring an increase in lithium (Rosso et al, 2016). At this stage, Kathleen was referred to the clinical nurse specialist in the specialist perinatal mental health team, with the expectation of developing a therapeutic alliance and commencing engagement regarding the pre-birth planning meeting. It was expected that they would work together to develop plans to maintain mental stability, and provide early intervention if any deterioration occurred in mental state during the pregnancy and postpartum periods. Available parenting supports in the local community were explored, and it was decided that the appropriate referrals would be made later in the pregnancy.
Pre-birth planning meeting
A pre-birth planning meeting is a valuable mechanism, bringing together key healthcare professionals with women and their families to plan care for the remainder of pregnancy, hospital admission and the postpartum period (NHS, 2019). Pre-birth planning meetings generally occur around 32/40 weeks and a copy of the minutes from this meeting is kept by all professionals involved. A copy was also held by Kathleen, in her case.
The clinical nurse specialist facilitated Kathleen to outline her mental health history, her early warning signs of relapse and the supports she had available to her. Kathleen's self-efficacy was encouraged and supported to facilitate her to tell her story and be an active participant in her plan of care. The meeting included Kathleen and her husband, the clinical nurse specialist, perinatal consultant psychiatrist and the registrar from the specialist perinatal mental health team. The community mental health nurse, who was familiar with Kathleen and engaged in her care, attended on behalf of the community mental health team. Both the consultant obstetrician and registrar attended, as well as midwives from the antenatal clinic, and the antenatal, labour and postnatal wards. Kathleen's GP and public health nurse were also in attendance. The meeting therefore included professionals across primary, secondary and tertiary services, encompassing obstetrics, mental health and public health services.
This meeting followed the format outlined by the NHS (2019) pre-birth planning: best practice toolkit for perinatal mental health services. One major early warning sign and potential trigger for deterioration of Kathleen's mental state was reduced or disturbed sleep. Kathleen described a relapse pattern where she may be overstimulated, and have difficulty initiating sleep and falling into a deep sleep. This would have a negative impact on her mood and could potentially be a prodrome for a manic episode (Ritter et al, 2011). The risk of postpartum deterioration was discussed in terms of the potential risks to herself and the baby, as well as risks from others to Kathleen. She had a significant history of deliberate self-harm via a potentially lethal method, as well as risks associated with her character, as when she was manic, she behaved in a way that was not in keeping with her personality.
Kathleen's strengths and protective factors were outlined, which included her concordance with the pharmacological regime, the 7-year period of being mentally stable and her engagement with both the specialist perinatal mental health team and community mental health team. Kathleen lived with her husband and parents, who were all supportive towards her in terms of her emotional and physical wellbeing.
The specifics of Kathleen's care for each stage of pregnancy and postpartum were discussed, and key care commitments were made (Table 3).
Table 3. Care commitments
| Stage/settlng | Commitment to care |
|---|---|
| Antenatal care |
|
| Antenatal admission |
|
| Labour and birth |
|
| Postnatal ward admission |
|
| Maternity hospital discharge planning |
|
| Crisis plan |
|
Outcome
As is often true for complex cases, some aspects could not be predicted. Kathleen was diagnosed with gestational diabetes, which was well controlled. However, around 38/40 weeks, her blood sugars became harder to regulate. Baby size for gestational age was large and the decision was taken to plan induction. When it began, a lithium level revealed her plasma level was climbing to potentially toxic levels. This necessitated an abrupt withdrawal of lithium while Kathleen was in labour,, with commencement of intravenous fluids to increase hydration and reduce the potential for toxicity. To counter the abrupt withdrawal of lithium, a low dose of an anti-psychotic, Olanzapine, was prescribed.
Kathleen delivered a healthy baby boy 16 hours after induction began and while she did miss some sleep, the Olanzapine aided sleep the following night. Lithium was recommenced on day 1 postpartum, at the pre-pregnancy dose of 1000mg/day with daily lithium level monitoring. Kathleen was facilitated with a quiet single room with less stimulation, her baby was fed overnight, and she was facilitated with increased visiting from her husband and daily reviews by both the obstetric and specialist perinatal mental health team. Her baby was reviewed by the neonatology team, who reported the baby as healthy and well. Kathleen was discharged on day 6 postpartum and was mentally well and stable, having not experiencing any fluctuations in mood.
During each day of admission, the specialist perinatal mental health team liaised with, and provided guidance and support to, midwives on the wards. These midwives were well placed to observe subtle changes in mental state and were informed of what symptoms to look for and the potential impact of any changes to mental state. This specific protected time between the specialist perinatal mental health team and ward midwives facilitated collaboration between the different disciplines, enabling a sharing of knowledge and experience.
Kathleen's outcome was what every mother hopes for; she left the hospital with both herself and her baby healthy and happy. She continues to be mentally well, now 18 weeks’ postpartum. Given the high risk of relapse and the significant potential for a postpartum psychosis, she attributes this outcome to the ‘safety net’ provided by the professionals involved. In this case, individual members of the team worked well together. Different mental health teams provided shared care in a way that was not familiar to them. The obstetric and mental health teams worked side by side, developing and adjusting care plans as required, providing robust care to Kathleen. Midwives in the hospital, and community services engaged with each other, developing new relationships and respect for each other's roles and practices. Community colleagues, such as the public health nurse and GP, engaged with the specialist perinatal mental health, community mental health and obstetric teams in a way that was not familiar to them. All interdisciplinary professionals working in their own fields came together for a common goal, to give Kathleen the best chance to avoid relapse. Kathleen and her family did not experience the trauma of a postpartum relapse.
Conclusions
Pregnancy and the postpartum period are a special time for a woman's life. Women who have enduring severe mental health issues, such as bipolar affective disorder, require support during such a vulnerable time. Women with bipolar affective disorder have the potential to become seriously mentally ill, with possibly devastating consequences for women, babies, families and society in general. As professionals, it is our responsibility to develop our services and respond to meet the needs of these women. This case review demonstrates that when services collaborate, outcomes for vulnerable perinatal women are improved. Discussing Kathleen's journey illustrates the clinical and organisational collaboration with women and their partners during this high-risk time. The case review strives to promote discussion of the complexities surrounding the perinatal health needs and support for women and their families.
‘My baby is 18 weeks old now. I am mentally well and stable. Having all the right mental health and obstetric supports in place supported me to become the mother I hoped and dreamed I would be’ Kathleen
Education and support for midwives is essential in continuing to promote quality care with women with complex needs. It is critical to increase knowledge of the mental healthcare needs of this vulnerable cohort of women among midwives and obstetricians, and similarly for mental health practitioners to increase their understanding of pregnancy and its potential impacts on a woman's mental health.
Key points
- When services are open to new ways of working, great work can be done for the benefit of women.
- Pre-birth planning meetings are an essential means of bringing many services together to form a strong safety net for vulnerable populations of women, such as those with bipolar affective disorder.
- Most professionals in healthcare have a goal to achieve good outcomes for patients; bringing together like-minded professionals for the benefit of the patient is a positive experience for all involved.
CPD reflective questions
- Is engaging in this way of team working a new concept?
- What would you foresee these challenges to working in this way?
- What are the potential benefits of working in this way?
- Could you envision working in this way within your healthcare setting?
- How do you think Kathleen felt at the pre-birth planning meeting? In terms of discussing her mental health history and planning for the future?