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Antenatal and postnatal mental health overview

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Antenatal and postnatal mental health HAI

About

What is covered

In pregnancy and the postnatal period, many mental health problems have a similar nature, course and potential for relapse as at other times. However, there can be differences; for example, bipolar disorder shows an increased rate of relapse and first presentation in the postnatal period. Some changes in mental health state and functioning (such as appetite) may represent normal pregnancy changes, but they may be a symptom of a mental health problem.
The management of mental health problems during pregnancy and the postnatal period differs from at other times because of the nature of this life stage and the potential impact of any difficulties and treatments on the woman and the baby. There are risks associated with taking psychotropic medication in pregnancy and during breastfeeding and risks of stopping medication taken for an existing mental health problem. There is also an increased risk of postpartum psychosis.
Depression and anxiety are the most common mental health problems during pregnancy, with around 12% of women experiencing depression and 13% experiencing anxiety at some point; many women will experience both. Depression and anxiety also affect 15–20% of women in the first year after childbirth. During pregnancy and the postnatal period, anxiety disorders, including panic disorder, generalised anxiety disorder, obsessive–compulsive disorder, post-traumatic stress disorder and tokophobia (an extreme fear of childbirth), can occur on their own or can coexist with depression. Psychosis can re-emerge or be exacerbated during pregnancy and the postnatal period. Postpartum psychosis affects between 1 and 2 in 1000 women who have given birth. Women with bipolar I disorder are at particular risk, but postpartum psychosis can occur in women with no previous psychiatric history.
Changes to body shape, including weight gain, in pregnancy and after childbirth may be a concern for women with an eating disorder. Although the prevalence of anorexia nervosa and bulimia nervosa is lower in pregnant women, the prevalence of binge eating disorder is higher. Smoking and the use of illicit drugs and alcohol in pregnancy are common, and prematurity, intrauterine growth restriction and fetal compromise are more common in women who use these substances, particularly women who smoke.
This pathway makes recommendations for the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth) and in women who are planning a pregnancy. The pathway covers depression, anxiety disorders, eating disorders, drug and alcohol-use disorders and severe mental illness (such as psychosis, bipolar disorder, schizophrenia and severe depression). It covers subthreshold symptoms as well as mild, moderate and severe mental health problems. However, the pathway focuses on aspects of expression, risks and management that are of special relevance in pregnancy and the postnatal period.
In this pathway, 'baby' refers to an infant aged between 0 and 12 months, and 'woman' to a female of childbearing potential, including girls and young women under 18 years.

Updates

Updates to this pathway

16 December 2014 Major update on publication of antenatal and postnatal mental health (NICE guideline CG192).

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Antenatal and postnatal mental health

What is covered

In pregnancy and the postnatal period, many mental health problems have a similar nature, course and potential for relapse as at other times. However, there can be differences; for example, bipolar disorder shows an increased rate of relapse and first presentation in the postnatal period. Some changes in mental health state and functioning (such as appetite) may represent normal pregnancy changes, but they may be a symptom of a mental health problem.
The management of mental health problems during pregnancy and the postnatal period differs from at other times because of the nature of this life stage and the potential impact of any difficulties and treatments on the woman and the baby. There are risks associated with taking psychotropic medication in pregnancy and during breastfeeding and risks of stopping medication taken for an existing mental health problem. There is also an increased risk of postpartum psychosis.
Depression and anxiety are the most common mental health problems during pregnancy, with around 12% of women experiencing depression and 13% experiencing anxiety at some point; many women will experience both. Depression and anxiety also affect 15–20% of women in the first year after childbirth. During pregnancy and the postnatal period, anxiety disorders, including panic disorder, generalised anxiety disorder, obsessive–compulsive disorder, post-traumatic stress disorder and tokophobia (an extreme fear of childbirth), can occur on their own or can coexist with depression. Psychosis can re-emerge or be exacerbated during pregnancy and the postnatal period. Postpartum psychosis affects between 1 and 2 in 1000 women who have given birth. Women with bipolar I disorder are at particular risk, but postpartum psychosis can occur in women with no previous psychiatric history.
Changes to body shape, including weight gain, in pregnancy and after childbirth may be a concern for women with an eating disorder. Although the prevalence of anorexia nervosa and bulimia nervosa is lower in pregnant women, the prevalence of binge eating disorder is higher. Smoking and the use of illicit drugs and alcohol in pregnancy are common, and prematurity, intrauterine growth restriction and fetal compromise are more common in women who use these substances, particularly women who smoke.
This pathway makes recommendations for the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth) and in women who are planning a pregnancy. The pathway covers depression, anxiety disorders, eating disorders, drug and alcohol-use disorders and severe mental illness (such as psychosis, bipolar disorder, schizophrenia and severe depression). It covers subthreshold symptoms as well as mild, moderate and severe mental health problems. However, the pathway focuses on aspects of expression, risks and management that are of special relevance in pregnancy and the postnatal period.
In this pathway, 'baby' refers to an infant aged between 0 and 12 months, and 'woman' to a female of childbearing potential, including girls and young women under 18 years.

Updates

Updates to this pathway

16 December 2014 Major update on publication of antenatal and postnatal mental health (NICE guideline CG192).

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Antenatal and postnatal mental health (2014) NICE guideline CG192
Guidance on the use of electroconvulsive therapy (2003) NICE technology appraisal guidance 59

Quality standards

Quality statements

Continuity of care

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

The woman and baby's individualised postnatal care plan is reviewed and documented at each postnatal contact.

Rationale

Postnatal care should be a continuation of the care the woman received during her pregnancy, labour and birth. Planning and regularly reviewing the content and timing of care, for individual women and their babies, and communicating this (to the woman, her family and other relevant postnatal care team members) through a documented care plan can improve continuity of care.

Quality measures

Structure
Evidence of local arrangements to ensure that the woman and her baby's individualised postnatal care plan is reviewed and documented at each postnatal contact.
Data source: Local data collection.
Process
The proportion of women and their babies who have an individualised and documented postnatal care plan, which is reviewed at each postnatal contact.
Numerator – the number of contacts in which the woman and baby's individualised postnatal care plan is reviewed and documented.
Denominator – the number of postnatal contacts.
Data source: The Maternity Services Secondary Uses Data Set, once implemented, will collect data on the date on which the care plan was created or changed. This covers antenatal, birth and postnatal care plans (global numbers 17201890 and 17201900).
Outcome
Women's satisfaction with the continuity and content of their postnatal care.
Data source: Local data collection. The Care Quality Commission Maternity Services Survey 2010 collected information about women's experiences of maternity care.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place to provide women and their babies with an individualised postnatal care plan, which is reviewed and documented at each postnatal contact.
Healthcare practitioners provide women and their babies with an individualised postnatal care plan, which is reviewed and documented at each postnatal contact.
Commissioners ensure that they commission services in which women are provided with an individualised postnatal care plan, which is reviewed and documented at each postnatal contact.

What the quality statement means for patients, service users and carers

Women and their babies have an individualised postnatal care plan, which is reviewed and documented at each postnatal contact.

Source guidance

Definitions of terms used in this quality statement

Postnatal care plan
The individualised postnatal care plan should be documented and developed with the woman, ideally in the antenatal period or as soon as possible after birth. The plan should be comprehensive and include as a minimum:
  • relevant factors from the antenatal, intrapartum and immediate postnatal period
  • details of a named midwife or health visitor, including a 24 hour telephone number to enable the woman to contact her named healthcare practitioner or an alternative practitioner should he or she not be available
  • details of the healthcare practitioners involved in her care and that of her baby, including roles and contact details
  • plans for the postnatal period including:
    • specific plans for managing pregnancy-related conditions when they occur, such as gestational hypertension, pre-eclampsia, thromboembolism, gestational diabetes, postnatal wound care and mental health conditions
    • details about adjustment to motherhood, emotional wellbeing and family support structures
    • plans for feeding, including specific advice about either breastfeeding support or formula feeding
    • plans for contraceptive care.
(Definition adapted with expert group consensus from NICE clinical guideline 37, recommendation 1.1.3.)
Postnatal contact
Women and their babies should receive the number of postnatal contacts appropriate to their care needs. A postnatal contact is a scheduled postnatal appointment which may occur in the woman or baby's home or another setting such as a GP practice or children's centre. Where a woman remains in hospital following delivery, her postnatal care plan should be reviewed on a daily basis until her transfer home and then reviewed at each subsequent contact.

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. The individualised postnatal care plan and the information within it should be accessible to women, including women who do not speak or read English and those with additional needs such as physical, sensory or learning disabilities.

Maternal health – life-threatening conditions

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women are advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten their lives and require them to access emergency treatment.

Rationale

Women are at increased risk of experiencing serious health events in the immediate hours, days and weeks following the birth, some of which could lead to maternal death or severe morbidity. Providing women with information about the symptoms and signs that may indicate a serious physical illness or mental health condition may prompt them to access immediate emergency treatment if needed. Emergency treatment could potentially avoid unnecessary deaths and severe morbidity.

Quality measures

Structure
Evidence of local arrangements to ensure that women are advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten her life and require her to access emergency treatment.
Data source: Local data collection.
Process
The proportion of women who are advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten her life and require her to access emergency treatment.
Numerator – the number of women in the denominator who are advised, within the first 24 hours, after birth of the symptoms and signs of conditions that may threaten her life and require her to access emergency treatment.
Denominator – the number of women who have given birth.
Data source: Local data collection.
Outcome
a) Incidence of potentially avoidable maternal morbidity and mortality.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on maternal deaths (global number 17207470). The Confidential Enquiries into Maternal Deaths (now undertaken by MBRRACE-UK) reports on rates of maternal death. MBRRACE are expanding their work programme to include severe maternal morbidity.
b) Women feel informed about symptoms and signs of postnatal life-threatening conditions.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women to be advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten their lives and require them to access emergency treatment.
Healthcare practitioners advise women, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten their lives and require them to access emergency treatment.
Commissioners ensure that they commission services that advise women, within 24 hours of the birth, of conditions that may threaten their lives and require them to access emergency treatment.

What the quality statement means for patients, service users and carers

Women are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions that should prompt her to call for emergency treatment.

Source guidance

Definitions of terms used in this quality statement

Expert group opinion is that the first postnatal contact should occur within 24 hours after the birth.
Information provision
The woman should receive accurate, evidence-based verbal and written information. If the woman is too unwell to receive this information within the first 24 hours after the birth, the information should be discussed once the woman has made a recovery and is able to identify symptoms and signs of life-threatening conditions in herself. All women should also be provided with a contact number that can be used at any time of the day or night to seek urgent maternity advice (for example, the labour ward triage number).
Symptoms and signs of life-threatening physical conditions
The following symptoms and signs are suggestive of potentially life-threatening physical conditions in the woman:
  • sudden and profuse blood loss or persistent, increased blood loss
  • faintness, dizziness or palpitations or tachycardia
  • fever, shivering, abdominal pain, especially if combined with offensive vaginal loss or a slow-healing perineal wound
  • headaches accompanied by visual disturbances or nausea or vomiting within 72 hours of birth
  • leg pain, associated with redness or swelling
  • shortness of breath or chest pain
  • widespread rash.
(Definition adapted with expert group consensus from NICE clinical guideline 37, recommendation 1.2.1, table 2.)
Symptoms and signs of life-threatening mental health conditions
The following symptoms and signs are suggestive of potentially life-threatening mental health conditions in the woman:
  • severe depression, such as feeling extreme unnecessary worry, being unable to concentrate due to distraction from depressive feelings
  • severe anxiety, such as uncontrollable feeling of panic, being unable to cope or becoming obsessive
  • the desire to hurt others or yourself, including thoughts about taking your own life
  • confused and disturbed thoughts, which could include other people telling you that you are imagining things (hallucinations and delusions).
(Definition adapted with expert group consensus from RCOG's Good practice point 14, section 5.)

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English. Written and verbal information should be appropriate for the woman's level of literacy, culture and language.

Infant health – life-threatening conditions

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women or main carers of babies are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.

Rationale

Babies may experience serious health conditions in the immediate hours, days and weeks following the birth, which can lead to severe illness or in rare cases, death. Providing the mother or main carer with verbal and written information about the symptoms and signs that might indicate their baby has a serious health problem may result in emergency treatment being sought more promptly. This information should be provided within 24 hours of the birth.

Quality measures

Structure
Evidence of local arrangements to ensure that the women or main carers of babies are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.
Data source: Local data collection.
Process
The proportion of women or main carers of the baby who are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.
Numerator – the number of women or main carers of babies who are advised, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.
Denominator – the number of mothers or main carers of babies.
Data source: Local data collection.
Outcome
a) Incidence of potentially avoidable infant morbidity and mortality.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on neonatal deaths (global number 17209680). The Confidential Enquiries into Perinatal Deaths (now undertaken by MBRRACE-UK) reports on rates of perinatal death. MBRRACE are expanding their work programme to include severe infant morbidity.
b) Women and main carers feel informed about symptoms and signs of potentially life-threatening conditions in the baby.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women or main carers of babies to be advised, within 24 hours of the birth, of the symptoms and signs of potentially life threatening conditions in the baby that require emergency treatment.
Healthcare practitioners advise women or main carers of babies, within 24 hours of the birth, of the symptoms and signs of potentially life-threatening conditions in the baby that require emergency treatment.
Commissioners ensure that they commission services that advise women or main carers of babies, within 24 hours of the birth, of the symptoms and signs of potentially life threatening conditions in the baby that require emergency treatment.

What the quality statement means for patients, service users and carers

Women or the main carer of the baby are advised, within 24 hours of the birth, of the symptoms and signs of potentially life threatening conditions in the baby that require emergency treatment.

Source guidance

Definitions of terms used in this quality statement

Expert group opinion is that the first postnatal contact should occur within 24 hours after the birth.
Information provision
The woman or main carer of the baby should receive accurate, evidence-based verbal and written information. If the baby is unwell and in hospital, the information should be provided to the mother or main carer prior to the baby's discharge.
The woman or main carer of the baby should also be provided with a contact number that can be used at any time of the day or night to seek urgent advice (for example, the labour ward triage number). The woman or main carer of the baby should be advised to contact the emergency services if they are very concerned about their baby's health.
Symptoms and signs of life-threatening conditions in the baby (0–3 months)
The following symptoms and signs are suggestive of potentially life-threatening physical conditions in the baby (0–3 months):
A major change in the baby's behaviour, for example:
  • less active than usual
  • less responsive than usual
  • more irritable than usual
  • breathing faster than usual or grunting when breathing
  • feeding less than usual
  • nappies much less wet than usual
  • has blue lips
  • is floppy
  • has a fit
  • has a rash that does not fade when pressed with a glass
  • vomits green fluid
  • has blood in their stools
  • has a bulging or very depressed fontanelle
  • has a temperature higher than 38°C
  • with the exception of hands and feet, feels cold when dressed appropriately for the environment temperature
  • within the first 24 hours after the birth:
    • has not passed urine
    • has not passed faeces (meconium)
    • develops a yellow skin colour (jaundice).
(Adapted with expert group consensus from information provided in the Department of Health's Birth to Five book [no longer in print but available for download], NICE clinical guideline 149 and NICE clinical guideline 160.)
Main carer
For the majority of babies the main carer will be the mother. For some babies the main carer could be a close relative, for example the baby's father or grandparent, or for looked-after babies this could be a foster parent.

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English.

Infant health – safer infant sleeping

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Safer infant sleeping is discussed with women, their partner or the main carer at each postnatal contact.

Rationale

There are specific behaviours that increase a baby's risk of sudden infant death syndrome. Providing the woman, her partner or the main carer with the opportunity to regularly discuss infant sleeping practices can help to identify and support them and the wider family to establish safer infant sleeping habits, and to reduce the baby's risk of sudden infant death syndrome.

Quality measures

Structure
Evidence of local arrangements to ensure that information about safer infant sleeping is discussed with women, their partner or the main carer at each postnatal contact.
Data source: Local data collection.
Process
a) Proportion of women, their partners or main carers of newborn babies who have a discussion about safer infant sleeping within 24 hours of the birth.
Numerator – the number of women, their partners or main carers of newborn babies who have a discussion about safer infant sleeping within 24 hours of the birth.
Denominator – the number of newborn babies.
Data source: Local data collection.
b) Proportion of women, their partners or main carers of newborn babies who have a discussion about safer infant sleeping at every postnatal contact.
Numerator – the number of postnatal contacts in which women, their partners or main carers of newborn babies have a discussion about safer infant sleeping.
Denominator – the number of postnatal contacts.
Data source: Local data collection.
c) Proportion of women, their partners or main carers of newborn babies who have a discussion about safer infant sleeping at a postnatal contact 10–14 days after the birth (at the midwifery and health visitor handover when the woman and baby are discharged from the care of the community midwifery team to the care of the health visitor).
Numerator – the number of women, their partners or main carers of newborn babies who have a discussion about safer infant sleeping at a postnatal contact 10–14 days after the birth.
Denominator – the number of newborn babies.
Data source: Local data collection.
d) Proportion of women, their partners or main carers of newborn babies who have a discussion about safer infant sleeping at the 6–8 week postnatal check.
Numerator – the number of women, their partners or main carers of newborn babies who have a discussion about safer infant sleeping at the 6–8 week postnatal check.
Denominator – the number of newborn babies.
Data source: Local data collection.
Outcome
a) Incidence of sudden infant death syndrome.
Data source: Office for National Statistics report Unexplained deaths in infancy – England and Wales, 2010.
b) Women's and main carers' knowledge about safer infant sleeping.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women, their partner or the main carer of the baby to have a discussion about safer infant sleeping at every postnatal contact.
Healthcare practitioners ensure that safer infant sleeping is discussed with the woman, her partner or the main carer at every postnatal contact.
Commissioners ensure that they commission services that provide the woman, her partner or the main carer of the baby with the opportunity to discuss safer infant sleeping at every postnatal contact.

What the quality statement means for patients, service users and carers

Women, their partner or the main carer are given the opportunity to discuss safer infant sleeping at every postnatal contact.

Source guidance

Definitions of terms used in this quality statement

Information provision
The woman, her partner or main carer of the baby should receive accurate, evidence-based verbal and written information about safer infant sleeping. This written information should be discussed with the woman, her partner or main carer within 24 hours of the birth, and safer infant sleeping discussed at each subsequent postnatal contact (including 10–14 days after the birth and at the 6–8 week postnatal check).
Main carer
For the majority of babies the main carer will be the mother. For some babies the main carer could be a close relative, for example the baby's father or grandparent, or for looked-after babies this could be a foster parent.
Postnatal contact
Women and their babies should receive the number of postnatal contacts appropriate to their care needs. A postnatal contact is a scheduled postnatal appointment that may occur in the woman or baby's home, a GP practice or children's centre, or a hospital setting if the woman or baby needs extended inpatient care. For the majority of women, babies and families the postnatal period ends 6–8 weeks after the birth.

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English. Verbal and written information should be appropriate in terms of the women's (and their families) level of literacy, culture, language and family circumstances.

Breastfeeding

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women receive breastfeeding support from a service that uses an evaluated, structured programme.

Rationale

Breastfeeding contributes to the health of both the mother and child in the short and longer term. Women should be made aware of these benefits and those who choose to breastfeed should be supported by a service that is evidence-based and delivers an externally audited, structured programme. Delivery of breastfeeding support should be coordinated across the different sectors.

Quality measures

Structure
Evidence of local arrangements for breastfeeding support to be provided through a service that uses an evaluated, structured programme.
Data source: Local data collection.
Process
a) Proportion of women who receive breastfeeding support through a service that uses an evaluated, structured programme.
Numerator – the number of women in the denominator who receive breastfeeding support through a service that uses an evaluated, structured programme.
Denominator – the number of women who breastfeed (exclusively or partially).
Data source: Local data collection.
b) Proportion of women who wanted to continue breastfeeding but stopped before they had planned to.
Numerator – the number of women who wanted to continue breastfeeding but stopped before they had planned to.
Denominator – the number of women who breastfed (exclusively or partially).
Data source: Local data collection.
Outcome
a) Rates of breastfeeding initiation.
Data source: The Maternity Services Secondary Uses Data Set, once implemented, will collect data on 'baby first feed breast milk status' (global number 17205882), 'baby breast milk status (at discharge from hospital)' including exclusive and partial breast milk feeding (global number 17207550). The Infant Feeding Survey 2010 collected self-report data on the prevalence and duration of breastfeeding in the first 8–10 months after the baby was born.
b) Rates of exclusive or partial breastfeeding on discharge from hospital and at 5–7 days, 10–15 days, 6–8 weeks and 16 weeks after the birth.
Data source: The Maternity Services Secondary Uses Data Set, once implemented, will collect data on 'baby first feed breast milk status' (global number 17205882), 'baby breast milk status (at discharge from hospital)', including exclusive and partial breast milk feeding (global number 17207550). The Children and Young People's Health Services Secondary Uses Data Set, once implemented, will collect data on 'breastfeeding status' (global number 17101340), including 'Exclusively Breast Milk Feeding', 'Partially Breast Milk Feeding' and 'No Breast Milk Feeding at all', and also data on observation date (breastfeeding status) (global number 17104440). The Infant Feeding Survey 2010 collected self-report data on the prevalence and duration of breastfeeding in the first 8–10 months after the baby was born.
c) Women's satisfaction with breastfeeding support.
Data source: The Care Quality Commission Maternity Services Survey 2010 collected information about women's experiences of maternity care and this included a section on 'Feeding your baby'.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that women receive breastfeeding support through a service that uses an evaluated, structured programme.
Healthcare practitioners ensure that women receive breastfeeding support through an integrated service that uses an evaluated, structured programme.
Commissioners ensure that they commission a service that delivers breastfeeding support through an evaluated, structured programme.

What the quality statement means for patients, service users and carers

Women receive breastfeeding support through a service that uses an evaluated, structured programme.

Source guidance

  • NICE clinical guideline 37 recommendation 1.3.3 (key priority for implementation)
  • NICE public health guidance 11 recommendations 1 (key priority for implementation) and 7 (key priority for implementation).

Definitions of terms used in this quality statement

Structured programme
NICE clinical guideline 37 recommends that all maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the Baby Friendly Initiative as a minimum standard. If providers implement a locally developed programme, this should be evidence-based, structured, and undergo external evaluation. The structured programme should be delivered and coordinated across all providers, including hospital, primary, community and children's centre settings. Breastfeeding outcomes should be monitored across all services.
Breastfeeding support
All people involved in delivering breastfeeding support should receive the appropriate training and undergo assessment of competencies for their role. This includes employed staff and volunteer workers in all sectors, for example, hospitals, community settings, children's centres and peer supporter services.

Equality and diversity considerations

Breastfeeding support should be culturally appropriate and accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English. Women should have access to an interpreter or advocate if needed. Special consideration will be needed if the mother and baby have been separated for any reason, for example if the baby has been admitted to neonatal care or the baby has been taken into care.

Formula feeding

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Information about bottle feeding is discussed with women or main carers of formula-fed babies.

Rationale

Babies who are fully or partially formula fed can develop infections and illnesses if their formula milk is not prepared safely. In a small number of babies these cause serious harm and are life threatening, and require the baby to be admitted to hospital. The mother or main carer of the baby needs consistent, evidence-based advice about how to sterilise feeding equipment and safely prepare formula milk.

Quality measures

Structure
Evidence of local arrangements to ensure that information about bottle feeding is discussed with women or main carers of formula-fed babies.
Data source: Local data collection.
Process
The proportion of women or main carers of formula-fed babies who have information about bottle feeding discussed with them.
Numerator – the number of women or main carers in the denominator who have information about bottle feeding discussed with them.
Denominator – the number of women or main carers of formula-fed babies.
Data source: Local data collection.
Outcome
a) Rates of hospital admissions for formula feeding-related conditions.
Data source: Local data collection.
b) Women's and main carers' knowledge of how to sterilise feeding equipment and safely prepare formula milk.
Data source: The Infant Feeding Survey 2010 collected self-report data on how mothers prepared powdered formula feed in the last 7 days, including whether they had followed all 3 recommendations for making up feeds (only making 1 feed at a time; making feeds within 30 minutes of the water boiling; and adding the water to the bottle before the powder).
c) Women's and main carers' satisfaction with feeding support.
Data source: The Care Quality Commission Maternity Services Survey 2010 collected information about women's experiences of maternity care and this included a section on 'Feeding your baby'.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that information about bottle feeding is discussed with women or main carers of formula-fed babies.
Healthcare practitioners discuss information about bottle feeding with women or main carers of formula-fed babies.
Commissioners ensure that they commission services in which information about bottle feeding is discussed with women or main carers of formula-fed babies.

What the quality statement means for patients, service users and carers

Women or main carers of formula-fed babies have the opportunity to discuss information about bottle feeding.

Source guidance

Definitions of terms used in this quality statement

Formula-fed baby
This statement relates to mothers and main carers who totally or partially formula feed their baby, and breastfeeding mothers who plan to formula feed their baby.
Information provision
The woman or main carer of the baby should receive accurate, evidence-based information that includes written information about formula feeding.
To ensure the mother or main carer has a good understanding of how to prepare formula feeds, it may be appropriate to give a demonstration as well as discussing bottle feeding.
Main carer
For the majority of babies the main carer will be the mother. For some babies the main carer could be a close relative, for example the baby's father or grandparent, or for looked-after babies this could be a foster parent.

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who don't speak or read English. Verbal and written information should be appropriate in terms of women's (and their families) level of literacy, culture, language and family circumstances.

Infant health – physical examination

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Babies have a complete 6–8 week physical examination.

Rationale

The purpose of the examination is to identify babies more likely to have conditions that would benefit from further investigation and management. This includes an overall physical examination as well as screening for eye problems, congenital heart defects, developmental dysplasia of the hip and undescended testicles. Most babies will be healthy, but the small number of babies who do have serious problems will benefit from prompt identification. Early treatment can improve the health of the baby and prevent or reduce disability.

Quality measures

Structure
a) Evidence of local arrangements to ensure that parents or main carers of babies are offered an appointment for the baby to attend for their 6–8 week physical examination before 10 weeks of age.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that a system is in place to monitor the competency of practitioners undertaking the 6–8 week physical examination.
Data source: Local data collection.
Process
Proportion of babies who have undergone a 6–8 week physical examination.
Numerator – the number of babies in the denominator who have undergone a 6–8 week physical examination.
Denominator – the number of babies aged 10 weeks.
Data source: Local data collection.
Outcomes
a) Incidence of physical abnormalities in babies.
Data source: Local data collection.
b) Health outcomes associated with early intervention for babies with physical abnormalities.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that babies are offered a complete 6–8 week physical examination.
Healthcare practitioners ensure that they perform a complete 6–8 week physical examination of babies and that they maintain the necessary competencies for this role.
Commissioners ensure that they commission services that offer a complete 6–8 week physical examination for babies, which is carried out in timely manner and by a competent practitioner.

What the quality statement means for patients, service users and carers

The mother or main carer of the baby is given the opportunity for their baby to have a complete 6–8 week physical examination, which is carried out in timely manner and by a competent practitioner.

Source guidance

Definitions of terms used in this quality statement

NICE clinical guideline 37 recommendation 1.4.11, 1.4.13 and the Newborn and Infant Physical Examination Standards and Competencies (March 2008) detail the components of the 6–8 week physical examination.
Note on measures
The National Screening Committee recommend that where possible, the baby's 6–8 week physical examination should be combined with the baby's first set of vaccinations to provide a 'one stop service'. However, as the baby's vaccinations should only exceptionally be scheduled before the age of 8 weeks, the 6–8 week examination is usually undertaken when the baby is at least 8 weeks of age. Therefore, for pragmatic reasons the examination should take place before 10 completed weeks of age, that is before 77 days.

Maternal health – weight management

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women with a body mass index (BMI) of 30 kg/m2 or more at the 6–8 week postnatal check are offered a referral for advice on healthy eating and physical activity.

Rationale

The woman's eating habits and physical activity levels could influence the health behaviour of the wider family, including children who are developing habits that may remain with them for life. Supporting the woman in the postnatal period to change her eating habits and physical activity levels may improve her health, her infant's health and the health of the wider family. It may also improve the outcomes of future pregnancies.
Women who are obese during pregnancy face increased risks of complications that include gestational diabetes, miscarriage, pre eclampsia, thromboembolism and maternal death. Risks for the infant include fetal death, stillbirth, shoulder dystocia, and macrosomia. Infants of obese women face health risks in childhood including diabetes and obesity in later life.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women have their BMI assessed and recorded at the 6–8 week postnatal check.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check are offered a referral for advice on healthy eating and physical activity.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that the local workforce has appropriate numbers of staff trained to deliver healthy eating and physical activity services to postnatal women.
Data source: Local data collection.
Process
a) The proportion of women who have their BMI recorded at the 6–8 week postnatal check.
Numerator – the number of women in the denominator who have their BMI recorded.
Denominator – the number of women who attend a 6–8 week postnatal check.
Data source: Local data collection.
b) The proportion of women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check who are offered a referral for advice on healthy eating and physical activity.
Numerator – the number of women in the denominator who are offered a referral for advice on healthy eating and physical activity.
Denominator – the number of women with a BMI of 30 kg/m2 or more who attend a 6–8 week postnatal check.
Data source: Local data collection.
c) The proportion of women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check who accept a referral for advice on healthy eating and physical activity.
Numerator – the number of women in the denominator who accept a referral for advice on healthy eating and physical activity.
Denominator – the number of women with a BMI of 30 kg/m2 or more who attend a 6–8 week postnatal check.
Data source: Local data collection.
Outcome
Women feel able to make informed decisions about healthy eating, physical activity and weight management for themselves and their family.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check to be offered a referral for advice on healthy eating and physical activity.
Healthcare practitioners offer women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check a referral for advice on healthy eating and physical activity.
Commissioners ensure that they commission services that offer women with a BMI of 30 kg/m2 or more at the 6–8 week postnatal check a referral for advice on healthy eating and physical activity.

What the quality statement means for patients, service users and carers

Women who have a body mass index of 30 kg/m2 or more at the 6–8 week postnatal check are offered a referral for advice on healthy eating and physical activity.

Source guidance

Definitions of terms used in this quality statement

Structured programme
Women should be offered a referral to an individual or group-based service that uses a structured programme. NICE public health guidance 11 recommendation 6 states that services should deliver a structured programme that:
  • addresses the reasons why women may find it difficult to lose weight, particularly after pregnancy
  • is tailored to the needs of an individual or group
  • combines advice on healthy eating and physical exercise (advising them to take a brisk walk or other moderate exercise for at least 30 minutes on at least 5 days of the week)
  • identifies and addresses individual barriers to change
  • provides ongoing support over a sufficient period of time to allow for sustained lifestyle changes.
Services should be delivered by an appropriately trained person. This is someone who can demonstrate expertise and competencies in healthy eating and/or physical activity, including weight management for women in the postnatal period. This may include midwives, health visitors, obstetricians, dietitians, GPs, nurses, midwifery assistants, support workers and those working in weight management programmes (commercial or voluntary).
(Adapted with expert group consensus from NICE public health guidance 27, recommendations 3 and 4).
Women who choose not to accept a referral should be given information about where they can get support on healthy eating and physical activity in future.

Equality and diversity considerations

Women should be able to access services that are appropriate to their cultural and religious beliefs, and that make relevant adjustments for anyone who has communication difficulties, and for those who don't speak or read English.

Emotional wellbeing and infant attachment

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women have their emotional wellbeing, including their emotional attachment to their baby, assessed at each postnatal contact.

Rationale

The baby's relationship with the mother (or main carer) has a significant impact on the baby's social and emotional development. In turn, the woman's ability to provide a nurturing relationship is partly dependent on her own emotional wellbeing. Regular assessment of the woman's emotional wellbeing and the impact of this on her attachment to her baby may lead to earlier detection of problems.

Quality measures

Structure
Evidence of local arrangements that women have their emotional wellbeing, including their emotional attachment to their baby, assessed at each postnatal contact.
Data source: Local data collection.
Process
a) Proportion of women whose emotional wellbeing, including emotional attachment to their baby, is assessed at each postnatal contact.
Numerator – the number of postnatal contacts in the denominator in which the mother's emotional wellbeing, including emotional attachment to the baby, is assessed.
Denominator – the number of postnatal care contacts.
Data source: Local data collection.
b) Proportion of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 5–7 days after the birth.
Numerator – the number of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 5–7 days after the birth.
Denominator – the number of women receiving a postnatal contact 5–7 days after the birth.
Data source: Local data collection.
c) Proportion of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 10–14 days after the birth (at the midwifery and health visitor handover when the woman and baby are discharged from the care of the community midwifery team to the care of the health visitor).
Numerator – the number of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 10–14 days after the birth.
Denominator – the number of women receiving a postnatal contact 10–14 days after the birth.
Data source: Local data collection.
d) Proportion of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 6–8 weeks after the birth.
Numerator – the number of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 6–8 weeks after the birth.
Denominator – the number of women receiving a postnatal contact 6–8 weeks after the birth.
Data source: Local data collection.
e) Proportion of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 16 weeks after the birth.
Numerator – the number of women whose emotional wellbeing, including their emotional attachment to their baby, is assessed at a postnatal contact 16 weeks after the birth.
Denominator – the number of women receiving a postnatal contact 16 weeks after the birth.
Data source: Local data collection.
Outcome
a) Incidence of postnatal mental health problems.
Data source: Local data collection.
b) Incidence of mother-to-baby emotional attachment problems.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that women are asked about their emotional wellbeing, including their mother-to-baby emotional attachment, assessed at each postnatal contact.
Healthcare practitioners ensure that women have their emotional wellbeing, including their mother-to-baby emotional attachment, assessed at each postnatal contact.
Commissioners ensure that they commission services that have local agreements to ensure women have their emotional wellbeing, including their mother-to-baby emotional attachment, assessed at each postnatal contact.

What the quality statement means for patients, service users and carers

Women have their emotional wellbeing, including their relationship with their baby (called 'emotional attachment'), assessed at each postnatal contact.

Source guidance

Definitions of terms used in this quality statement

Postnatal contacts
Women and their babies should receive the number of postnatal contacts that are appropriate to their care needs. A postnatal contact is a scheduled postnatal appointment that may occur in the woman or baby's home or another setting such as a GP practice, children's centre or this could be a hospital setting where women and/or the baby requires extended inpatient care.
Emotional wellbeing
NICE public health guidance 40 defines emotional wellbeing as 'being happy and confident and not anxious or depressed'.
Mother-to-baby emotional attachment
This involves the formation of a secure bond between the mother and the baby, in which the mother responds sensitively and appropriately to the baby's signals, providing an environment in which the baby feels secure.

Equality and diversity considerations

Communication between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who don't speak or read English.

Maternal health – mental wellbeing

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Women who have transient psychological symptoms ('baby blues') that have not resolved at 10–14 days after the birth should be assessed for mental health problems.

Rationale

Women experience emotional changes in the immediate postnatal period which usually resolve within 10–14 days after the birth. Women who are still feeling low in mood, anxious, experiencing negative thoughts or lacking interest in their baby at 10–14 days after the birth may be at increased risk of mental health problems. These women should receive an assessment of their mental wellbeing.

Quality measures

Structure
Evidence of local arrangements for women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth to have an assessment for mental health problems.
Data source: Local data collection.
Process
Proportion of women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth who are assessed for mental health problems.
Numerator – the number of women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth who are assessed for mental health problems.
Denominator – the number of women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth.
Data source: Local data collection.
Outcome
Incidence of postnatal mental health problems.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth to have an assessment for mental health problems.
Healthcare practitioners ensure that women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth are assessed for mental health problems.
Commissioners ensure that they commission services with local arrangements for women in whom transient psychological symptoms ('baby blues') have not resolved at 10–14 days after the birth to have an assessment for mental health problems.

What the quality statement means for patients, service users and carers

Women in whom 'baby blues' have not resolved at 10–14 days after the birth are assessed for mental health problems.

Source guidance

Definitions of terms used in this quality statement

Transient psychological symptoms ('baby blues')
NICE clinical guideline 37 recommendation 1.2.25 provides 'tearfulness, feelings of anxiety and low mood' as examples of the symptoms and signs of unresolved transient psychological symptoms.
Assessment for mental health problems
For women who have a possible mental health issue, NICE clinical guideline 45 recommends that healthcare practitioners may consider the use of self-report measures such as the Edinburgh Postnatal Depression Scale (EPDS), Hospital Anxiety and Depression Scale (HADS) or Patient Health Questionnaire-9 (PHQ-9) as part of a subsequent assessment process.

Equality and diversity considerations

Communication between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who don't speak or read English.

Parent–baby attachment

This quality statement is taken from the postnatal care quality standard. The quality standard defines clinical best practice for postnatal care and should be read in full.

Quality statement

Parents or main carers who have infant attachment problems receive services designed to improve their relationship with their baby.

Rationale

Problems with parent-to-baby attachment may result in the baby developing emotional, psychological or behavioural issues in childhood. Providing family-based interventions could improve attachment, thereby providing the building blocks for the child to develop healthy behaviours and mental wellbeing.

Quality measures

Structure
Evidence of local arrangements to ensure that parents or main carers with infant attachment problems receive services designed to improve their relationship with their baby.
Data source: Local data collection.
Process
Proportion of parents or main carers with infant attachment problems who receive services designed to improve their relationship with their baby.
Numerator – the number of parents or main carers with infant attachment problems who receive services designed to improve their relationship with their baby.
Denominator – the number of parents or main carers with infant attachment problems.
Data source: Local data collection.
Outcome
a) Emotional, behavioural and social wellbeing of developing babies.
Data source: Local data collection.
b) Parental or main carer satisfaction with services to support parenting skills.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that parents or main carers with infant attachment problems receive services designed to improve their relationship with their baby.
Healthcare practitioners offer parents or main carers with infant attachment problems services designed to improve their relationship with their baby.
Commissioners ensure that they commission services that have systems in place to offer parents or main carers with infant attachment problems services designed to improve their relationship with their baby.

What the quality statement means for patients, service users and carers

Parents or main carers who are having difficulties forming a bond with their child are able to receive services designed to improve their relationship with their baby.

Source guidance

Definitions of terms used in this quality statement

Services to improve parent-baby relationships
Services have the aim of promoting emotional attachment and improving parenting skills. Services should be tailored to the needs of the family and baby and may include the woman, partner and wider family. Services should be sensitive to a wide range of attitudes, expectations and approaches in relation to parenting. NICE public health guidance 40 provides guidance about the types of services which may provide additional parenting support, for example a series of intensive home visits delivered by an appropriately trained nurse, baby massage and video interaction.
Main carer
For the majority of babies the main carer will be the mother. For some babies the main carer could be a close relative, for example the baby's father or grandparent, or for looked-after babies this could be a foster parent.

Equality and diversity considerations

In order to promote equality, the parents of babies who are vulnerable to poor parent-baby relationships may require additional intensive support. Services should take into account the parent's first language, and this may influence the interventions to achieve specified goals around the baby's communication, speech and language development.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

When prescribing psychotropic medication for women of childbearing potential, take account of the latest data on the risks to the fetus and baby.
Consider gradually stopping benzodiazepines in women who are planning a pregnancy, pregnant or considering breastfeeding.
When choosing an antipsychotic, take into account that there are limited data on the safety of these drugs in pregnancy and the postnatal period.
Do not offer depot antipsychotics to a woman who is planning a pregnancy, pregnant or considering breastfeeding, unless she is responding well to a depot and has a previous history of non-adherence with oral medication.
Do not offer valproate for acute or long-term treatment of a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeeding.
If a woman is already taking valproate and is planning a pregnancy, advise her to gradually stop the drug because of the risk of fetal malformations and adverse neurodevelopment outcomes after any exposure in pregnancy.
Do not offer carbamazepine to treat a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeedin
If a woman is already taking carbamazepine and is planning a pregnancy or becomes pregnant, discuss with the woman the possibility of stopping the drug (because of the risk of adverse drug interactions and fetal malformations).
Do not offer lithiumAlthough this use is common in UK clinical practice, at the time of publication (December 2014), lithium did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective.
If antipsychotic medication has not been effective and lithium is offered to a woman who is planning a pregnancy or pregnant, ensure:
  • the woman knows that there is a risk of fetal heart malformations when lithium is taken in the first trimester, but the size of the risk is uncertain
  • the woman knows that lithium levels may be high in breast milk with a risk of toxicity for the baby
  • lithium levels are monitored more frequently throughout pregnancy and the postnatal period.
Recognise that women who have a mental health problem (or are worried that they might have) may be:
  • unwilling to disclose or discuss their problem because of fear of stigma, negative perceptions of them as a mother or fear that their baby might be taken into care
  • reluctant to engage, or have difficulty in engaging, in treatment because of avoidance associated with their mental health problem or dependence on alcohol or drugs.
All healthcare professionals providing assessment and interventions for mental health problems in pregnancy and the postnatal period should understand the variations in their presentation and course at these times, how these variations affect treatment, and the context in which they are assessed and treated (for example, maternity services, health visiting and mental health services).
  • she should not be secluded after rapid tranquillisation
  • restraint procedures should be adapted to avoid possible harm to the fetus
  • when choosing an agent for rapid tranquillisation in a pregnant woman, an antipsychotic or a benzodiazepine with a short half-life should be considered; if an antipsychotic is used, it should be at the minimum effective dose because of neonatal extrapyramidal symptoms; if a benzodiazepine is used, the risks of floppy baby syndrome should be taken into account
  • during the perinatal period, the woman's care should be managed in close collaboration with a paediatrician and an anaesthetist.
If a pregnant woman has taken psychotropic medication with known teratogenic risk at any time in the first trimester:
  • confirm the pregnancy as soon as possible
  • explain that stopping or switching the medication after pregnancy is confirmed may not remove the risk of fetal malformations
  • offer screening for fetal abnormalities and counselling about continuing the pregnancy
  • explain the need for additional monitoring and the risks to the fetus if she continues to take the medication.
Seek advice from a specialist if there is uncertainty about the risks associated with specific drugs.

Glossary

Cognitive behavioural therapy
Severe and incapacitating depression, psychosis, schizophrenia, bipolar disorder, schizoaffective disorder and postpartum psychosis.
A formal psychological intervention usually delivered face to face (either in a group or individually) by a qualified therapist who has specific training in the delivery of the intervention.
(Serotonin-) noradrenaline reuptake inhibitor
Selective serotonin reuptake inhibitor
Tricyclic antidepressant

Paths in this pathway

Pathway created: November 2011 Last updated: December 2014

© NICE 2014

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