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Contents lists available at ScienceDirect

Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Case study

Midwifery care: A perinatal mental health case scenario

Joanne Marnes *, Pauline Hall 1
University of South Australia, School of Nursing and Midwifery, GPO Box 2471, Adelaide, South Australia 5001, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 14 May 2013 Received in revised form 12 July 2013 Accepted 15 July 2013 Keywords: Postnatal Depression Psychosocial assessment Midwifery Screening

The establishment of the National Perinatal Depression Initiative (NPDI, 20082013) has brought a focus across Australia for the need to identify women at risk of perinatal mental health disorders, suggesting that routine screening by relevant health professionals may aid earlier detection, better care and improved outcomes. Midwives are frequently the primary point of contact in the perinatal period and thus ideally placed to identify, interpret and manage complex situations, including screening for perinatal mental health disorders. This paper offers strategies that could be implemented into daily midwifery practice in order to achieve the goals consistent with the National Perinatal Depression Initiative. A case study (Jen) and discussion, guided by recommendations from the Australian Nursing and Midwifery Competency standards and beyondblue Clinical Practice Guidelines, are used to demonstrate how midwifery care can be provided. In accordance with her legal obligations, the midwife should act within her scope of practice to undertake a series of psychosocial and medical assessments in order to best determine how midwifery care and support can be of benet to Jen, her infant and her family. Suggestions described include administration of validated screening questionnaires, clinical interview, physical assessment, discussion with partner, awareness of the motherinfant interactions and questioning around babys sleep and feeding. Based on evaluation of the information gained from a bio-psycho-social assessment, suggestions are made as to the midwifery care options that could be applied. 2013 Australian College of Midwives All rights reserved.

1. Background The establishment of the National Perinatal Depression Initiative1 (NPDI, 20082013) by the Australian government has brought an integrated focus for relevant health professionals to screen antenatal and postnatal women in order to identify those at risk of perinatal mental health disorders. The aims of the NPDI include increased awareness and screening for perinatal mental health disorders, improved training for health professionals and additional perinatal and infant mental health programmes and facilities to complement existing services. It is hoped that this will achieve earlier detection, better care and improved outcomes for women and their families.1 Midwives in Australia are guided by the National Competency Standards for the midwife2 and a Code of Ethics3 in the provision of woman-centred care for each individual woman. The resulting professional relationship, built on trust, leaves midwives ideally placed to identify, interpret and manage complex situations, including screening for perinatal mental health disorders.

* Corresponding author. Tel.: +61 8 8302 1832; fax: +61 8 8302 2168. E-mail address: nursing.enquiries@unisa.edu.au (J. Marnes). 1 Tel.: +61 8 8302 1832; fax: +61 8 8302 2168.

Perinatal mental health clinical practice guidelines were internationally peer reviewed, endorsed by the National Health and Medical Research Council (NHMRC) and published in 2011.4 Recommendations include that women should be offered routine screening using the Edinburgh Postnatal Depression Scale (EPDS)5 in the antenatal and postnatal period, alongside questions around psychosocial domains. The EPDS5 is a widely used 10-item selfadministered scale used to measure current symptoms of depression, with research supporting its effectiveness in the identication of both perinatal depression and anxiety.6,7 The Antenatal Risk Questionnaire (ANRQ)8 is a 9-item self-report questionnaire based upon psychosocial risk factors and has been shown to be highly acceptable for use in practice by both women and midwives.8 The Postnatal Risk Questionnaire (PNRQ) is a 12item equivalent, with the additional three questions relating to the experiences of birth and early parenting. Both the ANRQ and PNRQ are currently used routinely in some Australian jurisdictions and include specic questions whereby a positive response can indicate that a woman may be at a high risk of developing perinatal depression and/or other mental health problems.8 Copies of the scales can be downloaded via the beyondblue9 and Black Dog Institute10 websites. This semi-ctional case study represents a scenario similar to which midwives are likely to come across in practice, and will be

1871-5192/$ see front matter 2013 Australian College of Midwives All rights reserved. http://dx.doi.org/10.1016/j.wombi.2013.07.002

Please cite this article in press as: Marnes J, Hall P. Midwifery care: A perinatal mental health case scenario. Women Birth (2013), http:// dx.doi.org/10.1016/j.wombi.2013.07.002

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used to demonstrate how midwifery care could be provided in accordance with good practice recommendations.4 The case scenario will be described, highlighting the key issues presented. Discussion of appropriate midwifery care, support and referral options will be offered. All names presented are pseudonyms. 1.1. Scenario Jen is a 35-year-old primiparous woman who has never had a sick day in her life. She and her partner, Pete, have recently had Becki, their rst baby, after 5 years trying to conceive. The couple achieved this pregnancy following several attempts using Assisted Reproductive Technology (ART). Jen gave up work as a primary school teacher at 36 weeks and plans to spend the next 5 years at home looking after Becki. Jen attended all antenatal care; her EPDS scale during pregnancy was scored at two, and her ANRQ score was eleven (the highest scoring item indicated that she likes to have a tidy house). Pete has contacted the midwife now that Becki is three weeks old saying he is concerned about Jen, she seems to be crying all the time for no reason and the house is more untidy than he has ever seen it. 2. Case scenario key issues Midwives are often under pressure to respond quickly to presenting clinical situations; this includes accurate identication of key issues. Points to note in this scenario are that Jen is crying all the time and her partner is concerned she is not acting her normal self. As Jens baby is now three weeks old, any baby blues are likely to have passed11 suggesting that this is not the reason for Jens tearfulness. With the timing of onset and described symptoms, it is possible that Jen may be suffering from postnatal depression (PND) and/or anxiety; conditions which affect up to one in seven women during the postnatal period.12 Another key issue is the suggestion that Jen, who likes to have a tidy house, has a perfectionist type personality which has been linked to PND.12 Additionally, it is possible that the couples difculties to conceive generated some level of prenatal anxiety,13,14 as research has also linked such technologies as Assisted Reproductive Technology (ART) to PND.15 Antenatal anxiety and depression are strongly associated with the occurrence of PND and, as recommended,4,16 Jen undertook antenatal screening for these disorders. Her EPDS score would be indicative of no risk of current depression, while her ANRQ score would be considered low risk, suggesting that Jen does not present with many of the risk factors usually considered to be signicant in the development of perinatal mental health disorders. However, it is important to note that these screening tools are only part of the assessment made by health professionals and do not give a denitive diagnosis.17 The scenario describes a lifestyle change for Jen as not only has she become a parent, she has also left her job and is now intending to stay home full time with Becki. This change requires Jen to adapt to a new life, which currently is a challenging one with the demands of early parenthood and associated effects on rest, comfort and emotions, alongside the physiological changes arising in the postnatal period.11 Jen may be feeling isolated as, being her rst baby, she may not yet have developed a new social network of friends and may be missing her work life and colleagues. 3. Discussion The overarching framework of woman-centred care is extended to include the womans family,3 relevant here as it is Pete who has made contact. The midwife has a duty of care to both Jen and her family.18 In order to be able to support Jen and her family as

required,2,3 the midwife needs to establish exactly what the issues are and their likely aetiology, as the risk factors for any mental illness can be psychological, social, and/or biological.14 As Jen has not made the initial request for help, the midwife needs to be sensitive in her approach, acknowledging the need for more information and understanding that she has only heard one perspective from Jens partner. Having explored Petes concerns further and providing him with relevant information and support, the midwife should offer to meet with Jen prior to the scheduled six week postnatal check. When the appointment does take place, it should allow time for adequate assessment, a home visit being ideal as women are often more comfortable talking about sensitive issues in the privacy of their own surroundings.17 3.1. Midwifery based bio-psycho-social assessment At the appointment, the midwife could gather information to help assess Jens mental health by readministering the EPDS in conjunction with a psychosocial scale such as the Postnatal Risk Questionnaire (PNRQ); this may identify whether Jen is experiencing symptoms of depression and/or anxiety, potentially indicating their source. The midwife should ensure that Jen understands how to use these tools and their purpose, before gaining and documenting consent.4 Jen should also be given the opportunity to go through the questionnaires alone because her answers may be inuenced by the presence of others.19 It is recognised that the EPDS can generate false positive results,20 thus suggesting some women are experiencing symptoms of depression but who are in fact not likely to be depressed. False positive results are particularly likely when screening is undertaken in the immediate postpartum period; the primary cause being the high prevalence of postpartum blues21 reported to affect 3075% of women during the rst week postpartum.22 Postpartum blues or baby blues typically improve with adequate self care, such as rest and good nutrition and usually remit within two weeks after onset.23 An EPDS score obtained from Jen at three weeks postpartum should therefore be reliable. Discussion should aim to clarify Jens answers24 and used to actively listen and respond to any questions Jen may have. The midwife can note her scores, including any variation between previous and current results, paying close attention to particular responses or totals which may place Jen in the signicant risk category.4 Within Australia, a low risk ANRQ score would mean that Jen should have received an information pamphlet on emotional wellbeing in the antenatal period,25 as the provision of such literature is recommended to be part of routine antenatal care. Such resources are currently provided free of charge in Australia by beyondblue and may be downloaded via the beyondblue website25 for access in other countries. Having read this information, Jen may have recognised in herself some of the symptoms of the mental health problems described and wish to discuss them. At this point, the midwife should again provide verbal and written information, to both Jen and Pete, about the signs, symptoms and treatment options for perinatal mental health problems.12 The transition to motherhood, with its profound changes to lifestyle in combination with the often unrelenting and unpredictable nature of early parenting, has been shown to increase the occurrence of mental health problems.26 Research has shown that women with perfectionist personalities may be more vulnerable than others, as the stress of their unrealistic high standards leads to feelings of guilt and of being overwhelmed.19,27 Additionally, women who have experienced fertility issues may have an idealised view of parenthood and are consequently unprepared for the reality,28 with some studies demonstrating that ART carries a higher risk of developing PND.15 Others suggest however, that the

Please cite this article in press as: Marnes J, Hall P. Midwifery care: A perinatal mental health case scenario. Women Birth (2013), http:// dx.doi.org/10.1016/j.wombi.2013.07.002

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higher incidence of PND amongst ART births is linked to the higher rate of multiple births and increased maternal age, rather than the ART itself.29,30 Either way, early postnatal care should assist Jen with this transition,2,3 with the midwife offering reassurance that emotional changes are normal at this time.31 The screening results can be analysed using the relevant guidelines, noting any high risk answers, in conjunction with clinical judgement, to evaluate whether further care or referral would be appropriate.32 Through conversation and open ended questions, the midwife may identify problems such as infant settling issues, feeding concerns or lack of sleep which has been associated with the development of PND in susceptible women.33,34 The midwife should explore the details surrounding these, as well as discover whether Jen is taking (or recently ceased) any medications, as these can also be risk factors for perinatal mental health disorders.32 A physical assessment of both mother and baby may aid the midwife to recognise any feeding or physical health issues, such as pain, impacting on Jens mood and behaviours.35,36 Reection on Jens birth experience may be useful to identify the cause behind her symptoms, for example, a large blood loss may have caused anaemia, resulting in fatigue and affecting her ability to cope.37,38 3.2. Motherinfant relationship During a home visit the midwife can observe interactions and behaviours between Jen and her baby. Evidence has shown that motherinfant interaction disturbed by depressive symptoms can result in poor attachment relationship.4,39 Woman-centred care involves caring for the infant and the wellbeing of Jens baby should be considered at all times.24 Seminal work by Bowlby40 describes attachment as an enduring emotional bond that connects one person to another. Secure attachment is formed when the parenting relationship is warm, safe, responsive and reliable and when basic needs are satised. Where secure attachment exists there is a balance between the infants exploration and attachment behaviour. Secure infants have a clear preference for their caregiver in times of distress.41,42 Secure attachment appears to offer some protection from postnatal depression26 and so the midwife should foster positive relationships between Jen and Becki, reinforcing the relationship with acknowledgement and praise of Jens abilities as a mother. Attachment disorders arise due to negative experiences in the early parentinfant relationship. Insecure attachment occurs due to unresponsive, intrusive or unpredictable parenting where basic needs and nurturing are not met consistently. Children who are insecurely attached cannot always use their caregivers as a secure base and they have difculties with emotional regulation. Insecure attachment has been shown to have damaging effects on the cognitive, emotional and behavioural development of children, with long term problems impacting into adulthood.19,43 However, it is important to note that insecure attachment may present in various forms26 and so observations, while potentially indicative of maternal mental health disorders, are not diagnostic. It is not a midwives role to diagnose motherinfant attachment problems, but with basic awareness of what to recognise midwives can appropriately refer for early intervention. If there are concerns, the family should be referred for a parentinfant assessment by a suitably qualied professional or team.32 3.3. Social support Women benet from both practical and emotional support during the postnatal period44 and the midwife should try to ascertain what level of support Jen is receiving, noting that, as a women who has suffered with fertility issues, she may feel unable

to express negativity or may feel she is not entitled to support.28 These issues should be addressed sensitively, possibly through analysis of the PNRQ and also through conversation, whilst being alert to any signs of domestic violence or other abuse which may indicate the need to talk in private. As fathers can also be affected by the transition to parenthood, nding themselves unclear how to be involved,45 Pete could be provided with the Dads handbook, A guide to the rst 12 months resource from beyondblue.46 This resource provides psychoeducation, and will help inform Pete how he can look after his own physical and mental health while adjusting to life with a new baby, as well as how to maintain a positive relationship with Jen.46 There is also a directory of services, such as beyondblue and the Post and Antenatal Depression Association (PANDA) helpline47 should he require additional support. With Jens consent, additional family members can also be educated about perinatal mood disorders and directed to these services so that they too can both receive and provide appropriate support.4 Low partner support has been found to be a risk factor in the development of postnatal depression27 and, if there are concerns, the midwife could explain this to the couple and suggest ideas as to how Pete could help support Jen. As part of routine midwifery care, the midwife will be alert to signs of domestic violence and would have screened for this in the antenatal period.48 Research indicates that the disclosure of domestic violence is increased with repeated assessment49 so, when alone with Jen, the midwife should again address this by asking relevant screening questions and employ further support and referral if required.50 3.4. The next step: advice, options and referral The midwife can form a clinical judgement about the need for further care once she has conducted and evaluated the initial assessments, taking care to identify any personal inuences that may impact on her judgement. This judgement is likely to be more accurate in a continuity of care model.16,51 The midwife should document and explain her ndings to Jen, allowing her to make informed decisions and to self determine her pathway of care3 by describing the options available. If the midwife feels she remains low risk, no referral is required but Jen should still be provided with information of the support and resources available, such as beyondblue and a local Perinatal Mental Health Team (PMHT), in case she should need to access them in the future. She should also be encouraged to self-manage access to the Child and Family Health Service, who usually offer community parenting groups and family support services.32 Lifestyle advice, such as ensuring a healthy diet, good rest and relaxation may also be benecial.4 Further check-ups should take place at mutually convenient times, in order to provide care which has minimal restriction on Jen and her family. However, if the midwife considers Jen to be at signicant risk of mental health issues, referral to her General Practitioner is also recommended. This would help ensure that Jen receives an appropriate mental health care plan and has access to available treatment, such as cognitive behaviour therapy or pharmacological therapy, if required.4,52,53 Additionally, if the midwife has identied the presence of symptoms such as mood swings, unusual beliefs or hallucinations which have occurred rapidly after the birth, this may indicate that Jen is suffering from peurperal psychosis and immediate psychiatric aid should be sought.4 Care should be collaborative and sensitive towards Jens individual circumstances, culture and beliefs, and information provision should use language that allows Jen to clearly understand what each option entails. Jens decisions about care should be documented, even if she has declined further treatment or referral. The midwife may suggest other avenues of support such as

Please cite this article in press as: Marnes J, Hall P. Midwifery care: A perinatal mental health case scenario. Women Birth (2013), http:// dx.doi.org/10.1016/j.wombi.2013.07.002

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4 J. Marnes, P. Hall / Women and Birth xxx (2013) xxxxxx 9. Beyondblue. http://www.beyondblue.org.au/resources/for-me/pregnancyand-early-parenthood/edinburgh-postnatal-depression-scale; 2013 [accessed May 2013]. 10. Black Dog Institute. http://www.blackdoginstitute.org.au/public/research/ researchtools; 2013 [accessed May 2013]. 11. Mazza D. Womens health in general practice. 2nd ed. Sydney: Elsevier; 2011. 12. Beyondblue. Perinatal depression and anxiety: a guide for primary health professionals . 2013. http://www.beyondblue.org.au/index.aspx?link_id=7.102&tmp=FileDownload&d=2484 [accessed April 2013]. 13. Austin MP, Tully L, Parker G. Examining the relationship between antenatal anxiety and postnatal depression. Journal of Affective Disorders 2007;101: 16974. 14. Hopkins Fishel A. Mental health disorders and substance abuse. In: Lowdermilk D, Perry , editors. Maternity and womens health care. 9th ed. Sydney: Elsevier; 2007. p. 90024. 15. Lee SH, Liu LC, Kuo PC, Lee MS. Postpartum depression and correlated factors in women who received in vitro fertilization treatment. Journal of Midwifery and Womens Health 2011;56:34752. 16. McArthur A. Evidence summary: antenatal: psychosocial assessment, evidence based recommended practices. The Joanna Briggs Institute; 2012 . http:// ovidsp.tx.ovid.com.ezlibproxy.unisa.edu.au/sp-3.8.0b/ovidweb.cgi?&S=JBCOFPLIHGDDLNFDNCOKNCFBEKNOAA00&Link+Set=S.sh.35%7c14%7csl_190 [accessed February 2013]. 17. Brealey S, Hewitt C, Green JM, Morell J, Gilbody S. Screening for postnatal depression is it acceptable to women and healthcare professionals? A systematic review and meta-synthesis. Journal of Reproductive and Infant Psychology 2010;28:32844. 18. Sullivan A. Involving parents: information and informed decisions. In: Sullivan A, Kean L, Cryer A, editors. Midwifes guide to antenatal investigation. Sydney: Elsevier; 2006. p. 1729. 19. Hanley J. Perinatal mental health. West Sussex: Wiley Blackwell; 2009: 949. 20. Gibson J, McKenzie-McHarg K, Shakespeare J, Price J, Gray R. A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatrica Scandinavica 2009;119:35064. 21. Dennis CL. Depressive symptomatology in the immediate postnatal period: identifying maternal characteristics related to true- and false-positive screening scores. Canadian Journal of Psychiatry Revue Canadienne de Psychiatrie 2006;51:26573. 22. Seyfried LS, Marcus SM. Postpartum mood disorders. International Review of Psychiatry 2003;15:23142. 23. Gruen G, Gentry R, Myers A, Jolly S. Beyond the birth: what no one ever talks about. 5th ed. Seattle, WA: Hedgehog Graphics; 2003. 24. Poole H, Mason L. Healthcare professionals views of screening for postnatal depression. The Free Library; 2008. http://www.thefreelibrary.com/Healthcare professionals views of screening for postnatal depression.-a0177830475 [accessed May 2013]. 25. beyondblue. Emotional health and wellbeing during pregnancy and early parenthood. 2012. http://www.beyondblue.org.au/index.aspx?link_id=7.980&tmp=FileDownload&d=615 [accessed February 2013]. 26. Flykt M, Kanninen K, Sinkkonen J, Punama ki RL. Maternal depression and dyadic interaction: the role of maternal attachment style. Infant and Child Development 2010;19:53050. 27. Milgrom J, Gemmill A, Bilszta JL, Hayes B, Barnett B, Brooks J, et al. Antenatal risk factors for postnatal depression: a large prospective study. Journal of Affective Disorders 2008;108:14757. 28. Hammarberg K, Fisher JRW, Wynter KH. Psychological and social aspects of pregnancy, childbirth and early parenting after assisted conception: a systematic review. Human Reproduction Update 2008;14:395414. 29. Ross L, McQueen K, Vigod S, Dennis CL. Risk for postpartum depression associated with assisted reproductive technologies and multiple births: a systematic review. Human Reproduction Update 2011;17:96106. ki R, Poikkeus P, Vilska S, Unkila-Kallio L, Sinkkonen J, et al. 30. Repokari L, Punama The impact of successful assisted reproduction treatment on female and male mental health during transition to parenthood: a prospective controlled study. Human Reproduction 2005;20:323847. 31. Gamble J, Creedy D. Complications in the postnatal period. In: Pairman S, Tracy S, Thorogood C, Pincombe J, editors. Midwifery: preparation for practice. 2nd ed. Sydney: Elsevier; 2010. p. 97187. 32. Department of Health. Chapter 140b: screening for perinatal anxiety and depression, perinatal practice guidelines. Government of South Australia; 2010 . http://www.health.sa.gov.au/ppg/Default.aspx?tabid=258 [accessed February 2013]. 33. Drheim SK, Bondevik GT, Eberhard-Gran M, Bjorvatn B. Sleep and depression in postpartum women: a population-based study. Sleep 2009;32:84755. 34. Sloan EP. Sleep deprivation and postpartum mental health: case report. Archives of Womens Mental Health 2011;14:50911. 35. Eisenach J, Pan PH, Smiley R, Lavandhomme P, Landau R, Houle T. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain 2008;140:8794. 36. Henderson A. Supporting the breastfeeding mother. In: Pairman S, Tracy S, Thorogood C, Pincombe J, editors. Midwifery: preparation for practice. 2nd ed. Sydney: Elsevier; 2010. p. 63353. 37. Aubuchon-Endsley NL, Thomas DG, Kennedy TS, Grant SL, Valtr T. Interactive relations among maternal depressive symptomatology, nutrition, and parenting. Women and Health 2012;52:197213.

peer support telephone calls, which have been shown to reduce depressive symptoms for women with PND.54 It is important to note that, if at any point the midwife feels that either Jen or Becki are at risk, for example, from domestic violence, suicide or abuse/ neglect, then there is an obligation to contact the relevant authorities2,3,55 and to manage the immediate risk through the development of both a safety plan and referral pathway as indicated.4 At an appropriate time, the midwife should also inform Jen and Pete that when an individual has experienced an episode of PND there is an increased likelihood of developing depression and/ or anxiety in future pregnancies/births.56 Equipping them with this knowledge will enable them to be watchful for symptoms and seek early intervention. 4. Conclusion This case scenario highlights the need for a holistic midwifery investigation into the presence of perinatal mental health disorders when concerning symptoms exist. Adhering to legislative requirements and guidelines, the midwife can undertake psychosocial and medical assessments or screening in order to inform practice and to determine how midwifery care and support can be of benet to the woman and her family. The provision of evidence-based education, care options and relevant learning resources can enable decision making by the woman, possibly aided by the inclusion of appropriate support networks. Informed midwifery care which considers a womans individual situation, and is based upon a collaborative womanmidwife partnership, will assist in the resolution of health issues faced by women and their families during the postnatal period. Many elements of this scenario are likely to be encountered in clinical practice and the suggested evidence-based midwifery responses to presenting mental health and psychosocial issues may be applied accordingly.

Acknowledgments Thank you to Dr. Jane Warland and Tracy-Anne Semmler-Booth for their contributions to this paper. Funding for the National Perinatal Depression Initiative has been provided by the Commonwealth and State Governments. References
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