Trudy Williams Maternal Medicine Specialist Midwife St Georges Foundation Trust

1. Considerations for
pregnancy and
the postnatal
period
Trudy Williams
Maternal Medicine Specialist Midwife
St Georges Foundation Trust

2. Particular considerations for pregnancy and
1 year post birth
Reducing maternal
mortality
Mental Health
Domestic abuse Postnatal recovery

3. Health
Professional
contacts
Pregnancy:
11 contacts with Maternity
health professionals
standard pregnancy
Postnatally:
Midwife contact varies – 2-3 times
up to 10-14 days. (enhanced 28/7)
Health visitor – home visit 14 days,
drop in clinics offered
GP 6/52 baby, 8/52 mum
MS team continuum: note maternal morbidity and
mortality up to a year
post birth

4. Reducing
maternal
mortality

5. Postnatal recovery and seeking support
Sexual dysfunction, pain, fear of
intimacy, incontinence
GP referral to perineal/urogynae specialist service
Musculoskeletal –back pain, pelvic
girdle pain
Physio (women’s health)
Trauma from birth
Debrief/birth reflections – contact maternity unit or GP referral
Trauma detrimental to psychological health, replays in
subsequent pregnancy or deters future hopes for another child
Birth trauma association.org

6. Mental health

9. What to do
Evidence of suicidal thinking must be acted on, even
where the focus of therapy is on another aspect of the
woman’s care.
• Consider A/E if suicidal ideation or thoughts of harm
to others
• Make direct contact with GP that day for review,
Community mental health team urgent referral
• NB: perinatal MH services-not for urgent referral and
not consistent services in all areas
SHARE THE INFORMATION

10. Depression/anxiety
10-20% of women
perinatal mental health
longstanding effects on
children and family
• family/friend or linked support,
• self insight and strategies,
• Health care support,
• medication
Protective
factors:
• PMH or FH- mental health issues,
• domestic abuse,
• poverty, migration status,
• unplanned/unwanted pregnancy,
• interpersonal conflict, bereavement,
• partner drug/alc/depression,
• inadequate support,
• worsening physical health, disability,
• child <1yo and or children with developmental issues.
Exacerbating
factors:

12. Domestic
Abuse
1:4 women
often starts in
pregnancy
Patient toilet door signs
Environment – patient alone
Interpreter
Question: frame indirect DIRECT
‘Because sadly domestic abuse is quite common, I ask all of my
patients’
‘how are things at home’ ‘How does your partner treat you’
‘Have you been hit or threatened by your partner or anyone else in
your home, do you feel controlled or isolated by your partner’
NB: be specific about abusive behaviour. ‘Do you feel safe’ may be
insufficient.

13. What to do
Immediate danger of harm – 999
– patient to stay until help arrives
Contact safeguarding/domestic
abuse lead
Domestic abuse services
Children’s services referral

14. Vulnerable
adult/family
Adult and childrens
Anyone can and should raise
concerns and make referrals.
Consider safeguarding children
course if working with
pregnant/postnatal women

15. Take home
messages
Women up to a year after the
birth have particularly
increased risk factors for
depression/suicide/domestic
abuse
MS team may have more
input than Midwives
postnatally
Ask questions and holistic
assessment
Vigilance for non attendance
or multi vulnerabilities
Consider the three P’s in a
pod to reduce maternal
mortality
Listen for cues and consider
envt (pt alone, privacy)
Liaise/share informationPick up the phone

16. Useful
resources
RCN Domestic abuse
NMC depression
Domestic abuse organisations
Maternity unit
Safeguarding lead. IDVA
Three P’s in a pod information video

17. Case Study

18. Lucy is expecting her second baby. She is referred late to the maternal medicine/MS clinic as Lucy denies any past medical
history initially in pregnancy but discloses the MS diagnosis at 33 weeks pregnancy.
MS diagnosis during her previous pregnancy - DMT commenced postnatally but Lucy stopped due to side effects. She did not
attend any MS appointments afterwards.
Several DNA’d appointments during pregnancy. Pregnancy uncomplicated, progressing well.
Invited for joint MS CNS/Maternal Medicine Midwife appointment. Lucy contacts the MS team to decline the appointment.
MS Administrator reports that Lucy sounded ‘irritated’ on the phone. Subsequently called by the Midwife to urge to attend,
Lucy declines initially stating that ‘it won’t help’ but eventually agrees.
What could be happening?
What are the risks?
What if she had declined the appointment for MS input?

19. At joint appoint: Lucy expresses that she has ongoing MS symptoms but feels that ‘no one can help her’ and she won’t
take the DMTs as they make her feel bad.
Discussion around support at home – husband works away a lot, too busy doing everything at home to have friends and
mum supportive but lives in the US.
Lucy is directly asked about her mood state, she expresses feeling low in mood, sad and alone.
After her last baby was born, she says that she used to cry in her garden with her back to the house to avoid her husband
and child seeing her. This lasted until her child was around 2 years old. She thought about ‘ending it’ a lot but couldn’t go
through with it. Denies domestic abuse but states that her husband is too busy for emotions.
FH: mum and grandmother – severe postnatal depression, suicide attempts –mental health unit admissions and
grandmother received electro convulsive therapy
Lucy has not disclosed this information in the pregnancy.
Risks?
Plan?