Care plan for second pregnancy?

Hello. I suffered PPP after my daughter was born in November 2009. I was sectioned and spent 4 weeks in a mother an d baby unit. I was lucky to recover quite soon after the right drug dosage was found. I was placed on olanzapine which I stayed on for quite some time. I was diagnosed with PND in the April after my daughter was born and with the help of yet more drugs I recovered.

Whilst ttc I had an appointment with the perinatal psychiatrist who treated me in the MBU and he discussed both drug treatment immediate post partum in any subsequent pregnancy and also a possible prophylactic admission to the MBU on giving birth. I am now almost 30weeks pregnant and do not have a care plan in place. My general psych said she would ask if the MBU Dr would see me but I have heard nothing, my CPN is currently off sick and has been since April. I am concerned now as I have done some online research of SIGN guidelines etc and it seems a care plan should be in place by 32 weeks! Has anyone had a care place in place for a subsequent pregnancy that they would mind sharing? Also I am concerned about going on olanzapine again as I gained 4stones on it last time in a very short space of time. I was not eating that badly and would hate to gain as much again.

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  • Hey sweetie, I didn't want to read and run. I will be back later to answer your question in full. I have a care plan that I am happy to discuss with you. x

  • Hiya. Afraid I can't help with sharing a care plan but just wanted to say how similar this sounds to my experience. I had an episode of pp after my child was born in Sept 09 and was sectioned, first into a general psych ward at my local hospital then to a specialist hospital a bit further from home before going into their M&B unit. Olanzapine was what I ended up on too, and was on for probably about a year. I've put on some weight which I'm struggling to lose (also not helped by lithium which has damaged my thyroid too) and am hoping to try for a 2nd baby soon. Although you've tried chasing all the medical people, have you tried going through your gp? I know mine was fantastic with me early days and may just be able to get in touch with right people on your behalf? And as for the weight gain, I'm quite philosophical about mine, I know it was from a bad time in my life and to think how far I've come and am well, happy and with a great family, the weight is something I know needs sorting but other things are more important. Another thing to consider could be some of Advanced Decision if you have firm ideas about what you would and wouldn't want treatment wise. I know this was a bit on the paperwork from my CPA reviews and would probably be best through your cpn. But again your gp could help? Not sure if this will help, good luck with it all anyway.

  • Hiya - really sorry to hear that after a good initial consultation with the perinatal psychiatrist it seems that your care plan has fallen through the gaps. How mental-health aware is your midwife? You could consider drawing something up with her either on her own or with a representative from the community mental health team as your CPN is off sick?

    I had a 5-year gap and then another pregnancy. I was really fortunate to have a new perinatal mental health service in place, and here are the main points of the care plan we drew up for the maternity ward and the community team:

    - Individual room on the postnatal ward to promote good sleep

    - Midwives to look after my baby overnight if I needed extra sleep, bringing her back for feeds

    - Sleeping tablets (Zopiclone) and Olanzapine prescribed for me before due date so I could take them on to the postnatal ward with me and use as required

    - Phone access for me to the Crisis Team if I had any worries out of hours

    - Daily monitoring for 3 days on the postnatal ward from specialist midwife (on-call psychiatrist referral if concerned)

    - Support from Wellbeing and Access team (CMHT) when discharged home, visiting every 2-3 days for first fortnight

    Hope this is helpful, and all the best with your new arrival, N

  • Hello there, I don't know if this will help but after my episode of PP in 1988 I thought I would not have any more children. Things changed and I did go on to have another baby girl in 1996 and again another in 1999. For the last two pregnancies as soon as I had delivered the baby I was given progesterone therapy - injections every day for I think a week or ten days. I also had a great support plan as my mother moved in to look after me and keep the house running, and I generally had a very stress free time postnatally. The progesterone therapy was organised by Dr Katherina Dalton but I think she may have passed away now. It was well documented and I also had to try to eat some starch every 3 hours to keep my blood sugar level. Do hope this is of some help. We also had a place booked at a Mother and baby unit just in case and I had support from my local CPN but we did not need them this time.

  • I too used Dr Dalton's progesterone therapy for my two subsequent pregnancies after the devastating experience of PP in 1982. I also took steps to avoid other stressors by having home births. I had progesterone by injection immediately after the birth, and then by progesterone suppositories in the following fortnight. I slept well, ate well and was a very happy mother. My experience does not prove that the hormonal therapy was the only cause of my good experiences of these births, but there seems to be every reason to try it - PP is a terrible affliction and frightens many into avoiding subsequent, longed for, pregnancies.

  • I am so happy to hear that someone else tried this plan. Like you I think there are so many contributing factors to PP but I chose this regime because it meant I could breast feed. This was not an option with oestrogen or lithium treatment in the post natal period. So blessed to read your reply. With my third pregnancy I was tempted to try on my own and not have the progesterone but it didn't seem worth the possible risk. Good to hear from you. Take care

  • Yes, I too breast fed both my second and third children. It was a great happiness and compensated a great deal for having lost the breast feeding with my first when I was snatched away with PP at day 6 after delivery.

    A recurrence of PP is indeed not worth the risk. I think I would counsel my own daughters to use progesterone just in case. There seem to be no serious contra-indications, whereas psychotropic drugs are a much bigger step.

  • Helen & Caroline thanks so much for sharing, i'm hoping to get pregnant with my 2nd baby next summer & am desperate to breastfeed as I was devastated that I was sectioned when my baby was 14days old & then on such a high dose of olanzapine that even when we were back together at the mbu breastfeeding just wasn't an option. Will definitely look into this treatment & hopefully have a good care plan in place to allow me to get on & be a mum without unnecessary risks to my mental health. Thank you both.

  • Good luck - you may have to be quite persistent. This treatment seems to be less popular now than it was in the 1980s though it is not clear to me that its usefulness has been disproved. Possibly psychiatrists feel more comfortable with anti psychotic drugs.

    I took the book, Depression after Childbirth by Katharina Dalton to my GP and asked for the progesterone to be prescribed and it was. Because I was having a home birth I did not really get involved with specialists at all.

  • I am 30 weeks pregnant with twins and had an episode of PP in 2010, I went for pre-conception advice and was told that a care plan would be put in place and it is being. I saw the mental health midwife at 14 weeks and the psychiatrist at 24, I have another appointment at 32 weeks to finalise everything, main points are undisturbed sleep so they are requesting (not guaranteed a private room) either my husband or Mom to stay with me to do night time feeds, I will take sleeping tablets and I will also take immediately after birth medication. I have requested not to take Olanzapeine this time due to the 5 stone weight gain I had last time so will be on Serquel or something similar sorry I can't remember exactly. Due to the fact I have an amazing support network at home as soon as the babies are ok to come home and I am not presenting any signs I will be allowed home, but will be monitored and will see the psychiatrist in the first week after delivery. This is all I can remember for now, but I would advise that you get in touch with your midwife or GP and push for an immediate appointment. Good luck, I firmly believe with the right care plan and the right support that we can have the experience we missed out on last time.

  • Hi postpartumproblems,

    Firstly, welcome to the site and I’m so glad you have found us online to help support you at the end of your second pregnancy – congratulations by the way! The team are always here to support whenever you need us and we try our best to not let posts go unanswered for too long.

    I had an episode of PP at the end of 2007 completely out of the blue. I was still under the care of the Early Intervention Team when I became pregnant again (which was planned) in the autumn of 2009. Together, my care-coordinator and I wrote a care-plan (“Just in case” plan as we called it) even before I fell pregnant, which then we adapted along the way after advice from various experts. While my husband and I were still deliberating about the risks of having another child we had a consultation with Dr Ian Jones (Cardiff University and APP). He listened to the story of my first PP episode and then advised us about the risks of reoccurrence and the options for preventing PP a second time. At the beginning of my 3rd trimester I also met with the psychiatrist from my local MIMHS team who gave me further advice which ended up altering my care-plan to include prophylactic medication during the last trimester, since she assessed my individual risk of reoccurrence to be nearer 75% than the 50% Dr Jones had suggested.

    Needless to say after that meeting, being given such a high risk factor for PP again, I was left feeling as though I had little choice but to take the anti-psychotics as soon as possible, although I did meet with a neonatologist concerning the risks to baby before starting the prophylactic Quetiapine (I too did not want to take Olanzipne due to the tremendous weight gain I experienced on them). The neonatologist was very understanding and thorough – he agreed that the risk of me becoming unwell far outweighed the minimal risks to baby’s health taking anti-psychotics so late in the pregnancy. The only concern they would have for my baby would be possible withdrawal symptoms after the birth which could be easily managed if necessary. We also arranged that he would be notified once baby was born so he could check baby over. It was really important to me that if I were to take the medication, my baby’s health came first. It certainly wasn’t an easy decision to make but proved the right one for me. I started the prophylactic medication at week 33 and my baby arrived at 37weeks. He was a good weight, just over 7lb so it didn’t matter that he came 3 weeks early!

    Just like Lou above, I am more than happy to share the details of my care plan with you and anyone else in the same situation. I think it would be easier if I copy and paste the document (removing all personal information) into a blog. When I have done this I will paste the link into a reply on your question.

    I hope you are managing ok during this pregnancy and feeling hopeful that this second time will be different. I found my second pregnancy to be a rollercoaster of emotions, with a lot of anxiety about what would happen after the birth. Somehow I managed to remain mainly positive but there were quite a few tears shed about the fear of being ill again, putting not only myself through the hell of PP again but my family and my 2 year old. I found all the extra meetings, decisions & consultations needed to make sure I remained well mentally postpartum quite intrusive – it was very draining. I was blessed to have a fantastic EIP care coordinator who did 99% of all the chasing up of the obstetric professionals involved, who to be honest needed quite a bit of convincing that preventing a second episode of PP was something that needed to be taken very seriously. I am so so thankful that my plan did prevent a second episode and it was incredible to experience my son’s first months as a well mother. The difference between my first and second experiences of motherhood with a newborn was like night and day!

    I will dig out the care plan and put it in a blog post as soon as possible :-) x

  • One other thought .... is it possible for you to speak to someone in the community psych team so they could replace your CPN with someone else? I know it won't be easy to get to know someone new but it would be really good to have a professional in mental health (not just the psychiatrists) co-ordinate things for you? The midwives and obstetricians don't always understand the risks involved with PP and are very quick to just take the attitude that "lightening won't strike twice", probably because they do not have sufficient training in perinatal mental health.

    How do you feel about the suggestion to be admitted to the MBU postpartum even if you prevent no signs of relapse? I imagine that being there just in case you became ill would be very difficult. It would take away the normal postpartum experience a mum could have if she had other preventative measures in place. Although being in the MBU straight away could give a sense of security knowing that you were right where you should be if you did become unwell. An alternative would be to ask the perinatal psychiatrist to visit you and check how you were whilst still on the materniy ward, and then at a later date visit at home. Whilst in-between, having the new CPN visit at home to keep an eye on you. We planned for my care to take place at home with the support of the community teams (EIP in my case), midwives, health visitors and family. I was fortunate that my husband could take more than 2 weeks off work to be with me 24/7, although we had the added complication and immense stress that my son became critically ill at 2 days old and was rushed to London for 3 weeks. His illness was totally unrelated to the medication I took in the 3rd trimester - the neonatal consultant checked for links to the anti-psychotics without me even asking, which was a such a relief because obviously it had crossed my mind! To look at my son now, born in 2010, you'd never know he was seriously ill when he was tiny.

    I hope some of this has helped and that when I find the care plan, the template can help you further.

  • Thank you very much to everyone who has replied. I appreciate your input and the time you have all taken to help.

    I emailed the perinatal psychiatrist from MBU on Thursday and hope he can advise me further on what I should have in place. I am very interested in your care plan hope so look forward to reading that.

  • Hi postpartumproblems,

    It's good to hear that you were able to email the perinatal psychiatrist and I hope you get a really helpful reply soon.

    I have found my care-plan but realised there is a little more work needed than I expected to put it into a blog for public eyes. Just wanted to let you know I haven't forgotten and it'll be on there as soon as possible.

    Whilst looking for the care plan I remembered something I did that proved to be extremely useful in the end - I had a medical history summary page right at the front of my antenatal notes, before the standard notes were even opened. In this was my due date, my history of PP, the current medication I was on and a summary of the care needed during labour and immediately postpartum. This was really appreciated by the midwives and professionals I saw once I went into labour as they didn't have to leaf through the entire notes to find what they needed. When I had someone ask me questions about what happened last time, I could easily and politely ask them to read the front sheet of my notes to find the answers, rather than getting me to repeat the whole story.

    Take care :-) x

  • Thank you Hope that is quite helpful and a very good idea. I appreciate you looking out your care plan, take your time posting it. Thanks again!

  • HopeafterPP has covered this perfectly. My care plan differs in structure from HopeafterPP's and we both had different approaches to care as everyone is an individual.

    Postpartumproblems if you'd like to see another variation of the care plans let me know and I will post mine also.

    Just to add, care plans can be long winded and the feedback I received from midwives is they didn't have the time to read such an in depth document at handover. I therefore had a one sided A4 document so they could quickly read and absorb the information needed.

    if you can try and stay on the postnatal ward as long as you can, don't rush home. The most important time is those first few weeks, if you can get a midwife to do the night feeds while you sleep, I personally feel this stands women in great stead.

    As I had twins, my second pregnancy, I had to stay in for 2 weeks due to twin 1 having feeding problems. My husband would feed one baby and the midwife would feed the other during the night. I also took sleeping tablets for the first 14 nights to ensure i got the sleep i needed. I started on medication the night after delivery. I didn't feel guilty, the twins will never know and being a healthy mum in the long term is best.

    please ask as many questions as you want, I know what a scary time it can be. xx

  • louLou thanks for replying. I would love to see your care plan if you wouldn't mind posting it? I don't want to rush home as I think it'll be easier for my daughter if I stay a little lingo get after having the baby and stay well rather than come home too quickly and have to disappear!

    I will most likely start on olanzapine after the birth but however as I have no care plan yet I don't know for definite.

  • Hello,

    I had PP with my first child in 2004. I was off medication by the third month after the birth. My second child was born in 2008 with no recurrence of PP. I had a care plan (a mental health worker came to discuss this with me) should I become ill. My activities in the third trimester were signicantly curtailed. I tried to get as much rest as possible, and went for regular reflexology sessions with a qualified therapist, something that I discovered helped after being ill.

    After the birth in hospital, I stayed in a room on my own for several days, and was monitored closely, but I did not need to have any medication.

    We operated a two-week isolation (more or less) after the birth. The fear of becoming ill was almost crippling, but we managed and I was well, thank goodness.

    I even managed to breast feed (up until 15 months!), doing the night feeds etc. as I didn't want to express milk.

    Hope this helps a little. I have to say that my PP episode was completely unprecedented. And I have been well since (although depressed!).

  • Thank you for sharing Virginia. I have not had a meeting as yet to discuss a care plan but it has been strongly suggested I take medication just in case. I am hoping to read the care plans that the previous posters have said they would look out and see what I can glean from them before getting a bit more proactive in chasing the relevant people!

  • I can see that your experience first time round was very different from mine; I hope that you can get a care plan in place that works. Whatever medication you decide you need to take, just try and get as much practical help as you can. All the very best.

  • I can't help with a care plan as I've only got the one child. If I have another it has been strongly recommended that I self-medicate straight after the birth. After my second episode I was given a choice -which medication would I prefer? I was given lots of information about lots of medication and chose Abilify. It hasn't affected my weight but I understand it might not be suitable for everyone.

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