Women and Birth 26 (2013) e112–e116

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: The establishment of the National Perinatal Depression Initiative (NPDI, 2008–2013) has brought a focus
Received 14 May 2013 across Australia for the need to identify women at risk of perinatal mental health disorders, suggesting
Received in revised form 12 July 2013 that routine screening by relevant health professionals may aid earlier detection, better care and
Accepted 15 July 2013
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
Keywords: perinatal mental health disorders.
Postnatal
This paper offers strategies that could be implemented into daily midwifery practice in order to
Depression
Psychosocial assessment
achieve the goals consistent with the National Perinatal Depression Initiative. A case study (Jen) and
Midwifery discussion, guided by recommendations from the Australian Nursing and Midwifery Competency
Screening 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 benefit 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 mother–infant interactions and questioning around baby’s 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.
ß 2013 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International
Books Australia Pty Ltd). All rights reserved.

1. Background Perinatal mental health clinical practice guidelines were

The establishment of the National Perinatal Depression
Initiative1 (NPDI, 2008–2013) 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.
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 self-
administered scale used to measure current symptoms of depres-
sion, with research supporting its effectiveness in the identification
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 12-item 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 specific
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-fictional case study represents a scenario similar to
which midwives are likely to come across in practice, and will be

1871-5192/$ – see front matter ß 2013 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
http://dx.doi.org/10.1016/j.wombi.2013.07.002

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 J. Marnes, P. Hall / Women and Birth 26 (2013) e112–e116
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 first 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 identification
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 Jen’s baby is now three weeks old, any ‘baby
blues’ are likely to have passed11 suggesting that this is not the
reason for Jen’s 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 couple’s difficulties 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 significant 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 definitive 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
first 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 woman’s 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
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e113
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 Jen’s partner. Having explored Pete’s 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 Jen’s 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 experienc-
ing 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 influenced by the presence of others.19
It is recognised that the EPDS can generate false positive
results,20 thus suggesting some women are experiencing symp-
toms 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 blues’21 reported
to affect 30–75% of women during the first 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 Jen’s 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 ‘significant 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 unpredict-
able 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
e114 J. Marnes, P. Hall / Women and Birth 26 (2013) e112–e116
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 Jen’s mood and behaviours.35,36
Reflection on Jen’s 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. Mother–infant relationship
During a home visit the midwife can observe interactions and
behaviours between Jen and her baby. Evidence has shown that
mother–infant 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 Jen’s baby
should be considered at all times.2–4
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 satisfied.
Where secure attachment exists there is a balance between the
infant’s 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 relation-
ships between Jen and Becki, reinforcing the relationship with
acknowledgement and praise of Jen’s abilities as a mother.
Attachment disorders arise due to negative experiences in
the early parent–infant 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 difficulties 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 mother–infant 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 parent–infant assessment by a
suitably qualified professional or team.32
3.3. Social support
Women benefit 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
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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,
finding themselves unclear how to be involved,45 Pete could be
provided with the ‘Dads handbook, A guide to the first 12 months’
resource from beyondblue.46 This resource provides psychoeduca-
tion, 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 Jen’s 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 influences 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 findings 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 beneficial.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
significant 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 identified 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 Jen’s
individual circumstances, culture and beliefs, and information
provision should use language that allows Jen to clearly under-
stand what each option entails. Jen’s 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
 J. Marnes, P. Hall / Women and Birth 26 (2013) e112–e116
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 benefit 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 woman’s individual
situation, and is based upon a collaborative woman–midwife
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.
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