Postpartum psychosis, new thoughts of harming the baby or self, or a rapidly changing mood: this is a psychiatric emergency. Refer the same day to the perinatal mental health or crisis team and do not leave the mother alone with the baby.
Screening and features
- Use the Edinburgh Postnatal Depression Scale, or the Whooley questions, antenatally and postnatally
- Low mood, anhedonia, guilt, poor sleep (beyond the baby), poor bonding
- Distinguish from the self-limiting 'baby blues' in the first days
- Ask directly about thoughts of self-harm and harming the baby
Red flags (urgent)
- Postpartum psychosis: confusion, delusions, hallucinations, mania
- Thoughts or acts of harm to self or baby
- Severe self-neglect or inability to care for the baby
- Rapid onset or fluctuating severe symptoms
Mild to moderate
- Low mood; guided self-help or CBT
- Monitor and support
- Continue breastfeeding support
Moderate to severe
- Consider an antidepressant (e.g. sertraline)
- Specialist perinatal input
- Assess mother and baby bonding
Puerperal psychosis / risk
- Rapid onset, delusions, confusion
- Thoughts of harm to self or baby
- Emergency perinatal psychiatry, admit
Management
1
1. Assess risk
Assess the safety of mother and baby. Involve the partner, family and health visitor with consent. Escalate urgently for red flags.
Assess the safety of mother and baby. Involve the partner, family and health visitor with consent. Escalate urgently for red flags.
↓
2
2. Treat
Mild to moderate: guided self-help or psychological therapy. Moderate to severe: a psychological therapy and consider an antidepressant. Sertraline is commonly used while breastfeeding (confirm with the BNF and specialist advice).
Mild to moderate: guided self-help or psychological therapy. Moderate to severe: a psychological therapy and consider an antidepressant. Sertraline is commonly used while breastfeeding (confirm with the BNF and specialist advice).
↓
3
3. Refer
Refer to the perinatal mental health team for moderate to severe illness, a history of serious mental illness, or any red flags.
Refer to the perinatal mental health team for moderate to severe illness, a history of serious mental illness, or any red flags.
↓
4
4. Monitor and plan
Early review after starting medication. Make a relapse and crisis plan; women with bipolar disorder or previous postpartum psychosis need a pre-birth plan and close monitoring.
Early review after starting medication. Make a relapse and crisis plan; women with bipolar disorder or previous postpartum psychosis need a pre-birth plan and close monitoring.
Remember
- A personal or family history of bipolar disorder or postpartum psychosis is high risk
- Do not stop effective medication abruptly in pregnancy or postpartum without advice
- Fathers and partners can also be affected
Pitfalls
- Missing postpartum psychosis (rapid, dangerous)
- Dismissing symptoms as normal tiredness
- Not asking about thoughts of harm to the baby
- Stopping medication abruptly for fear of breastfeeding
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026