WORK for the Best: PLAN for the WORSE: A Case Study for a High Risk, Non-Compliant Maternity Patient with Significant Mental Health Diagnoses
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- Discuss challenges seen in care of bipolar clients during pregnancy.
- Discuss components of a multi-disciplinary approach for the care of the bipolar client. during pregancy, birth and the post-partum period.
- Discuss individualization of care for bipolar patients during pregancy, birth and the post-partum period.
Bipolar disorder is a serious, recurrent psychiatric illness, treated with anti-manic agents, such as lithium, antipsychotic medications, and anticonvulsants, all of which have potential risks for the fetus, and significant side effects for the mother. Many of these women have co-morbidities as well. Sometimes women will change their medications to protect their fetus, but suffer relapse of symptoms that jeopardize their safety and well-being. Because of its relatively high prevalence during the reproductive years, learning about the management of bipolar disease is important for nurses caring for women of childbearing years.
Case:
Our patient C.M. is a 36 year old G3, P3. She had a complicated psychiatric history with many inpatient hospitalizations for bipolar disorder, borderline personality, post-traumatic stress disorder, and anorexia with several attempts at suicide.
She had one uncomplicated vaginal delivery 6 years previously, and a second pregnancy 14 months ago delivered by C section for fetal distress. She also had psychiatric destabilization after both pregnancies and was unable to have custody of either child.
When she discovered she was pregnant she changed her name, did not pursue prenatal care, and stopped all meds.
She began care at 24 weeks gestation after referral from the Emergency Department. She was planning to deliver at home alone. Her obstetrician reached out to us after C.M. become verbally abusive in the office.
We called together a team that consisted of risk management, legal services, pastoral/ethics care, emergency room, crisis mental health, and maternity and newborn care.
We worked with ED to have everything needed in case she came in by squad. We had her come in for weekly non-stress tests, with the same nurse so we could begin to gain her confidence and track well-being. DYFS was in a position to say if C.M. insisted on a home birth she would not be given custody of her baby. C.M. was very angry, but did agree to a scheduled c/section.
She had a safe delivery. She wasn’t stable enough to be able to take her child home initially, but worked closely with her physicians and DYFS, and within a month of her discharge was re-stabilized. She has been able to successfully regain custody of her daughter under supervision by DYFS.
Conclusion:
It can 'take a village' to care for mentally ill maternity patients, but the outcomes are worth the work and coordination
Keywords:
Bipolar, mental illness and pregnancy
