Postnatal mental health — structured oral station (12 minutes)

Opening prompt — "What are you going to do?"

Model response — say it in this order: ^[1][2]

• "This is puerperal psychosis until proven otherwise. Insomnia preceding the mood change, perplexity, labile mood and the belief the baby is sending signs are the classic presentation in the first two weeks, and this is a psychiatric emergency."
• "I am not sending her home. I want an urgent same-day psychiatric assessment, and I will aim for a mother-and-baby admission if one is available. She is not to be left alone."
• "In parallel I exclude the organic mimics — sepsis, thyroid storm, eclampsia and posterior reversible encephalopathy syndrome, Wernicke encephalopathy, substance withdrawal, and autoimmune encephalitis. Temperature, pulse, blood pressure, oxygen saturation, glucose, and the appropriate bloods."
• "I establish infant safety and involve the partner with her consent."^[1][2]

Examiner is listening for: the word 'emergency' and a timeframe in hours; a same-day psychiatric pathway rather than a referral letter; the active exclusion of organic causes; and explicit attention to the infant. ^[1]

Probe 1 — "Why are you so certain this isn't just severe baby blues?"

• "Because baby blues do not carry bizarre delusions, perplexity or insomnia out of proportion to the baby. Blues peak at day 4 and resolve within two weeks with intact insight. The belief that the baby is sending signs is psychotic content."^[1]
• "And the incidence of first-onset postpartum psychosis is low — 0.25 to 0.6 per 1000 births in register studies — but when it presents it deteriorates fast, and the risk of suicide and infanticide is real."^[1]

Probe 2 — "She is breastfeeding. How does that change the pharmacology?"

• "Pharmacological treatment of puerperal psychosis is led by psychiatry, typically an antipsychotic, often with lithium. The point I hold is the principle: most perinatal psychotropics are compatible with feeding with monitoring, but lithium in lactation needs maternal levels and infant serum lithium and thyroid surveillance, and the decision is a specialist one."^[2]
• "For a depressive episode without psychosis, my first-line drug would be sertraline 50 mg once daily, because the mother-infant serum study showed very low transfer into milk with no reported infant adverse effects, and a low relative infant dose under 10 per cent is the reassurance threshold."^[5]

Probe 3 — "She has a sister with bipolar disorder. What does that change for her next pregnancy?"

• "It raises the stakes considerably. Puerperal psychosis is a presentation of bipolar-spectrum illness in most women, and the recurrence risk in a future pregnancy is high — after a prior puerperal psychosis the relapse rate is around 29 per cent."^[3]
• "I would arrange a pre-conception consultation with perinatal psychiatry. Prophylactic medication through pregnancy and the postpartum dramatically lowers relapse — in the meta-analysis, bipolar women medication-free in pregnancy relapsed postpartum in 66 per cent, falling to 23 per cent on prophylaxis."^[3][6]

Probe 4 — "Her partner is in the corner and very frightened. What do you say?"

This is a scored communication domain. Demonstrate it with actual words. ^[1]

• Turn to him, use his name, get to his eye level: "This is a serious illness that can come on very quickly after a baby is born, and it is not anyone's fault. We are calling the psychiatry team now and she will be looked after in hospital, ideally with the baby with her. I will keep telling you what is happening."
• Address the fear directly: "The thoughts she is having are part of the illness, and they are treatable. The baby is safe and will be cared for. I will make sure you know where the baby is at all times."
• Give him a job and a contact: "Can you stay with her while I make the calls? Here is the number to ring if anything changes before the team arrives."^[1]

Probe 5 — "Once she is stable, what is the follow-up plan?"

• Specialist perinatal mental health follow-up, a documented medication plan, and structured relapse-prevention including sleep protection and a written early-warning-signs plan.^[2]
• A pre-conception plan for the next pregnancy, with prophylaxis agreed in advance, because the recurrence risk is high and the window to act is before the next delivery, not after it.^[6]