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CASC Linked OSCE

STATION TITLE:
ASSESSMENT OF A PREGNANT LADY

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CASC Linked OSCE

STATION TITLE: ASSESSMENT OF A PREGNANT LADY

Instructions to Candidate

You are about to see a woman who has been referred by the GP for an assessment of her
current mental state and advice on management. She is 10 weeks pregnant.

Tasks:

 Take a history to clarify her current symptomatology.


 Your are not expected to carry out a full MSE or risk assessment.
 You may wish to take notes as in the next station you will talk with her husband.

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CASC Linked OSCE

STATION TITLE: ASSESSMENT OF A PREGNANT LADY


Instructions to Simulated Patient
You are Tracy Taylor, a 35-year-old married woman referred to a psychiatrist by your GP
because of depressed mood. You are 10 weeks pregnant and have one other child, a boy aged
7 months. You have been married for 6 years. You describe your husband as supportive. You
have been working as a senior administrator in charge of 10 staff. You have no past
psychiatric history and have always been regarded as competent, efficient and a high
performer.
Your first child was the result of a planned pregnancy. You planned to take 6 months
maternity leave. There were some problems during the labour, which resulted in a caesarean
section. There were no problems with the baby. You felt very tired after the birth. You had a
great deal of difficulty getting the baby to latch on, but persisted breast feeding. Your mother
is a housewife who came daily to help out.
Three weeks postpartum, you were still feeling very tired. The baby was feeding every three
hours. Even between feeding you found it difficult to get to sleep. Whilst you tried to eat
well, your appetite was poor. You felt somewhat detached from the baby, but did not feel
you could tell anyone. You felt increasingly guilty that you were a bad mother. You
constantly worried whether the baby was getting adequate nutrition and phoned the health
visitor regularly. Your husband and mother were very supportive. They saw that you were
tired and quieter. They reassured you that it was normal to take time to adapt to a new baby.
As time passed by, you became more anxious and began to worry that something bad was
going to happen to the baby. This evolved into a feeling that someone was going to take your
baby away. Evan though the baby was sleeping throughout the night, your insomnia
increased. At times you would become so frightened that you locked yourself in the
bathroom for hours.
You started to believe that your baby was possessed by demons. You were afraid to look at
the baby’s eyes, fearing that you would see something malevolent. Your mood was low and
you became increasingly tearful. You did not have any thoughts of harming the baby or
yourself. You did not have any obsessional thoughts about the baby nor did you believe that
others were interfering with your thoughts. You did not have any hallucinations.
You did not tell your family your beliefs about the baby. As you had felt well during the
pregnancy, your husband suggested that you get pregnant again. You went along with this,
hoping that it will make you feel better. You became pregnant 5 months after the birth of the
first child. This has not helped; you have continued to be withdrawn, anxious and tense.
They finally suggested that you see your family doctor who referred you to the psychiatrist.
There is a history of depression in a maternal grand mother and your mother had depression
following your birth that required hospitalisation. You are an only child.
At the interview, you should sit slightly hunched over, clasping your hands. Whilst you
should be clean and wearing well cared clothes, you should wear no make up and your hair
should not be brushed. You should make only a minimum of movements and your voice
should be monotonous and quiet. Make sure, however, that the candidate can hear you. You
do not hear voices or have other odd experiences. But you are absolutely convinced that your
baby has been possessed by demons and are afraid to look at the baby’s eyes as you are

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CASC Linked OSCE

afraid that you will see the demon looking out at you. You have no wish to harm the baby,
whom you see as innocent. You do not wish to harm yourself or others. You feel hopeless
and unable to change what is happening. Everything in life is an effort and you cannot see
anything positive about the pregnancy. Refer to your child as the ‘baby’, unless asked
specifically for his name.
If the examining doctor interviews you in an empathic manner, you should answer questions
posed freely. If they are cold, mechanical or ask poorly structured questions, display some
hesitancy. Seek clarification where appropriate. Do not give out information unless asked
appropriate questions.

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CASC Linked OSCE

STATION TITLE: ASSESSMENT OF A PREGNANT LADY

Examiner please mark one lozenge for each objective

Key: A=excellent, B=good, C=average, D=fail, E=severe fail

CONSTRUCT: The station tests the ability of the candidate to take a focused history of
postpartum depression with psychotic features.

A B C D E
Communication

Taking history of current & previous pregnancy

Eliciting features of depression

Establishing psychotic features

Simple, sensitive exploration of plans for pregnancy

GLOBAL RATING

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CASC Linked OSCE

STATION TITLE: ASSESSMENT OF A PREGNANT LADY

Notes to examiners:

The candidate can be expected to take a history and carry out a MSE that is focused, fluent
and demonstrate empathy with the patient’s experience. They should use an appropriate mix
of open and close ended questioning and display advanced listening skills. A ‘check list
approach’ to history taking should not be rewarded. The candidate should be expected to
ask a range of questions to elicit the way in which a patient with postpartum illness may
present. They should focus on the individual’s experience of the disorder. Exploration of
circumstances of both pregnancies should occur including patient’s experience about the
child. They should also ask about how things have been after the birth of the patient’s first
child and her support network.
They should attempt to identify those mood symptoms that the patient is experiencing as
well as screening for other mood symptoms that might occur in such disorders. They should
attempt to identify those delusions that the patient is experiencing, and has experienced, as
well as screening for other abnormal beliefs might be held in such disorders. They should
demonstrate in their questioning that they are seeking to understand whether the patient’s
beliefs may carry risks for the patient and her child/pregnancy. In exploring the patient’s
beliefs, the candidate is expected to demonstrate the desire to understand the patient’s
experience rather than ascertaining whether delusions are present or not. They should also
ascertain whether there are mood congruent delusions at present. As there are no other
psychotic symptoms of note, the candidate should demonstrate an awareness of how to
screen for symptoms and have the insight to move on when such screening is not
productive.
Candidates should stick to the task indicated in the instructions. They cannot obtain extra
marks for straying outside the tasks identified. A very good candidate may not cover all
possible symptoms, but as this is an assessment of skill, they should be appropriately
rewarded for the skills in carrying out the task. Conversely, a poor candidate may cover all
possible symptoms but not in a manner appropriate to the clinical setting enacted, in
particular they may not seek to understand the patient’s perspective. The marks for such a
candidate should reflect this poor performance.