If PND remains unidentified, untreated or is moderately severe the woman may be experiencing some thoughts and behaviour that present a risk to her or her baby. For most women their thoughts of harm or suicide are fleeting and represent a desire for their pain and distress to go away, for example a desire to go away and not come back.

It is vital to assess what thoughts she has been having and if she is concerned for herself, particularly when these fleeting thoughts take on greater detail or become more prevalent. It can be particularly difficult to share these thoughts as they are scary and distressing to acknowledge. Family and partners may not know how to respond to these feelings and thoughts.

The areas of risk that need to be assessed should include:

Suicide - thoughts, details and plans to take her own life

Self Harm - behaviour that puts herself at risk physically (self mutilation) or the use of alcohol or drugs as a form of self medication, eg binging

Harm to baby - this may be due to neglect and difficulty caring for the baby, physical abuse as a result of the mother's inability to cope or emotional harm due to limited bonding and attachment. Infanticide is a rare and devastating outcome of PND.

Mental Health risks - the woman may not be acknowledging the degree of severity of her symptoms and therefore not seeking or accepting treatment, or if she may be deteriorating rapidly. Her well being can be put at increased risk.

Family, friends and health professionals need to be able to approach these areas of potential risk with the woman by gently but firmly asking her direct questions. Being able to avoid overreacting is important to encourage her to speak openly. Some examples of questions include:

• Do you ever have thoughts or feelings that scare you?
• Do you ever have thoughts or feelings that make you worry about your or your baby's safety?
• Do you have any thoughts of suicide or hurting yourself?
• Do these thoughts ever become more detailed such as in a plan?
• Can you tell me about your plan?
• What stops you carrying out your thoughts or plan?
• What would you do if you felt that you couldn't stop yourself from acting out your thoughts?

For many women it can be a relief to be asked questions such as these and to be able to speak openly about their thoughts, especially if they are received in an open and supportive way. If the woman has responded in a way that is concerning the following interventions may be necessary:

• Ensure that someone is with the woman and her baby
• Ask the woman to promise - contract - to not acting on her thoughts and feelings until a support network can be put in place
• Arrange for her to see her GP or Crisis Assessment Treatment Team as soon as possible to be assessed and supported
• If the risk is more immediate the woman may need to be admitted to hospital via ambulance, emergency department or GP
• Encourage her to continue to talk about how she has been feeling, what causes her to have these thoughts and what support she needs.