Agreement: I Agree Body: Dear Editor, Limb reports that births at North Devon District Hospital have been suspended, that women may travel up to two hours in labour, and that antenatal advice was then portrayed as teaching people how to give birth in a car.1 The last claim was misleading. It has also crowded out a more important gap in the diversion plan. When births are moved, trusts usually specify the receiving unit, ambulance cover, and consultant arrangements. They much less often specify what happens if the mother becomes acutely psychotic after delivery. Postpartum psychosis is uncommon, about 1–2 per 1000 births, but it is a psychiatric emergency.2 3 It may begin abruptly, with confusion, delusions, hallucinations, severe insomnia, or a rapidly changing mental state. It is not baby blues. The usual failure is late recognition, not absence of treatment. Published protocols are already available. High-risk women—those with bipolar disorder, previous postpartum psychosis, or a strong family history—should have a written medicine plan before transfer becomes routine. After delivery, prophylaxis with lithium, or an antipsychotic where lithium is unsuitable, should be decided by a perinatal psychiatrist in advance, with baseline blood tests and a plan for levels, thyroid function, and neonatal liaison.4 5 Acute illness should not be managed in primary care or deferred to a routine midwife visit. The woman needs urgent psychiatric review and, in most cases, admission. The best-evidenced acute sequence is stepwise: a benzodiazepine for severe insomnia or agitation; a second-generation antipsychotic for psychosis or mania; then lithium, which has the strongest evidence for remission and for preventing relapse in the first postnatal year.4 5 Electroconvulsive therapy should be available early if she is catatonic, refusing food and fluid, severely suicidal, or not improving. Antipsychotic monotherapy is a weaker long-term strategy; many women remit only after lithium is added.4 Medicine choice must also take account of breastfeeding, renal function, and the neonate. Olanzapine and lorazepam are often used when lactation is being continued; lithium requires specialist monitoring and may lead to a decision not to breastfeed.5 None of this should be started from a headline or an antenatal class. It needs a named on-call route from the receiving obstetric unit to psychiatry the same day. A diversion or reopening plan that lists travel times but not this pathway is incomplete. Until same-day assessment and an agreed medicine protocol sit on the risk register beside staffing and ambulances, the plan covers only half of the emergency. References 1. Limb M. Maternity unit faces media storm over “how to give birth in a car” classes. BMJ. Accessed 6 September 2026. https://www.bmj.com/content/394/bmj-2026-100700 2. Perry A, Gordon-Smith K, Jones L, Jones I. Phenomenology, epidemiology and aetiology of postpartum psychosis: a review. Brain Sci 2021;11:47. 3. VanderKruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS. The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry 2017;17:272. 4. Bergink V, Burgerhout KM, Koorengevel KM, et al. Treatment of psychosis and mania in the postpartum period. Am J Psychiatry 2015;172:115-23. 5. Jairaj C, Seneviratne G, Bergink V, Sommer IE, Dazzan P. Postpartum psychosis: a proposed treatment algorithm. Bipolar Disord 2023;25:557-66. Competing interests: None No competing Interests: Yes The following competing Interests: Electronic Publication Date: Sunday, September 6, 2026 - 03:14 AI use: No, I have not used AI Highwire Comment Subject: Maternity unit faces media storm over “how to give birth in a car” classes Workflow State: Released Full Title: Postpartum psychosis should be on the maternity diversion risk register Highwire Comment Response to: Maternity unit faces media storm over “how to give birth in a car” classes Check this box if you would like your letter to appear anonymously:: Last Name: Prakash First name and middle initial: Om Email: drjhirwalop@yahoo.co.in Address: Department of Geriatric Mental Health Occupation: Professor of Psychiatry & Head, Department of Geriatric Mental Health Affiliation: Institute of Human Behaviour and Allied Sciences (IHBAS) BMJ: Additional Article Info: Rapid response Twitter: @ompsychiatrist