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Practice case P2-11 · Face-to-face · simulated patient

“I’m just tired” — six weeks after the birth

A new mother has come for her postnatal check. The health visitor is worried about her. She says she is just tired.

Reviewed and kept current

Station family: Perinatal mental health assessment · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026.

Candidate instructions

Read this as you would outside the room

You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.

	Information
Your role	Foundation Year 2 doctor in a general practice. Your supervising GP is available.
Patient	Mrs Nadia Siddiqui, 31, hospital pharmacist on maternity leave. Her husband is in the waiting room with their baby, Yusuf, aged six weeks.
Reason for appointment	Six-to-eight-week postnatal check. Message from the health visitor yesterday: “EPDS score 17. Tearful, flat. Please review.”
Records	Emergency caesarean section at 39 weeks for fetal distress after a long labour; postpartum haemorrhage of 1.2 litres; haemoglobin 98 g/L at discharge, on oral iron. Breastfeeding. No past psychiatric history. No known allergies.

Your task

•

Assess her mood and how she is coping.

•

Assess the risk to her and to her baby.

•

Explain what you think is going on and agree a plan with her.

•

No physical examination is required in this station.

Folded away

For the actor and the examiner

1 · Actor script — role player only

Candidates: do not open until you have consulted.

Persona and manner

Nadia Siddiqui, 31, hospital pharmacist. High-achieving, organised, used to coping. Now exhausted, flat and ashamed. You speak quietly and look at your hands.
Your husband Bilal is supportive but back at work on long shifts. Your own mother lives 200 miles away; your mother-in-law visits daily and means well, but you feel watched.

Opening line — say this verbatim

“I’m fine, honestly. I’m just tired. The health visitor’s making a fuss over a questionnaire.”

Volunteer freely if given the space

You cry most days. “I don’t feel how I’m supposed to feel.”
You cannot sleep even when Yusuf sleeps.

Only if asked

Low mood most of the day for about four weeks — it started around two weeks after the birth and has not lifted. Nothing gives you pleasure. You feel guilty: “He deserves a better mother.”
Little appetite. You lie awake from two until four with racing worries. You cannot concentrate — you forgot your iron tablets for days.
Bonding: “I look after him like a patient. I feed him, change him. I don’t feel… it.”
The birth was frightening. You sometimes replay the theatre lights and the alarm, but it does not dominate your days.
Intrusive thoughts (only if asked gently, or invited to add anything): sudden pictures of dropping him down the stairs, or the pram rolling into the road. They horrify you. You now avoid carrying him downstairs — Bilal does it — and you check that he is breathing ten or more times a night. You have never wanted to hurt him and never have.
Thoughts of suicide (only if asked directly): “Sometimes I think they’d be better off without me.” No plan, no intent, no preparations. “I couldn’t do that to Bilal or my mum.” Your faith matters to you. You have never harmed yourself.
No voices. No strange beliefs about yourself or the baby. You are not confused. No periods of feeling high, speeded up or not needing sleep. No family history of bipolar disorder or psychosis.
No alcohol or drugs. Breastfeeding is going reasonably well. Your bleeding has settled; the wound has healed.

Impact on daily life — home and work (only if asked)

You have not left the house for a week and have not showered for three days.
You cannot face the baby group. Friends from work have drifted.
“I’m a pharmacist and I can’t even work out a feed chart.” You dread the day you have to go back.

Ideas, concerns and expectations

Idea: “I’m just not cut out for this” — or simply lack of sleep.
Concerns: “If I tell you what goes through my head, you’ll take him away.” Also: tablets and breastfeeding; what your professional regulator and colleagues would think.
Expectation: to be told it is normal and to go home; perhaps something to help you sleep.

Cues to deliver, timed

Minute 2: “Everyone else seems to love it.” — your eyes fill.
Minute 4, if risk has not been asked about: “I have… horrible thoughts sometimes. I can’t say them.”
If asked “You’re not going to harm the baby, are you?”: “No! Of course not.” — and shut down.

If the doctor summarises and asks whether you want to add anything

If the intrusive thoughts have not come out: a long pause — “There’s something I haven’t said. I get these pictures in my head — of dropping him. I would never. But what kind of mother thinks that?”
If they have: “I’m frightened of being on my own with him all day. Is that normal?”

How to respond to the doctor

If the doctor explains that this is postnatal depression — common, treatable and not your fault; that frightening, unwanted thoughts are very common in new mothers and that being horrified by them is a sign you are not going to act on them; and that telling a doctor about these thoughts is not a reason for anyone to take Yusuf away — the aim is to help you care for him: you cry with relief — “I thought I was a monster.”
If the doctor says social services must be told because of the thoughts: terror — “Please don’t. Please.”
If the doctor dismisses it as baby blues or tiredness: “OK.” You leave.
If treatment options are explained — talking therapy, an antidepressant that is compatible with breastfeeding, the specialist perinatal team, the health visitor, practical help and involving Bilal: you ask, as a pharmacist, “Is sertraline really all right with breastfeeding?” and accept a considered answer.
If asked whether Bilal can join you: yes, you would like that.

Do not

Volunteer the intrusive images or the thoughts of being “better off without me” unless asked sensitively or invited to add anything.
Describe voices, strange beliefs or confusion — you have none.

2 · Examiner mark sheet — generic scheme plus the key facts for this case

Domain marks — with the key facts that earn a 4 at this station

Domain (GMC wording) · key facts for this case	1	2	3	4	Score
1 · Data gathering, technical and assessment skills Core depressive symptoms, onset and duration; sleep, appetite, concentration; bonding with the baby; the birth Asks directly about suicide and about thoughts of harm to the baby — gently, normalising first; distinguishes unwanted intrusive images from intent Red flags: psychotic symptoms, confusion, mania, sudden change, estrangement from the baby; alcohol and drugs ICE (fears Yusuf will be taken away; tablets and breastfeeding) and impact — not leaving the house, self-care, isolation; support at home	☐	☐	☐	☐	/4
2 · Clinical management skills Summary and check, then the working diagnosis: moderate-to-severe postnatal depression with anxiety and unwanted intrusive thoughts — no intent to harm; passive suicidal thoughts only Why not: baby blues (too late, too long); postpartum psychosis (no hallucinations, delusions, confusion or mania); anaemia and thyroiditis checked with bloods Plan: supervising GP today; urgent perinatal mental health referral; talking therapy and sertraline (compatible with breastfeeding) discussed; health visitor; Bilal involved; bloods Safety-net: suicidal thoughts stronger or planned, any urge to act on thoughts about the baby, voices, strange beliefs, confusion or no sleep at all → same-day emergency help (crisis line, NHS 111, 999) · Follow-up: call in 48–72 hours; review within a week	☐	☐	☐	☐	/4
3 · Interpersonal skills Gentle pace; normalises before asking about harm; never leading Responds to shame; separates thoughts from intent; “you are not a monster” Honest reassurance about safeguarding — the aim is to keep mother and baby together Treats her as a fellow professional; shared decision on treatment; checks understanding	☐	☐	☐	☐	/4
Station total					/12

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory ☐ Borderline ☐ Satisfactory ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4.

3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

Mark	Domain 1 · Data gathering, technical and assessment skills	Domain 2 · Clinical management skills	Domain 3 · Interpersonal skills
4	Open start; then core symptoms — low mood, loss of pleasure, guilt, energy — with onset two weeks after the birth and duration of about four weeks; mental state observed and reflected back (“you look exhausted and close to tears”) Biological and cognitive symptoms: sleep beyond what the baby causes, appetite, concentration Bonding and feelings towards the baby; the experience of the birth Asks directly about suicide and about thoughts of harming the baby, normalising first; explores the intrusive images — unwanted, distressing, resisted, no intent — and the avoidance and checking they have led to Red flags: hallucinations, delusions (especially about the baby), confusion, elation or no need for sleep, a sudden change in mental state, persistent feelings of incompetence or estrangement from the baby; alcohol and drugs; past and family psychiatric history ICE: believes she is “not cut out for this”; fears Yusuf will be removed, and what tablets mean for breastfeeding and for her career; expects to be told it is normal Impact on daily living: not leaving the house, not washing, avoiding the stairs with the baby, isolated; support — husband at work, mother far away, feels watched by visiting family	Summarises what she has said and checks whether there is anything she wants to add Working diagnosis with justified differentials: postnatal depression of at least moderate severity, with anxiety and unwanted intrusive thoughts — four weeks of pervasive low mood, loss of pleasure, guilt, insomnia even when the baby sleeps, and detachment from the baby, an EPDS of 17, passive suicidal thoughts without plan or intent. Baby blues is excluded by timing (it peaks in the first week and settles by two). Postpartum psychosis — an emergency — is unlikely: no hallucinations, delusions, confusion or elation. The intrusive images are unwanted, horrify her and are resisted, which is characteristic of postnatal anxiety or obsessional thoughts, not of intent to harm. Anaemia after her haemorrhage and postpartum thyroiditis can mimic or worsen this and need blood tests; some features of birth trauma are present Explains the diagnosis plainly: common (more than one in ten mothers), treatable, not a failing Discusses with the supervising GP today; urgent referral to the specialist perinatal mental health team — persistent feelings of incompetence as a mother and estrangement from the baby are recognised red flags Treatment options shared: prioritised access to talking therapy; an SSRI — sertraline is compatible with breastfeeding; not a sleeping tablet alone Support: health visitor, Bilal brought in with her consent, protected sleep (a night feed covered), peer support; bloods — full blood count, ferritin, thyroid function Safeguarding explained honestly: unwanted intrusive thoughts without intent are not a reason to refer to children’s social care; the aim is to support her to care for Yusuf Safety-net: if thoughts of ending her life become stronger or she starts to plan, if she ever feels an urge to act on the thoughts about Yusuf, or if she — or Bilal — notices voices, strange beliefs, confusion, a sudden change or not sleeping at all → same-day emergency help: the perinatal team’s crisis line, NHS 111 (mental health option) or 999 / the emergency department; Bilal is told these warning signs with her consent. Follow-up: a telephone call from the practice in 48–72 hours and a face-to-face review within one week (sooner than usual because of the suicidal thoughts and any new antidepressant) with a named GP; blood results (full blood count, ferritin, thyroid function); confirmation that the perinatal team has made contact; the health visitor updated with her consent.	Unhurried; lets her finish; does not accept “I’m fine” but does not push Normalises before asking about frightening thoughts; never uses leading or accusing questions Responds to shame and guilt; says clearly that the thoughts do not make her a bad or dangerous mother Addresses the fear of losing Yusuf honestly and early Respects her professional knowledge; makes treatment a shared decision Offers to bring Bilal in; checks what she has understood and what she will do this week
3	Depressive symptoms, suicide and thoughts about the baby all explored; one of the psychosis screen, bonding, or the impact on daily life and support missing.	Correct diagnosis explained with reasoning, perinatal referral and treatment options; one of the bloods, involving the husband / health visitor, the specific safety-net or early follow-up missing.	Warm and non-judgemental; one fear (the baby being removed, breastfeeding, her career) not addressed.
2	Mood history adequate but risk enquiry incomplete — asks about self-harm but not the baby, or accepts “I’m fine”; ICE not elicited.	Depression recognised but managed as routine: leaflet and review in a month; or antidepressant prescribed with no discussion of breastfeeding; differentials not considered; safety-net generic.	Kind but rushed or formulaic; risk questions asked as a checklist; limited response to her distress.
1	Generic tiredness history; no risk assessment. Or unsafe: does not ask about suicide or about harm to the baby; or asks in a leading or accusing way so that she shuts down and nothing is learned.	“Baby blues — it will pass”; or a sleeping tablet; no safety-net and no follow-up. Or unsafe: tells her that social services must be informed because of her thoughts, without any indication of intent; or gives a sleeping tablet and reassurance without asking about suicide or psychotic symptoms; or lets her leave with no plan.	Leading or judgemental questions (“you’re not going to hurt him, are you?”); platitudes (“you should be enjoying this time”). Or unsafe: dismissive, stigmatising or threatening.

4 · GMC feedback statements — where underperformance was identified — with case-specific examples

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

GMC feedback statement	Underperformance it signals (generic)	Case-specific examples
1 · Consultation	Disorganised or unstructured consultation	Runs the physical postnatal check — wound, bleeding, contraception, the baby’s weight — and reaches her mood in the last two minutes; no structure to the mental health assessment.
2 · Issues	Key issues or priorities not recognised	Accepts “I’m just tired” and the health visitor’s score is never discussed; does not recognise that assessing her mood and the risk to her and the baby is the whole task.
3 · Time	Poor time management	Lengthy birth story and feeding history; risk, diagnosis and plan not reached.
4 · Findings	Abnormal findings or results, or their implications, not identified	Does not use EPDS 17, the 1.2-litre haemorrhage or haemoglobin 98; hears “I look after him like a patient” and does not recognise estrangement from the infant as a red flag.
5 · Examination	Physical examination or use of instruments not competent	Mental state examination counts as examination in PLAB 2: does not notice, or reflect back to her, her flat affect, poor eye contact and tearfulness; does not explore thought content or insight.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	“Baby blues” at six weeks; or labels unwanted intrusive images as a risk to the child; postpartum psychosis never screened for; anaemia and thyroid not considered.
7 · Management	Management plan not reflecting current best practice	Zopiclone for sleep; an SSRI with no mention of breastfeeding; no perinatal team referral; review “in a month”; no crisis numbers; tells her social services must be informed.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	“You should be enjoying this — you have a healthy baby”; visible alarm when she describes the images; no response to “what kind of mother thinks that?”
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Misses “everyone else seems to love it” and “I have horrible thoughts sometimes”; never gives her the opening to say them.
10 · Language	Language or explanations not understandable; understanding not checked	“You have PND with ego-dystonic intrusive thoughts; I’ll refer you to perinatal psychiatry and start an SSRI” — no plain-English version; does not check what she will tell Bilal.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

Timing matters. Baby blues: tearfulness peaking around days three to five, gone by two weeks. Postnatal depression: more than one in ten mothers, usually within the first three months, lasting weeks to months. Postpartum psychosis: one or two per thousand births, usually within two weeks — a psychiatric emergency.
NICE CG192: if postpartum psychosis is suspected, refer to a secondary mental health service — preferably a specialist perinatal team — for immediate assessment, within four hours. Mothers should be admitted with their babies to a mother and baby unit wherever possible.
MBRRACE-UK “red flags” needing urgent senior psychiatric assessment: a recent significant change in mental state or new symptoms; new thoughts or acts of violent self-harm; new and persistent expressions of incompetency as a mother or estrangement from the infant. Suicide remains a leading cause of maternal death in the year after pregnancy.
The Edinburgh Postnatal Depression Scale is a ten-item screen; 13 or more suggests a depressive illness, and item 10 asks about self-harm. It supports, but does not replace, a clinical assessment.
Unwanted, distressing intrusive thoughts or images of harm coming to the baby are very common in new parents. When they are ego-dystonic — horrifying, resisted, leading to avoidance and checking — and there is no intent, they indicate anxiety or obsessional symptoms, not a risk to the child. Ask about them; do not treat disclosure as a safeguarding trigger in itself.
Treatment (NICE CG192): for moderate or severe postnatal depression consider a high-intensity psychological intervention (such as CBT), or an antidepressant if she understands the risks and prefers medication, declines therapy or has not responded to it; combine them if either alone has not worked. Perinatal referrals should be assessed within two weeks, with therapy starting within one month of that assessment. Sertraline (with paroxetine) is an SSRI of choice when breastfeeding a healthy term baby — very small amounts reach the milk; ask her to watch Yusuf for drowsiness, poor feeding or irritability (NHS Specialist Pharmacy Service; NICE CG192).
Check full blood count, ferritin and thyroid function: anaemia after haemorrhage and postpartum thyroiditis both mimic or worsen low mood.
After starting an antidepressant, review within one week when there is any concern about suicide risk (NICE NG222).
Involve the partner and the health visitor with her consent. An F2 would discuss this consultation with the supervising GP the same day.

Where candidates lose marks at this station

Accepting “I’m just tired”.
“You’re not going to harm the baby, are you?”
Calling it baby blues at six weeks.
Treating intrusive thoughts as a safeguarding referral.
A sleeping tablet and a review in a month.
Forgetting the haemoglobin and the thyroid.

Guidelines for this station

6 · MLA content map tags for this case

MLA content map	This station
Domain 1 · Areas of clinical practice	Mental health · Obstetrics and gynaecology
Domain 3 · Clinical and professional capabilities	History, examination and differential diagnosis · Safeguarding vulnerable patients · Managing risk · Communication with patients, relatives and carers · Safe prescribing
Domain 5 · Patient presentations	Mental health problems in pregnancy or postpartum · Altered mood · Sleep problems · Suicidal thoughts
Domain 6 · Conditions	Postpartum depression · Postpartum psychosis
Station family	History, diagnosis and management — Perinatal mental health assessment

7 · My marks and reflection — practice log form

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-11

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-11-low-mood-after-childbirth

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Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.

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