Psychiatric disorders of childbirth
Encyclopedia
This entry covers the complications of childbirth
(delivery, labour, parturition) itself, not those of pregnancy
or the postpartum period. Even with modern obstetrics
and pain control, childbirth is still an ordeal for many. Some women fear it so much that they avoid marriage
or childbearing (tocophobia) and some have such a dreadful experience that they suffer post-traumatic symptoms
for months, or give way to pathological complaining. Occasionally women, who cannot bear the pregnant state, make importunate demands for early delivery. On the other hand, delivery can occur without pain, or while the mother is unconscious. During delivery, and immediately afterwards, dramatic complications
are occasionally seen - acts of desperation
, delirium
, coma
, rage
reactions or neonaticide
. All these complications are explained in detail elsewhere . They will now be briefly reviewed in turn.
. Tocophobia can be primary (before the first child is born) or secondary (typically after extremely traumatic deliveries). Elective Caesarean section
is one solution, but psychotherapy
can also help these women to give birth vaginally .
, simulate rupture of the membrane
s, or manipulate instruments pretending to be in labour (obstetric factitious disorder
).
). But it can happen in sleep or normal daytime activities . Women can give birth without knowing it, not only when anaesthetised, but also when profoundly drunk. The commonest cause of unconscious delivery is eclampsia
(sudden onset of epileptic
convulsion
s), but any medical cause of coma can have this effect. In a few cases, stupor
or coma has no explanation, as in the patient summarised below .
. This clouding of consciousness lasted for a few minutes or a few hours. Usually the mother recovered as soon as the baby was delivered, but confusion could continue into the puerperium. An example is summarised below . This form of delirium was frequent in the early 19th century, but became rare in hospital
deliveries.
, a woman may lose control and hit out. There have been instances of a mother reaching down to seize the baby and haul it out, or even attacking the newborn. One mother killed the child in the presence of a midwife - see below. This is probably a factor in the violence
of some neonaticides, when the infant is decapitated
, stabbed
many times, or its head smashed. In some cases, violence has occurred during delirium. This is important for medico-legal practice, because, in a clandestine delivery, it would be impossible to know whether or not rage was part of a wider cognitive disturbance
.
or despair
can stimulate them to take desperate remedies. Women have dragged out the baby with their own hands. There are several descriptions of auto-Caesarean section and about twenty cases of attempted or completed suicide
.
in which the newborn is murder
ed. The definition is ‘within the first 24 hours’, but it usually happens immediately after the birth. It can be called ‘criminal neonaticide’ to distinguish it from ‘customary neonaticide’, a practice used in certain cultures at certain times to limit the population. Criminal neonaticide is usually perpetrated by a mother who has concealed her pregnancy, and faces disgrace and ruin. Although the pregnancy is unwanted, the crime is typically not planned. The perpetrators are highly disturbed, but not ‘mentally ill’. The state of mind of these young women, in their pain, despair, exhaustion and lonely peril, test out the definition of insanity
. Most of the assaults on the infant suggest panic; a few, which involve head trauma or stabbing, testify to hatred
and fury. Neonaticide can occur during delirium. In Europe and North America, it used to be a major public health
problem. Its frequency has dwindled almost to zero, but this may not be true in other parts of the world.
. Delirium can start after delivery, and occasional cases of stupor have been reported. These early postpartum states have forensic importance, because the infant often needs resuscitation, and can suffocate in mucus
or blood
. They are relevant to ‘infanticide by neglect
’.
s, it is common for women to give birth without any professional help – with neither obstetrician nor midwife in attendance - and without anaesthetics. These mothers, and others who give birth in secret after a concealed pregnancy, are still at risk of these severe manifestations.
or complications requiring emergency Caesarean section, some mothers suffer nightmare
s, and intrusive images and memories
(‘flashbacks’), similar to those occurring after other harrowing experiences. They can last for months . Some avoid further pregnancy (secondary tocophobia), and those who become pregnant again may experience a return of symptoms, especially in the last trimester. Rates up to 5.9% of deliveries have been reported . There is some evidence that early counseling reduces these symptoms. Enduring symptoms require specific psychological treatment.
fantasies may continue for weeks or months, interfering with infant care. This disorder can be treated by a psychotherapeutic approach that distracts the mother from her grievances, and reinforces productive child-centered activity.
was touched. An hour after the birth she suddenly awoke and looked around bewildered, seeming not to understand where she was. When told she was the mother of a healthy boy, she looked incredulous and said, "How can that be?" Given her baby, she said, "God! Doctor! What a strange thing to happen! I knew nothing about it".
, threw herself about and pleaded for medicine to kill her. Suddenly she looked about her with staring eyes and no longer knew where she was - did not know she was in labour and did not recognize the doctor. She must go home - her mother was calling her. After a dose of morphine
, she lost consciousness, and the baby was delivered. When she woke, she asked what was crying, and why her belly had become so small. She had felt nothing and would not believe her baby had been born.
, she kicked the midwife out of the way, tore the infant out of the birth canal, and smashed it against the bedpost, killing it instantly.
gave her a diary
in which to record the main events of the day, especially Stephanie's progress, and her experiences in looking after her. This was called the 'happy book'. At each session he listened to her bitter complaints about her husband's outrage and then asked to see the 'happy book'. Gradually the complaining reaction faded.
Childbirth
Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...
(delivery, labour, parturition) itself, not those of pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
or the postpartum period. Even with modern obstetrics
Obstetrics
Obstetrics is the medical specialty dealing with the care of all women's reproductive tracts and their children during pregnancy , childbirth and the postnatal period...
and pain control, childbirth is still an ordeal for many. Some women fear it so much that they avoid marriage
Marriage
Marriage is a social union or legal contract between people that creates kinship. It is an institution in which interpersonal relationships, usually intimate and sexual, are acknowledged in a variety of ways, depending on the culture or subculture in which it is found...
or childbearing (tocophobia) and some have such a dreadful experience that they suffer post-traumatic symptoms
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
for months, or give way to pathological complaining. Occasionally women, who cannot bear the pregnant state, make importunate demands for early delivery. On the other hand, delivery can occur without pain, or while the mother is unconscious. During delivery, and immediately afterwards, dramatic complications
Complications of pregnancy
Complications of pregnancy are the symptoms and problems that are associated with pregnancy. There are both routine problems and serious, even potentially fatal problems. The routine problems are normal complications, and pose no significant danger to either the woman or the fetus...
are occasionally seen - acts of desperation
Desperation
Desperation is a horror novel by Stephen King. It was published in 1996 at the same time as its "mirror" novel, The Regulators. It was made into a TV film starring Ron Perlman, Tom Skeritt, and Steven Weber in 2006....
, delirium
Delirium
Delirium or acute confusional state is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior...
, coma
Coma
In medicine, a coma is a state of unconsciousness, lasting more than 6 hours in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound, lacks a normal sleep-wake cycle and does not initiate voluntary actions. A person in a state of coma is described as...
, rage
Rage (emotion)
Rage is a feeling of intense anger. It is associated with the Fight-or-flight response and oftentimes activated in response to an external cue, such as the murder of a loved one. The phrase, 'thrown into a fit of rage,' expresses the immediate nature of rage that occurs before deliberation. If left...
reactions or neonaticide
Neonaticide
Neonaticide is the killing of a newborn infant less than 24 hours old. It can be divided into criminal neonaticide, which is usually by a mother under severe psychological stress, and customary neonaticide, a practice used in certain cultures at certain times to limit the population.Neonaticide is...
. All these complications are explained in detail elsewhere . They will now be briefly reviewed in turn.
Tocophobia
The word comes from the Greek tokos, meaning parturition. Early authors like Ideler wrote about this fear, and , in 1937, Binder drew attention to a group of women who sought sterilization because of tocophobia. In the last 40 years there have been a series of papers published mainly from ScandinaviaScandinavia
Scandinavia is a cultural, historical and ethno-linguistic region in northern Europe that includes the three kingdoms of Denmark, Norway and Sweden, characterized by their common ethno-cultural heritage and language. Modern Norway and Sweden proper are situated on the Scandinavian Peninsula,...
. Tocophobia can be primary (before the first child is born) or secondary (typically after extremely traumatic deliveries). Elective Caesarean section
Caesarean section
A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...
is one solution, but psychotherapy
Psychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
can also help these women to give birth vaginally .
Demands for early delivery
Expectant mothers occasionally pester the obstetrician, again and again, demanding an immediate intervention (such as Caesarean section), even though it endangers the health or survival of the infant. Other women may induce bleedingBleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
, simulate rupture of the membrane
Fetal membranes
The fetal membranes, or chorioamniotic membranes, are the amnion and chorion which surround and protect a developing fetus....
s, or manipulate instruments pretending to be in labour (obstetric factitious disorder
Factitious disorder
Factitious disorders are conditions in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms. Factitious disorder by proxy is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person who is in their...
).
Painless and unconscious labour
The phenomenon of painless labour is well known. It used to be thought that this occurred only in insane women (such as those with catatoniaCatatonia
Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described in 1874: Die Katatonie oder das Spannungsirresein ....
). But it can happen in sleep or normal daytime activities . Women can give birth without knowing it, not only when anaesthetised, but also when profoundly drunk. The commonest cause of unconscious delivery is eclampsia
Eclampsia
Eclampsia , an acute and life-threatening complication of pregnancy, is characterized by the appearance of tonic-clonic seizures, usually in a patient who had developed pre-eclampsia...
(sudden onset of epileptic
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
convulsion
Convulsion
A convulsion is a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body. Because a convulsion is often a symptom of an epileptic seizure, the term convulsion is sometimes used as a synonym for seizure...
s), but any medical cause of coma can have this effect. In a few cases, stupor
Stupor
Stupor is the lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain. This is often mistaken for delirium and treated with Haldol and or other anti-psychotic drugs...
or coma has no explanation, as in the patient summarised below .
Delirium during labour
Before anaesthetics were introduced, it was recognized that a woman in severe labour could suddenly become confusedConFusion
ConFusion is an annual science fiction convention organized by the Stilyagi Air Corps and its parent organization, the Ann Arbor Science Fiction Association. Commonly, it is held the third weekend of January. It is the oldest science fiction convention in Michigan, a regional, general SF con...
. This clouding of consciousness lasted for a few minutes or a few hours. Usually the mother recovered as soon as the baby was delivered, but confusion could continue into the puerperium. An example is summarised below . This form of delirium was frequent in the early 19th century, but became rare in hospital
Hospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
deliveries.
Parturient rage
In the extremity of her painPain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
, a woman may lose control and hit out. There have been instances of a mother reaching down to seize the baby and haul it out, or even attacking the newborn. One mother killed the child in the presence of a midwife - see below. This is probably a factor in the violence
Violence
Violence is the use of physical force to apply a state to others contrary to their wishes. violence, while often a stand-alone issue, is often the culmination of other kinds of conflict, e.g...
of some neonaticides, when the infant is decapitated
Decapitation
Decapitation is the separation of the head from the body. Beheading typically refers to the act of intentional decapitation, e.g., as a means of murder or execution; it may be accomplished, for example, with an axe, sword, knife, wire, or by other more sophisticated means such as a guillotine...
, stabbed
Stabbing
A stabbing is penetration with a sharp or pointed object at close range. Stab connotes purposeful action, as by an assassin or murderer, but it is also possible to accidentally stab oneself or others.Stabbing differs from slashing or cutting in that the motion of the object used in a stabbing...
many times, or its head smashed. In some cases, violence has occurred during delirium. This is important for medico-legal practice, because, in a clandestine delivery, it would be impossible to know whether or not rage was part of a wider cognitive disturbance
Cognitive distortion
Cognitive distortions are exaggerated and irrational thoughts identified in cognitive therapy and its variants, which in theory perpetuate certain psychological disorders. The theory of cognitive distortions was first proposed by Aaron T. Beck. Eliminating these distortions and negative thoughts is...
.
Acts of desperation
In women facing death during obstructed labour, panicPanic
Panic is a sudden sensation of fear which is so strong as to dominate or prevent reason and logical thinking, replacing it with overwhelming feelings of anxiety and frantic agitation consistent with an animalistic fight-or-flight reaction...
or despair
Wiktionary
Wiktionary is a multilingual, web-based project to create a free content dictionary, available in 158 languages...
can stimulate them to take desperate remedies. Women have dragged out the baby with their own hands. There are several descriptions of auto-Caesarean section and about twenty cases of attempted or completed suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
.
Neonaticide
This is a form of infanticideInfanticide
Infanticide or infant homicide is the killing of a human infant. Neonaticide, a killing within 24 hours of a baby's birth, is most commonly done by the mother.In many past societies, certain forms of infanticide were considered permissible...
in which the newborn is murder
Murder
Murder is the unlawful killing, with malice aforethought, of another human being, and generally this state of mind distinguishes murder from other forms of unlawful homicide...
ed. The definition is ‘within the first 24 hours’, but it usually happens immediately after the birth. It can be called ‘criminal neonaticide’ to distinguish it from ‘customary neonaticide’, a practice used in certain cultures at certain times to limit the population. Criminal neonaticide is usually perpetrated by a mother who has concealed her pregnancy, and faces disgrace and ruin. Although the pregnancy is unwanted, the crime is typically not planned. The perpetrators are highly disturbed, but not ‘mentally ill’. The state of mind of these young women, in their pain, despair, exhaustion and lonely peril, test out the definition of insanity
Insanity
Insanity, craziness or madness is a spectrum of behaviors characterized by certain abnormal mental or behavioral patterns. Insanity may manifest as violations of societal norms, including becoming a danger to themselves and others, though not all such acts are considered insanity...
. Most of the assaults on the infant suggest panic; a few, which involve head trauma or stabbing, testify to hatred
Hatred
Hatred is a deep and emotional extreme dislike, directed against a certain object or class of objects. The objects of such hatred can vary widely, from inanimate objects to animals, oneself or other people, entire groups of people, people in general, existence, or the whole world...
and fury. Neonaticide can occur during delirium. In Europe and North America, it used to be a major public health
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...
problem. Its frequency has dwindled almost to zero, but this may not be true in other parts of the world.
Pathological states of mind immediately after delivery
After such an ordeal, there may be exhaustion, fainting and shockShock
Circulatory shock, commonly known simply as shock, is a life-threatening medical condition that occurs due to inadequate substrate for aerobic cellular respiration...
. Delirium can start after delivery, and occasional cases of stupor have been reported. These early postpartum states have forensic importance, because the infant often needs resuscitation, and can suffocate in mucus
Mucus
In vertebrates, mucus is a slippery secretion produced by, and covering, mucous membranes. Mucous fluid is typically produced from mucous cells found in mucous glands. Mucous cells secrete products that are rich in glycoproteins and water. Mucous fluid may also originate from mixed glands, which...
or blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
. They are relevant to ‘infanticide by neglect
Neglect
Neglect is a passive form of abuse in which a perpetrator is responsible to provide care for a victim who is unable to care for himself or herself, but fails to provide adequate care....
’.
Frequency of these complications
In countries with state-of-the-art obstetrics, these complications are rare. But in poorer countries with high birth rateBirth rate
Crude birth rate is the nativity or childbirths per 1,000 people per year . Another word used interchangeably with "birth rate" is "natality". When the crude birth rate is subtracted from the crude death rate, it reveals the rate of natural increase...
s, it is common for women to give birth without any professional help – with neither obstetrician nor midwife in attendance - and without anaesthetics. These mothers, and others who give birth in secret after a concealed pregnancy, are still at risk of these severe manifestations.
Post-traumatic stress disorder (PTSD)
Postpartum PTSD was first described in 1978 . Since then over 60 papers have been published. After excessively painful labours, or those with a disturbing loss of control, fear of stillbirthStillbirth
A stillbirth occurs when a fetus has died in the uterus. The Australian definition specifies that fetal death is termed a stillbirth after 20 weeks gestation or the fetus weighs more than . Once the fetus has died the mother still has contractions and remains undelivered. The term is often used in...
or complications requiring emergency Caesarean section, some mothers suffer nightmare
Nightmare
A nightmare is an unpleasant dream that can cause a strong negative emotional response from the mind, typically fear or horror, but also despair, anxiety and great sadness. The dream may contain situations of danger, discomfort, psychological or physical terror...
s, and intrusive images and memories
Intrusive thoughts
Intrusive thoughts are unwelcome involuntary thoughts, images, or unpleasant ideas that may become obsessions, are upsetting or distressing, and can be difficult to manage or eliminate. Most people experience these thoughts...
(‘flashbacks’), similar to those occurring after other harrowing experiences. They can last for months . Some avoid further pregnancy (secondary tocophobia), and those who become pregnant again may experience a return of symptoms, especially in the last trimester. Rates up to 5.9% of deliveries have been reported . There is some evidence that early counseling reduces these symptoms. Enduring symptoms require specific psychological treatment.
Complaining reactions
Another reaction to a severe labour experience is pathological complaining. These women complain bitterly about perceived mismanagement, or some other unfortunate event (see example below). Angry rumination and vengefulRevenge
Revenge is a harmful action against a person or group in response to a grievance, be it real or perceived. It is also called payback, retribution, retaliation or vengeance; it may be characterized, justly or unjustly, as a form of justice.-Function in society:Some societies believe that the...
fantasies may continue for weeks or months, interfering with infant care. This disorder can be treated by a psychotherapeutic approach that distracts the mother from her grievances, and reinforces productive child-centered activity.
A case of unexplained coma during labour
A 26 year old woman was in labour for the second time. Shortly after the waters broke, she laid both hands on her head and drew her knees high up, maintaining this position motionless for the last half hour of the birth. She was mute, her eyes fixed on a point. She reacted neither to questions nor pin-prick, and blinked only when her corneaCornea
The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Together with the lens, the cornea refracts light, with the cornea accounting for approximately two-thirds of the eye's total optical power. In humans, the refractive power of the cornea is...
was touched. An hour after the birth she suddenly awoke and looked around bewildered, seeming not to understand where she was. When told she was the mother of a healthy boy, she looked incredulous and said, "How can that be?" Given her baby, she said, "God! Doctor! What a strange thing to happen! I knew nothing about it".
A case of delirium during labour
A 20 year old woman was in her first labour. After the waters broke, the pains became so strong that she screamed and bellowed like an animal, became cyanoticCyanosis
Cyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is...
, threw herself about and pleaded for medicine to kill her. Suddenly she looked about her with staring eyes and no longer knew where she was - did not know she was in labour and did not recognize the doctor. She must go home - her mother was calling her. After a dose of morphine
Morphine
Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
, she lost consciousness, and the baby was delivered. When she woke, she asked what was crying, and why her belly had become so small. She had felt nothing and would not believe her baby had been born.
A case of parturient rage
A 40 year old woman experienced such stormy pains during her first delivery that her whole body trembled. As the head was passing through the vaginaVagina
The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...
, she kicked the midwife out of the way, tore the infant out of the birth canal, and smashed it against the bedpost, killing it instantly.
A case of pathological complaining
A young English woman was married to a Frenchman. After the birth of their first child (a daughter), her husband gave her the name Gisèle, while the mother wanted to call her Stephanie. He immediately agreed to this change, but that did not solve the problem. Giving the baby the wrong name had ruined their marriage and, indeed, the mother's whole life. The psychiatristPsychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...
gave her a diary
Diary
A diary is a record with discrete entries arranged by date reporting on what has happened over the course of a day or other period. A personal diary may include a person's experiences, and/or thoughts or feelings, including comment on current events outside the writer's direct experience. Someone...
in which to record the main events of the day, especially Stephanie's progress, and her experiences in looking after her. This was called the 'happy book'. At each session he listened to her bitter complaints about her husband's outrage and then asked to see the 'happy book'. Gradually the complaining reaction faded.