Psychiatric disorders of childbirth

PSYCHIATRIC DISORDERS of CHILDBIRTH

Introduction
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
The word tocophobia 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 Scandinavia. 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.

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 bleeding, simulate rupture of the membranes, or manipulate instruments pretending to be in labour (obstetric factitious disorder).

Painless and unconscious labour
The phenomenon of painless labour is well known. It used to thought that this occurred only in insane women (such as those with catatonia). 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 convulsions), 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.

Delirium during labour
Before anaesthetics were introduced, it was recognized that a woman in severe labour could suddenly become confused. 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.

Parturient rage
In the extremity of her pain, 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.

Acts of desperation
In women facing death during obstructed labour, panic 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.

Neonaticide
Neonaticide is a form of infanticide in which the newborn is murdered. 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.

Pathological states of mind immediately after delivery
After such an ordeal, there may be exhaustion, fainting and shock. 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’.

Frequency of these complications
In countries with state-of-the-art obstetrics, these complications are rare. But in poorer countries with high birth rates, 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 stillbirth or complications requiring emergency Caesarean section, some mothers suffer nightmares, 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.

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 vengeful 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 cornea 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 cyanotic, 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.

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 vulva, 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 Gis&egrave;le, 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 psychiatrist 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.