Psychiatric disorders of childbirth (parturition, labor, delivery), as opposed to those of pregnancy or the postpartum period, are psychiatric complications that develop during or immediately following childbirth. Despite modern obstetrics and pain control, these disorders are still observed. Most often, psychiatric disorders of childbirth present as delirium, stupor, rage, acts of desperation, or neonaticide. These psychiatric complications are rarely seen in patients under modern medical supervision. However, care disparities between Europe, North America, Australia, Japan, and other countries with advanced medical care and the rest of the world persist. The wealthiest nations represent 10 million births each year out of the world's total of 135 million. These nations have a maternal mortality rate (MMR) of 6–20/100,000. Poorer nations with high birth rates can have an MMR more than 100 times higher. In Africa, India & South East Asia, as well as Latin America, these complications of parturition may still be as prevalent as they have been throughout human history.
Three settings for childbirth Modern childbirth In nations with state-of-the-art obstetric services, childbirth is usually supervised by a midwife or obstetrician. Pain can be relieved by nitrous oxide, pethidine or an epidural anesthetic. Complications can be dealt with promptly, if necessary, by emergency Caesarean, also known as a C-section. These services are now standard procedure in many countries. Even so, parturition can still be a severe ordeal, and at least one third find it to be a traumatic experience. Labor may last anywhere from a few hours to a few days, thus leading to an emotionally and physically intense experience, as shown by the frequency of post-traumatic stress disorder. The complications listed below, though rare, can still occur.
Historic childbirth "Historic childbirth" is a term used to describe the birth of children before the introduction of effective pain relief in 1847.Simpson J Y (1847) A new anaesthetic agent, more efficient than sulphuric ether. Lancet 50: 549-560. During that time psychiatric complications were clearly described, well recognized and common in countries with the best health services. Those conditions still exist in nations with high birth rates and a dearth of trained staff. At the beginning of this century only about one third of births in tropical Africa and South-East Asia were attended by doctors or midwives. Although there has been some improvement since then, it is still true that about half the births in many nations are not supervised by skilled attendants. Traditional birth attendants are widespread.
Clandestine labor The third setting is concealed labor, endured by a woman who has dissembled her pregnancy. Not only is there no analgesia or skilled attendance, but there is no emotional support; on the contrary, the mother's mental state is disturbed by anger, fear, shame or despair. Most neonaticides occur in this setting. Perpetrators have rarely given a personal account, but experienced obstetricians have attempted a graphic description of their state of mind.Gall F J (1822). Sur l'Origine des Qualités Morales et des Facultés Intellectuelles de l'Homme. Paris, Boucher, page 390.Anonymous (1831-1832) Über die bei dem Verdachte eines Kindermords höchst nötige Vorsicht in der Beurtheilung der die Schwangerschaft und Geburt begleitenden Umstände der Mutter, rücksichtlich ihrer Beziehung zu dem Tode des Kindes. Wildberg's Magazin für der Gerichtlichen Arzneiwissenschaft 1: 82-88. There is objective evidence that complications are much more common.Freyer M (1887) Die Ohnmacht bei der Geburt vom gerichtsärzlichen Standpunkt. Berlin, Springer.
Tokophobia
The word comes from the Greek τόκος (tókos), meaning parturition. Early authors like IdelerIdeler K W (1856) Über den Wahnsinn der Schwangeren. Charité-Annalen 7: 28-47. wrote about this fear, and, in 1937, BinderBinder H (1937) Psychiatrische Untersuchungen über die Folgen der operativen Sterilisierung der Frau durch partielle Tubenresektion. Schweizer Archiv für Neurologie und Psychiatrie 40: 1-49. drew attention to a group of women who sought sterilization because of tokophobia. In the last 40 years there have been a series of papers published mainly from Scandinavia. Tokophobia 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.
Obstetric factitious disorder Factitious disorder (self-induced illness) can take many forms, and, during pregnancy, they include obstetric complications such as antepartum bleeding and hyperemesis. Presentation of factitious disorders during pregnancy can also take the form of simulation of labor by contractions of the abdominal muscles or manipulation of tocodynamometry.Lee C Y, Lau M P H (1983) Manipulation of external tachodynomometer by the patient: case report. Henry Ford Hospital Medical Journal 31: 170-172.Bayer-Zwirello L A, Keroack E, O'Grady J P, Gimovsky M L (1994) Fetal heart rate monitoring casebook. Journal of Perinatology 14: 77-79.Brink J N, Emerick L E, Caplan J P, Chambliss L R (2014) Use of real-time ultrasonography to diagnose pseudolabor. Psychosomatics 55: 392-395. Case studies of pregnant women with factitious disorders have documented the repeated self-induction of premature labor by rupture of the membranes, by prostaglandin suppositories, or both.
Delirium during labor Under the name 'parturient delirium', this is defined as an acute clouding of consciousness, lasting minutes or hours, with full recovery. Onset is usually towards the end of labor, and recovery after the birth. Any of the following may be observed – incoherent speech, misidentification of persons, visual hallucinations, inappropriate behavior such as singing, or memory loss for the episode. A phasic course, with alternate delirium and clarity, continuation into the puerperium, and recurrence after another pregnancy have been described in a few cases.
It was one of the first psychiatric disorders, related to childbearing, to be described,Kirkland T (1774) Treatise on childbed fevers and on the methods of preventing them. London, Baldwin and Dawson, pages 60-62. and its importance in the early 19th century is indicated by an early classification, stating that it was one of two recognized forms of puerperal insanity.Reid J (1848) On the causes, symptoms and treatment of puerperal insanity. Journal of Psychological Medicine 1: 128-151. More than 50 cases have been described, most of them in the epoch when parturition was endured without effective pain relief. The disorder has almost disappeared in nations with advanced obstetrics, with only two early 20th century reports.Pollack (1929) Psychosisok a terhesség, szülés és gyermekágy alatt. Orvosi Hetilap 44: 1110-1104.Ciulla U (1940) Disturbi psichici e psicosi nello stato puerperale. Monitore Ostetrico-Ginecologico 12: 577-626. But, within the last ten years, there were 28 nations in which fewer than half the births were attended by skilled birth attendants; they included Nigeria, Pakistan, Ethiopia and Bangladesh, each with more than 3 million births/year. In 2012, it was estimated that 130-180 million infants would be delivered in the quinquennium 2011-2015 without skilled birth attendance. There are still many countries where parturition in the 21st century is like that in Europe in the early 19th century, and women are at risk of becoming delirious during labor.
Unconscious delivery Childbirth can occur during natural sleep, and under excessively heavy sedation, including alcohol intoxication.Clay C (1841) On the prevalence of almost unconscious parturition in manufacturing districts. Lancet, pages 404-407. A diverse list of medical disorders have led to delivery during coma, including head injury, antepartum bleeding, severe hypotension and hypothermia. Of these the commonest is eclampsia. There are ten cases in the literature of unexplained stupor or coma, including cases with features of catatonia.Van Rooy (1908) Een geval van bewusteloosheid tijdens de baring. Verslag van het behandelde in de Vergarderomgem vam Januari to Mei 1908, der Nederlandsche Gynaecologische Vereeniging te Amsterdam door Dr. Catharine van Tussenbroek. Nederlander Tijdschrift voor Verloskunde en Gynaecologie 18: 284-287.
Acts of desperation In women facing death during obstructed labor, panic or despair can drive them to take desperate remedies. There are about twenty cases of suicide or suicide attempts. The suicidal motive is not depression or shame, but unbearable pain and despair. The methods – throwing themselves out of the window, hanging or drowning – show the extremity of the woman's suffering.
There are more than 20 descriptions of auto-Caesarean section. In a few cases the apparent motive has been psychiatric illness, but the majority were either the destruction of an unwanted child, or desperate remedies when the infant cannot be delivered and the nearest obstetric unit was beyond reach. Most of these cases have been reported from poor countries, where contributions to literature are scarce, and they may be more common there. The mother usually survives, but few infants survive.
Psychosis during labor Various psychoses can start during labor. Of the organic psychoses, eclamptic, Donkin, epileptic and infective psychoses have all started during labor, although postpartum onset is usual. These differ from parturient delirium in their duration, lasting at least a few days, rather than a few hours. In addition, there are 19 cases of bipolar episodes with onset during labor; they differ from parturient delirium in their symptomatology (mania rather than delirium) and duration measured in weeks. These cases are evidence that, on the balance of probability, the trigger of bipolar/cycloid episodes is already active during parturition.
Parturient rage