Psychiatric disorders of childbirth are mental disorders developed by the mother related to the delivery process itself. They overlap with the organic prepartum and postpartum psychoses and other psychiatric conditions associated with having children. Symptoms include rage, or in rare cases, neonaticide..
There are many distinct forms of psychosis which start during pregnancy (prepartum) or after delivery (postpartum). In Europe and North America, only one – polymorphic psychosis (postpartum psychosis)– is commonly seen. Postpartum bipolar disorder, referred to in the DSM-5 as bipolar, peripartum onset, is a separate condition with no psychotic features. Historically, about one quarter of psychoses after childbirth were 'organic' and would now be classified as a form of delirium. This means that a severe mental disturbance, usually in the form of delirium, develops as a complication of a somatic illness.
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 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.
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  . They also include simulation of labour by contractions of the abdominal muscles  or manipulation of tocodynamometry   . Other women have induced premature labour by rupture of the membranes or by prostaglandin suppositories or both . These extreme cases illustrate the strong wish that some women have to bring pregnancy to an end; occasionally they importunately demand premature delivery, whatever the risk to the infant.
Delirium during labour
Under the name ‘parturient delirium’, this is defined  as an acute (usually sudden) clouding of consciousness, lasting minutes or hours, with full recovery. Onset is usually towards the end of labour, and recovery after the birth. Any of the following may be observed – incoherent speech, misidentification of persons, visual hallucinations, inappropriate behaviour 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 , 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 . 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  . 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 labour.
Childbirth can occur during natural sleep , and under excessively heavy sedation, including alcohol intoxication . 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 .
Acts of desperation
In women facing death during obstructed labour, panic or despair can drive them to take desperate remedies. There are about twenty cases of suicide attempts or completed suicide . 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 mother’s suffering.
There are more than 20 descriptions of auto-Caesarean section . In a few cases the apparent motive has been the destruction of an unwanted child, or psychiatric illness, but the majority have been 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 labour
Various psychoses can start during labour . Of the organic psychoses, eclamptic, Donkin, epileptic and infective psychoses have all started during labour, although postpartum onset is usual. These differ from parturient delirium in their duration, lasting at least a few days, not a few hours. In addition, there are 19 cases of bipolar episodes with onset during labour; they differ from parturient delirium in their symptomatology (mania rather than delirium) and a 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.
During the final painful contractions which lead to the expulsion of the infant, some women have become extremely angry. Before the introduction of effective pain relief (1847), obstetricians were familiar with this, and referred to it under names like parturient rage, furor uterinus, Wut der Gebärenden and colère d’accouchées. Some mothers lost control and attacked their husband, obstetricians, midwives or other attendants. At one time it was common, and clearly described  . It still occurs occasionally under modern obstetric conditions.
The infant is at risk, because angry mothers have reached down to haul the baby out, or made a dangerous assault on the new-born; for example, a 40-year old mother, at the end of her 1st pregnancy, kicked away the midwife, tore out the infant, and killed it by striking its head against the bedpost . If this can occur during supervised labours, how much more often will it occur in clandestine births, where the mother has no pain relief or support, and is already bitterly angry about the behaviour of the child’s father. In most neonaticides, the infant is killed by suffocation, drowning or exposure. But in a minority there is extraordinary brutality – the head smashed with multiple fractures or splintering of bone, the head cut or torn off, the infant stabbed many times, or a combination of these. The pathology bears witness to the mother’s mental state. Nowadays, this phenomenon would not regarded as a mental illness, and the only diagnosis could be ‘unspecified disorder of adult personality and behaviour’ . But this has not always been so. In France, Esquirol mentioned a mother who stabbed her infant 26 times with a pair of scizzors; she was acquitted because the judges considered that she was suffering from mental derangement . There is an insoluble judicial problem, because violence is sometimes a feature of delirium; in a clandestine birth, it is impossible to know whether consciousness was clouded or not.
Pathological mental states immediately after the birth
Immediately after the birth, an exhausted mother, fainting or in shock, may not be able to care for the new-born, who often needs resuscitation, and can suffocate in mucus or blood. Exhaustion alone, without syncope or delirium, can prevent a mother from helping a dying infant; in clandestine labours, it can be fatal to the new-born, without mens rea.
Brief states of delirium have been described with onset after the birth, less common but similar to those that occur during parturition. There are about 20 in the literature . Several of them have been accompanied by violence, and, after recovery a few hours later, followed by amnesia. Occasionally mothers have had recurrent episodes.
Postpartum stupor has been described  , beginning immediately or very shortly after the birth. The mother remains speechless, immobile and unresponsive to any stimuli for hours or even a day or more . These stupors differ in duration and clinical features from postpartum bipolar disorder. They have been phasic, with recovery and relapse. Their cause is unknown.
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.
Another reaction to a severe experience of childbirth is pathological complaining (paranoia querulans in the International Classification of Diseases) . These mothers complain bitterly about perceived mismanagement. The complaints, directed at midwives or other staff members, vary from lack of pain relief, unnecessary epidural anaesthesia, poor condition of the baby, humiliation or ‘dehumanization’, excessive use of technology, student examinations, or lack of explanation and sympathy . Occasionally the content is truly absurd – one mother’s intense resentment was her husband suggesting the wrong name for the infant. In response to these ‘outrages’, mothers may harangue the midwives repeatedly or write critical letters, and are preoccupied with fantasies of revenge – ‘beating the midwives to pulp’, ‘smashing the doctor’s head in’, ‘burning the hospital down’. Angry rumination may continue for weeks, months or more than a year. The frequency is similar to post-traumatic stress disorder , and there is an association between the two complications. The effect on child care is like that of severe depression, but the emotional state (furious anger, not sadness and despair) and treatment strategy are different. Psychotherapy is directed at distracting the mother from her grievances, and reinforcing productive child-centered activity; a diary is a useful focus – the therapist listens with sympathy to her complaints, then turns to the written record, expressing pleasure and interest in the mother’s achievements in spite of them.
Postpartum infective delirium was described by Hippocrates: 8/17 female cases in the 1st and 3rd books of epidemics suffered from postpartum or post-abortion sepsis, all complicated by delirium. In Europe and North America the foundation of the metropolitan maternity hospitals, together with instrumental deliveries and the practice of attending necropsies, led to epidemics of streptococcal puerperal fever, resulting in maternal mortality rates up to 10%. The peak was about 1870, after which antisepsis and asepsis gradually brought them under control. These severe infections were often complicated by delirium, but it was not until the nosological advances of Chaslin  and Bonhöffer  that they could be distinguished from other causes of postpartum psychosis. Infective delirium hardly ever starts during pregnancy, and usually begins in the first postpartum week. The onset of sepsis and delirium are closely related, and the course parallels the infection, although about 20% of patients recover from the infection, but develop chronic confusional states. Recurrences after another pregnancy are rare.
Alcohol withdrawal states (delirium tremens) are recognized in addicts whose intake has been interrupted by trauma or surgery. This can occur after childbirth.
A severe mental disorder was described by Wernicke  and Korsakoff. Its most striking feature is loss of memory, which can be permanent. The cause is vitamin B1 (thiamine) deficiency, usually found in severe alcoholics. It can also result from pernicious vomiting of pregnancy (hyperemesis gravidarum). Over 125 cases have been reported in the world literature and, although thiamine treatment has been available since 1936, these cases still occur in countries with advanced medical services, due to rehydration without vitamin supplements. A few patients have developed symptoms after the death of the foetus, miscarriage, termination of pregnancy or delivery.
Inborn errors of the Krebs-Henseleit urea cycle lead to hyperammonaemia. In carriers and heterozygotes, encephalopathy can develop in pregnancy or the puerperium. Cases have been described in carbamoyl phosphate synthetase 1, argino-succinate synthetase and ornithine carbamoyltransferase deficiency. This is the form of postpartum psychosis most recently described.
Before the advent of antibiotics, streptococcal infections occasionally led to a condition called Chorea gravidarum. Chorea gravidarum, a severe variant of Sydenham's chorea, can have a number of psychiatric complications – character change, depression, Tourette's syndrome, hypnogogic hallucinations, defect states and acute psychosis. But it still occurs as a result of systemic lupus or anti-phospholipid syndromes. Nevertheless, chorea psychoses are very rare, with only about 50 prepartum cases reported in the literature. Occasionally, they can break out after delivery, or after a termination of pregnancy.
All the above causes have a specific connection with childbearing. But diseases that have no such connection can fortuitously lead to postpartum psychosis, for example neurosyphilis, encephalitis, meningitis, thyroid disease or ischaemic heart disease.
Cerebral venous thrombosis
Puerperal women are liable to thrombosis, especially thrombophlebitis of the leg and pelvic veins. Aseptic thrombi can also form in the dural venous sinuses and the cerebral veins draining into them. Most patients present with headache, vomiting, seizures and focal signs such as hemiplegia or dysphasia, but a minority of cases have a psychiatric presentation. The incidence is about 10/10,000 births in Europe and North America, but much higher in India, where large series have been collected.
Pituitary necrosis following postpartum haemorrhage (Sheehan's syndrome) leads to failure and atrophy of the gonads, adrenal and thyroid. Chronic psychoses can supervene many years later, based on myxoedema, hypoglycaemia or Addisonian crisis. But these patients can also develop acute and recurrent psychoses, even as early as the puerperium.
Other vascular disorders
Arterial occlusion may be due to thrombi, amniotic fragments or air embolism. Postpartum cerebral angiopathy is a transitory arterial spasm of medium caliber cerebral arteries; it was first described in cocaine and amphetamine addicts, but can also complicate ergot and bromocriptine prescribed to inhibit lactation. Subarachnoid haemorrhage can occur after miscarriage or childbirth. Epidural anaesthesia can, if the dura is punctured, lead to leakage of cerebrospinal fluid and subdural haematoma. All these can occasionally present with psychiatric symptoms.
Women with a lifelong epileptic history are also liable to psychoses during labour in the puerperium. Women occasionally develop epilepsy for the first time in relation to their first pregnancy, and psychotic episodes have been described.
International perspective on organic psychoses
With the great improvement in obstetric care, severe complications of pregnancy and childbirth have become rare. There is, however, a great contrast between Europe, North America, Australia, Japan and some other countries with advanced medical care, and the rest of the world. The wealthiest nations produce only 10 million children each year, from a total of 135 million. They have a maternal mortality rate (MMR) of 6–20/100,000. Some poorer nations with high birth rates have an MMR more than 100 times as high, and, presumably, a corresponding prevalence of severe morbidity. For example, in Sub-Saharan Africa, 21 nations, with a combined birth rate of over 14 million, have an MMR >1,000/100,000. Only a minority of deliveries in sub-Saharan Africa and South Asia are attended by skilled personnel (doctors, nurses or midwives). In Dar es Salaam, the majority of postpartum psychoses are organic. In Africa, India & South East Asia, and Latin America, these organic disorders may still be as important as they have been throughout human history.
- Brockington I F (2017) The Psychoses of Menstruation and Childbearing. Cambridge, Cambridge University Press.
- Lishman W A (1997) Organic Psychiatry, 3rd edition. Oxford, Blackwell.
- Ideler K W (1856) Über den Wahnsinn der Schwangeren. Charité-Annalen 7: 28-47.
- Binder H (1937) Psychiatrische Untersuchungen über die Folgen der operativen Sterilisierung der Frau durch partielle Tubenresektion. Schweizer Archiv für Neurologie und Psychiatrie 40: 1-49.
- Nerum H, Halvorsen L, Sørile T, Øian P (2006) Maternal request for Cesarean section due to fear of birth: can it be changed through crisis-orientated counseling? Birth 33: 221-228.
- Goodlin R C (1985) Pregnant women with Munchausen syndrome. American Journal of Obstetrics and Gynecology 153: 207-210.
- Jureidini J (1993) Obstetric factitious Disorder and Munchausen syndrome by proxy. Journal of Nervous and Mental Disease 181: 135-137.
- Lyman D (2004) Pseudolabor: a new conversion disorder subtype? A case presentation and literature review. Primary Care Companion Journal of Clinical Psychiatry 6: 61-64.
- 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.
- Feldman F D, Hamilton J C (2006) Serial factitious disorder and Munchausen syndrome by proxy in pregnancy. International Journal of Clinical Practice 60: 1675-1678.
- name="Cambridge 2017, p94-100."
- Kirkland T (1774) Treatise on childbed fevers and on the methods of preventing them. London, Baldwin and Dawson, pages 60-62.
- Reid J (1848) On the causes, symptoms and treatment of puerperal insanity. Journal of Psychological Medicine 1: 128-151.
- 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.
- Prata N, Passano P, Rowne T, Bell S, Walsh J, Potts M (2011) Where there are (few) skilled birth attendants. Journal of Health, Population and Nutrition 29: 81-91.
- Crowe S, Utley M, Costello A, Pagel C (2012) How many births in sub-Saharan Africa and South Asia will not be attended by a skilled birth attendant between 2011 and 2015? BMC Pregnancy and Childbirth 12: 4.
- name="Cambridge 2017, p94."
- Clay C (1841) On the prevalence of almost unconscious parturition in manufacturing districts. Lancet, pages 404-407.
- name="Cambridge 2017, p104."
- name="Cambridge 2017, p101 & 103."
- 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.
- name="Cambridge 2017, p114."
- Szabo A, Brockington I F (2014) Auto-Caesarean section: a review of 22 cases. Archives of Women’s Mental Health 17: 79-81.
- name="Cambridge 2017, p115-6."
- Kluge M (1833) Mania parturientium transitoria. Medizinische Zeitung 2: 97-98.
- Scanzoni F W (1855) Franz A Kiwisch Ritter von Rotterau’s Klinische Vorträge über specielle Pathologie und Therapie der Krankheiten des weiblischen Geschlechtes. Prage, Calve, page 520.
- Albert, of Euerdorf (1850) Wut der Gebarenden und Wöchnerinnen. Medizinisches Correspondenzblatt Bayerischer Ärzte 11: 737-738.
- World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, WHO, F69, page 224.
- Gall F J (1822). Sur l'Origine des Qualités Morales et des Facultés Intellectuelles de l'Homme, et sur les Conditions de leur Manifestation. Paris, Boucher, volume 1, pages 391-391.
- name="Cambridge 2017, p118-9."
- Kelso J (1840) Nervous exhaustion dependent on and complicating the puerperal state with cases. Lancet i: 945-948.
- Tott C A (1844) Fälle von melancholia attonita bei Neuenbunderen. Neue Zeitschrift für Geburtskunde 16: 187-190.
- name="Cambridge 2017, p119-122."
- Bydlowski M, Raoul-Duval A (1978) Un avatar psychique méconnu de la puerperalité: la névrose traumatique post obstétricale. Perspectives Psychiatriques 4: 321-328.
- Söderquist J, Wijma B, Wijma K (2006) The longitudinal course of post-traumatic stress after childbirth. Journal of Psychosomatic Obstetrics and Gynaecology 27: 113-119.
- Adewuya A O, Ologun Y A, Ibigbami O S (2006) Post-traumatic stress disorder after childbirth in Nigerian women: prevalence and risk factors. British Journal of Obstetrics and Gynaecology 113: 284-288.
- The ICD-10 Classication of Mental and Behavioural Disorders: clinical descriptions and diagnostic guidelines. Geneva, World Health Organization, pages 97 & 98.
- Brockington I F (1996) Motherhood and Mental Health. Oxford, Oxford University Press, pages 154-156.
- Brockington I F, Macdonald E, Wainscott G (2006) Anxiety, obsessions and morbid preoccupations in pregnancy and the puerperium. Archives of Women’s Mental Health 9: 253-263.
- Hippocrates (5th century BC) Epidemics, volume 1, and Aphorisms, volume 4, in the edition translated by W H S Jones (1931). London, Heineman.
- Chaslin P (1895) Confusion Mentale Primitive, Stupidité, Démence aiguë, Stupeur Primitive. Paris, Harmattan.
- Bonhöffer K (1910) Die symptomatischen Psychosen im Gefolge von akuten Infektionen und inneren Erkrankungen. Leipzig and Wien, Deutlicke.
- Wernicke C (1881) Lehrbuch der Gehirnkrankheiten für Äezte und Studirende, volume 2. Kassel & Berlin, Fischer, pages 229-242.
- Korsakow S S (1887) Über eine besonderer Form psychischer Störung. Archiv für Psychiatrie21: 671-704.
- Brockington I F (2006) Eileithyia's Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 23-49.
- Brockington I F (2006) Eileithyia's Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 287-288.
- Brockington I F (2006) Eileithyia's Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 289-293.
- Yamada N, Fukui M, Ishii K, Shibata H, Okabe H, Ohomiya H, Matsunobu A, Nishizima M 1980) A case of adult form hypercitrullinemia with consciousness disturbance and marked hypertransaminasenemia after delivery. Nihon Shokakibyo Gakkae Zasshi 77: 1655-1660.
- Sandras C M S, Bourgignon H (1860) Traité Pratique des Maladies Nerveuses. Paris, Germer-Baillière, pages 397-411.
- Marcé L V (1860) L'État mental dans la chorée. Mémoirés de l'Académie de Médecine 24: 30-38.
- Breton A (1893) État mental dans la chorée. Thèse, Paris, no. 124.
- Brockington I F (2006) Eileithyia's Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 1-23.
- Brockington I F (2006) Eileithyia's Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 301-319.
- Kalbag R M, Woolf A L (1967) Cerebral Venous Thrombosis, with Special Reference to Primary Aseptic Thrombosis. Oxford, Oxford University Press.
- Lanska D J, Kryscio R J (2000) Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke 31: 1274-1282.
- Srinavasan K (1988) Puerperal cerebral venous and arterial thrombosis. Seminars in Neurology 8:222-225.
- Brockington I F (2006) Eileithyia's Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 279-286.
- Jack T M (1982) Post-partum intracranial subdural haematoma. A possible complication of epidural analgesia. British Medical Journal 285: 972 only.
- Brockington I F (2006) Eileithyia's Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 239-267.
- Brockington I F (2006) Eileithyia's Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 271-275.
- Hill K, AbouZahr C, Wardlaw T (2001) Estimates of maternal mortality for 1995. Bulletin of the World Health Organization 79: 182-192.
- AbouZahr C, Wardlaw T (2001) Maternal mortality at the end of the decade. Bulletin or the World Health Organization 79: 561-573.
- Ndosi N K, Mtawali M L, 2002) The nature of puerperal psychosis at Muhimbili National Hospital: its physical co-morbidity, associated main obstetric and social factors. African Journal of Reproductive Health 6: 41-49.