Updated: Jan 12
She screamed frantically as she held her baby in her arms; a few minutes after delivery. What followed was a brief period of speech babbling and a loss of consciousness, in the premises of her compound after a home delivery. She was awakened by the gush of water on her face by onlookers and surprised neighbors. Her response however belittled the little optimism they had after their feeble attempts at resuscitating her. Her incomprehensible giggles and groans pushed them into a state of disbelief and panic. Was the baby the cause of this havoc? Could the journey of pregnancy have carried a weight greater than her mind could bear? Let’s find out as we delve into Post-Partum Psychosis…using a story from a cold Monday Morning.
Current Location is Consulting Room 2. Time check 9:06am. With the doors wide open, walks a young man in his thirties. Right behind him, is a young woman also in her thirties. Not surprising is it? Their resemblance dispelled any thoughts of them being a couple. However I was taken aback, when their identical rings flashed in unison, as the woman handed me a pink card in the comfort of her hands.
“A patient is examined immediately she enters the consulting room” A favorite lecturer of mine would say! A quick scan at her showed a recent weight gain. Evidenced by the overfilling of an undersized blouse. She was neatly dressed in an African skirt with a head gear gracing her head. Her husband, a rather serious man uttered a few words, amidst groans and a face full of pensive thoughts. There was something amiss and it was my duty to find out.
This patient’s name had been emblazoned on a referral form from the Family Medicine department with complaints of poor sleep and abnormal behaviour 3 months after a Caesarean Section(C/S). A patient referral form is a paper used to ensure harmonization between colleagues of different specializations in collaborating on the effectiveness of a patient’s treatment plan. An effective referral system ensures a close relationship between all levels of the health system and helps to ensure people receive the best possible care. It also assists in making cost-effective use of hospitals and primary health care services.
Theoretically, the referral process is simple – if the initial diagnosis concludes that the patient needs special care or medical guidance then the patient’s primary provider will suggest providers or schedule an appointment with a specialist. The patient fulfills their end of the bargain by going to the specialist and getting treated.
A Caesarean Section is often necessary when a vaginal delivery would put the baby or mother at risk. This woman was delivered her baby through a C/S because her baby had a birth weight of 4.7kg. She could have tried delivering vaginally however research states that women with larger babies have longer labors and have an increased risk of not having the cervix dilate fully or not having the fetus' head drop down. There could also be an increased risk of trauma to the vagina and surrounding areas, including an increased risk of a 4th degree laceration (a tear that extends into the rectum).
The most common reason why a woman would have a caesarean section is obstructed labor, also known as Labor dystocia. This occurs when the baby does not exit the pelvis during childbirth due to being physically blocked, despite the uterus contracting normally.
The immediate postpartum period is a time of heightened risk for the development of acute psychotic illness in mothers—usually presenting as a form of bipolar disorder, often ending in tragic consequences. In a research conducted among mothers in the Niger State of Nigeria, the study revealed that the incidence of Puerperal psychosis among Post Cesarean section patients was very high therefore the need for special attention among these group of women.
This woman had an uneventful surgery and was safe and sound after the delivery of the baby. To minimize the transmission of Coronavirus from affected individuals close to her, she was discharged home after a few days to meet the jubilant cheers of her family and friends.
However this was short lived!
The baby was admitted to a hospital 3 days after its integration into the community as its newest member; for reasons of Neonatal Pyrexia – fever after birth.
The condition rendered the baby immobile in an incubator for a total of 5 days under the continuous care of a team of specialists. This stressful period could have been a trigger to the development of a mental disorder in a woman whose skyrocketing hormones had just began dwindling. Being the introvert she was structured to be, her personality had encased her in; as she internalized most issues pertaining to the baby and brooded over them day and night without confiding in her husband; because the society had perceived her to be a strong woman.
The baby was discharged a week after admission; safe and sound as it displayed its neonatal reflexes
as a sign of victory every time it felt happy.
3 months after discharge of the baby, it hit the mother – like a Subarachnoid Hemorrhage. She was found to be lying on the floor by her husband, when he woke up. Several busts and jolts could not bring this woman into consciousness, as she lay happily on the ground in the wonderland of inertness.
After an hour of uninterrupted sleep, she woke up with a scared look on her face, looking suspiciously around the room and checking for tampered locks in the house. All the reassuring statements uttered by her husband fell on deaf ears as she clutched her baby to her chest throughout the day, as she kept saying “You shall not have my baby this time” into thin air.
Any time she stepped out of the house to catch some air, she would hurriedly step back in as she interpreted the natural stern look of men as deluded thoughts of wanting to either harm her, or her baby.
This persisted for about 3 weeks, because her husband tried different attempts; all which resulted in the same result of implosion, for which she was brought to our facility for expert management.
Further history revealed she had experienced persistent low mood for 3 weeks. This was caused predominantly by the incessant fear and belief either her baby or her, was going to be harmed by a group of men in no time. A marked decrease in appetite accompanied this symptom because she felt she was likely to be poisoned by these men who could have access to her house at any time.
According to her husband, she had experienced two other instances of such complaints after major stressful events in her lives for which no treatment was sought, because they resolved spontaneously. But this like a pest, kept feeding on her mind and grew with the passage of time that she needed the intervention beyond that the community could offer.
She reported with the results of a CT scan, which surprisingly showed normal results. Laboratory investigations conducted also had similar findings.
Then, a diagnosis of Post-Partum Psychosis was made for which she automatically became a candidate for Electro Convulsive Therapy (ECT). Electroconvulsive therapy, formerly known as electroshock therapy, is a psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders. A usual course of ECT involves multiple administrations, typically given two or three times per week until the patient is no longer suffering symptoms. ECT is administered under anesthesia with a muscle relaxant and can differ in its application in different ways. These treatment parameters can pose significant differences in both adverse side effects and symptom remission in the treated patient.
Although ECT can be very effective for many individuals with serious mental illness, it is not a cure. To prevent a return of the illness, most people treated with ECT need to continue with some type of maintenance treatment. This typically means psychotherapy and/or medication or, in some circumstances, ongoing ECT treatments.
The procedure and its adverse side effects were explained extensively to the woman in the presence of her husband as they nodded their heads in agreement to every sentence. She then consented to treatment and asked to be admitted so preparation for the procedure could start. Win – Win Situation.
Postpartum psychosis (sometimes called puerperal psychosis) is an example of psychotic disorder that occurs in women who have recently delivered a baby. This syndrome is most often characterized by the mother's thoughts of harming either her infant or herself, delusions and symptoms of depression.
The incidence of postpartum psychoses has been estimated at 1–2 per 1000 births. It is said to be more frequent in primiparous women and in those who have suffered previous major psychiatric illness. In particular, women with a history of bipolar disorder have a 20% risk of puerperal relapse. However, about half of women who develop puerperal psychosis do not have any form of ‘high-risk’.
Various studies have highlighted several risk factors such as primiparity, pregnancy complications, a cesarean section, a female baby, a lack of social support, stressful life events, estrogen withdrawal, a family history of psychosis, sleep loss, and many others.
The symptoms of postpartum psychosis can often begin within days of the delivery, although the mean time to onset is within 2 to 3 weeks and almost always within 8 weeks of delivery. Characteristically, patients begin to complain of fatigue, inability to sleep, and restlessness. They may have episodes of tearfulness and exaggerated changes in mood. Later, suspiciousness, confusion, incoherence, irrational statements, and obsessive concerns about the baby's health and welfare may be present.
A favorable outcome is associated with a good premorbid adjustment and a supportive family network. Subsequent pregnancies are associated with an increased risk of another episode, sometimes as high as 50 percent.
Postpartum psychosis is a psychiatric emergency. Antipsychotic medications and lithium often in combination with an antidepressant, are the treatments of choice. Suicidal patients may require transfer to a psychiatric unit to help prevent a suicide attempt.
The mother is usually helped by contact with her baby if she so desires, but the visits must be closely supervised, especially if the mother is preoccupied with harming the infant.
Psychotherapy is indicated after the period of acute psychosis, and therapy is usually directed at helping the patient accept and be at ease with the mothering role. Changes in environmental factors may also be indicated, such as increased support from the husband and others in the environment.
Most studies report high rates of recovery from the acute illness.
If you know anyone who suffers this condition, kindly refer to a psychiatrist for expert management because we need a better world, with a better you in it. Let us save our women because pregnancy is a journey.
To be pregnant is to be vitally alive, thoroughly woman, and distressingly inhabited. Soul and spirit are stretched – along with body – making pregnancy a time of transition, growth, and profound beginnings. – Anne Christian Buchanan
Thanks for reading.