Chapter 3
Psychological Aspects of High-Risk Pregnancy
Gail Greenspan Aboudi and Ruth P. Zager
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Gail Greenspan Aboudi, MD
Clinical Assistant Professor of Psychiatry and Human Behavior, Jefferson Medical College, Philadelphia, Pennsylvania (Vol 3, Chap 3)

Ruth P. Zager, MD
Clinical Professor of Pediatrics and Psychiatry, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania (Vol 3, Chap 3)



The term high-risk pregnancy usually refers to a pregnancy that is complicated by a serious medical condition that may jeopardize the outcome of the pregnancy. Considerable research has been done to document the effect of psychiatric conditions and psychosocial factors on both the pregnant woman and the fetus. High-risk pregnancies involve one or more of these factors. This chapter reviews the constant interchange between the medical and psychological aspects of pregnancy. Included are common psychological responses to some of the medical illnesses that can complicate pregnancy. The course of pregnancy through various psychiatric disorders is described, and appropriate interventions for the obstetrician are recommended.

Each woman's pregnancy experience is based on many factors that qualitatively influence her conscious and unconscious responses to her pregnancy. These factors can be classified as biologic, psychological, and psychosocial. More than any other medical condition, pregnancy requires constant attention to the patient's emotional and physical well-being. The obstetrician is uniquely positioned to attend to these functions. Despite today's sophisticated technology and exciting advances in neonatal care, the changing family structures and the lack of adequate prenatal care contribute to significant problems in some women's pregnancies. Not all pregnancies are simple, straightforward events, and short shrift sometimes is given to the important emotional and psychosocial factors that can complicate pregnancy.

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For most women, pregnancy is a natural and joyful event. The woman's discovery that she is pregnant usually is accompanied by a sense of fulfillment and excitement. There may be a psychological withdrawal into herself, in which both her biologic and emotional energy is claimed for the creative process that is taking place.1 Pregnancy may be viewed as a developmental process that is unique to women, during which new levels of emotional maturity may be achieved. Deutsch2 recognized pregnancy as a time in which different psychological processes may occur simultaneously: the fulfillment of the deepest yearnings of the mother and the emergence of conflicts that have remained dormant for many years. The resolution of some of these conflicts is one of the psychological tasks of pregnancy.3 Preparation for the new baby and for the subsequent changes in social and marital relations also is recognized as a psychological task of pregnancy.

More contemporary theories of female psychology, although not focusing exclusively on pregnancy, add to the understanding of it. The concept of primary femininity first described by Stoller,4 has gained much acceptance as an essential element of the development of sexual identity in women. Becoming pregnant can be seen as part of a natural progression along this line. Another important concept is that women more naturally base their sense of self on their connections with others, whereas men seem to base theirs on autonomy and achievement.5 Both the psychological readiness of the mother to engage with the fetus and the physiological symbiosis are key elements in the development of maternal-fetal attachment.

It is important to ascertain the patient's emotional response to her pregnancy, what it means to her and her significant others, and what she expects to occur during the pregnancy. Unrealistic expectations and assumptions can fuel unnecessary apprehension and anxiety, which thereby increase the emotional stress on the patient. Cohen6 advocated the use of several general screening questions to determine whether the patient has “early signs of maladaptation to pregnancy.” His questions are about prior untoward pregnancy experiences that may influence the current pregnancy, problematic experiences with support systems, problems with child care, and the patient's health concerns. Cohen6 suggested that the presence of certain indicators requires further evaluation of the patient. Theut and colleagues7 developed scales to measure a prospective mother's and father's anxiety related to the pregnancy.

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Concurrent medical illness in the expectant mother increases the complexity of the patient's care and creates stress and difficulty for both the mother and the obstetrician. Despite tremendous advances in prenatal care and perinatal intensive care, the management of the medically high-risk mother remains a challenge. Many conditions are subsumed under the term high-risk pregnancy. These include diabetes, hypertension, anemia, pulmonary disease, seizure disorders, lupus, venereal diseases, acquired immune deficiency syndrome, and tuberculosis. In addition, various genetically transmitted diseases, such as myotonic dystrophy, and phenylketonuria, Tay-Sachs disease, and sickle-cell anemia, are considered potentially high risk, and preconception counseling generally is recommended for these patients. As pointed out by Taysi,8 most women, even in the more developed countries, do not visit a physician until the second month of pregnancy so that, unfortunately, they have not taken advantage of genetic counseling.

Women who are at high risk have greater levels of anxiety and depression than low-risk women.9 The woman's emotional response may be affected by lifestyle changes necessitated by the high-risk condition, such as hospitalization, prolonged bed rest, and frequent interventions to monitor fetal growth. For some women, these parameters may be viewed as infringements on their freedom, and may lead to resentment of the fetus. If the patient also must make other major life changes, such as absence from a career, she must deal with the loss of that aspect of her life as well. Clearly, psychosocial support systems will play a major part in the woman's adjustment to such stressors.10

Pregestational diabetes is one of the most common high-risk conditions. Because the frequency of maternal and fetal complications is increased when blood glucose levels are elevated, careful follow-up of these women is necessary.11 Most women will be cooperative with the monitoring, dietary restrictions, and insulin requirements, but they may express a sense of emotional unease and worry throughout the pregnancy. Recognition of the patient's subjective reactions will allow the obstetrician to suggest counseling when necessary.

The woman who has had cancer will experience strong feelings about her pregnancy; her ambivalence may be heightened by her fears about her own prognosis. In the case of breast cancer, there are additional psychological considerations because the breast traditionally symbolizes nurturance, caring, and femininity.12,13 Many women who have had breast cancer worry about exacerbation of the cancer as a result of hormonal stimulation from the pregnancy. In addition, these women may be apprehensive about the risk of breast cancer in other family members.

The reaction of the pregnant woman to the diagnosis of any of these medical conditions will depend partly on the chronology of the illness. If it is a newly diagnosed condition, then the woman must cope with the initial shock and distress that accompany the diagnosis of any medical illness. The disbelief and initial denial may be strong because most persons in early adulthood do not expect to become ill. Especially during pregnancy, the discovery of disease runs counter to the usual psychological state of mind. Psychological denial may lead to noncompliance with medical treatment recommendations, especially early in the pregnancy.

The woman with a chronic illness who becomes pregnant will be more psychologically adjusted to her illness, but may fear that the pregnancy may exacerbate the illness. In addition, she may have concern about potential harm to her baby as a result of her condition. These fears usually are reality based; the obstetrician should determine to what extent the patient may worry excessively.

The psychological sequelae of cesarean delivery should be noted. Surgical delivery is fairly common today; the indications and statistics are described elsewhere in this textbook. The short-term effects are notable because cesarean delivery is the only major surgical procedure in which the postoperative period is spent caring for another person. The immediate tasks of new motherhood cannot be postponed until the mother's recovery is complete. Recognizing this inherent conflict and recommending additional support for the new mother can be valuable parts of the obstetrician's advice.

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As with any medical procedure, the patient's comfort with and acceptance of technology is dependent on the provision of adequate education and preparation for the procedure. Informed consent should encompass these aspects of preparation for the various prenatal screening tests that are available today. The most common technologic procedures include amniocentesis, ultrasound, chorionic villi sampling (CVS), and fetal monitoring during labor and delivery.

The psychological response to these procedures will vary from one woman to another, but the usual response is anxiety, apprehension, and worry about potential harm to the fetus. One study of psychological response to amniocentesis showed a significant reduction in anxiety and depressive affect after the results of the test were relayed to the patient.14 In this study, there were no abnormal findings, which may have altered the outcome to some extent. Another study that compared emotional responses to CVS with those to amniocentesis found an earlier reduction of anxiety and depression in the CVS group.15 However, study samples were relatively small, and follow-up studies are needed.

Ultrasound evaluation has become almost a standard procedure in obstetric care, and as such, it does not carry the degree of tension and worry that more invasive procedures do. At Thomas Jefferson University Hospital, the ultrasound team includes the expectant mother in the process as much as possible, pointing out the fetal heart beating and other significant features during the procedure. Of course, adequate measures must be taken if abnormalities are detected to ensure that the woman receives the information in an appropriate manner; a good working relationship between the obstetrician and the radiologist is essential.

Clearly, even procedures that are somewhat invasive and anxiety provoking, when performed compassionately and with adequate patient preparation, can be safe and even helpful to the pregnant woman's emotional state.

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Patients who are psychologically at high risk must be identified. The obstetric history, especially regarding miscarriages, stillbirths, and perinatal deaths, and the patient's response to them, should be elicited carefully.

If mourning of the prior miscarriage or other loss has not been addressed, the patient may experience a resurgence of memories of the prior, lost pregnancy in addition to feelings of increased anxiety during the current pregnancy.7,16 To a lesser degree, such grieving also has been found in fathers.16

A thorough history must be obtained, including questions about previous psychological problems and the use of alcohol and substances of abuse. Sometimes psychologically high-risk patients are not recognized immediately, especially when the history is unrevealing or ambiguous. The physician should evaluate carefully any patient who provides an unexpected response to the physician's questions, statements, or instructions. An inappropriate response often signifies an emotionally driven reaction. A patient may be so anxious that she does not really hear what has been said; obviously, the source of the anxiety must be identified. Similarly, a patient may be so depressed that she does not react to what the physician has said. When the patient is inappropriately active or jocular, or quickly becomes belligerent, the following problems may be present: alcohol or other substance abuse, a personality disorder, or an anxiety disorder. The patient who exhibits peculiar speech or thinking that is atypical may be under the influence of alcohol or other substances of abuse or may have a psychotic disorder.

The presence of a psychological problem may jeopardize the welfare of the mother and fetus. It can interfere with the patient's ability to cope with the pregnancy and comply adequately with the medical needs of her condition.

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Because the patient who has a psychiatric disorder during or after pregnancy must be considered a high-risk patient, it is important for the obstetrician to be familiar with the mental illnesses that commonly occur in pregnant and postpartum women. Once the psychiatric problem is identified, the appropriate interventions can be made. Unfortunately, psychiatric disorders often are undetected by primary care physicians; when they are diagnosed, they often are treated incompletely.17,18 The pregnant patient who has psychiatric problems presents unique challenges for both the obstetrician and the psychiatrist.

There is a lower incidence of mental illness during pregnancy than after pregnancy.19,20 These findings are consistent with the long-held clinical observation that pregnancy seems to protect women against emotional illness. However, a few studies have shown no significant differences in the incidence of depression in pregnant and nonpregnant women.21,22 More studies are needed to clarify this point.

Psychiatric illness during pregnancy seems to predispose women to similar problems after pregnancy. Both first-trimester depression and first-trimester anxiety correlate with postpartum depression.11,23 It is helpful to identify patients with a psychiatric history because they are at risk of exacerbation of their illness during and after pregnancy. A contributing factor may be the need to discontinue the patient's psychotropic medications during the first trimester; this practice is discussed more fully later.

Affective Disorders

The incidence of depression is considerably higher after pregnancy than during pregnancy. Although the numbers vary from one study to another, the incidence is between 10% and 20% during the first 6 weeks after delivery.19,24,25 Because the birth of a child can be identified as a recent stressor, many researchers classify postpartum depression as distinct from other affective disorders. According to O’Hara and colleagues,26 the rates of depression in women of childbearing age are the same regardless of whether they are in the postpartum period.26 Thus, it is controversial whether postpartum depression is a distinct clinical entity.

Postpartum Blues

The postpartum blues are a common occurrence in the postpartum period. This mild form of depressed mood usually resolves fairly quickly. They also are called the baby blues, and occur in 50% to 80% of women during the first week after delivery.27

The typical symptoms of the baby blues are lability of mood, tearfulness, sleep disturbance, and irritability. In addition, the woman may have hostile thoughts and feelings toward the newborn, alternating with more positive emotions. Fatigue and somatic complaints also are common.

These symptoms are similar to those of major depression, but they are not as severe or protracted. The onset of these depressive symptoms can be within the first postpartum week; they usually last for a week to 10 days. Symptoms that continue for longer than 2 weeks suggest that the illness has progressed to a true postpartum depression.3

This condition usually can be treated by the obstetrician, with a combination of supportive and educational approaches. Because of the sleep deprivation that often starts during the first week postpartum, the obstetrician can help the new parents to support each other in adjusting to the infant's sleep-wake cycle.28 Reassuring the new mother that these symptoms are nearly universal, and usually transient, is a helpful intervention. Failure to resolve the depressive symptoms, or inadequacy of social supports to aid the mother during this period, may necessitate referral to a psychiatrist or social service agency.

Postpartum Depression

The symptoms of postpartum depression are those of major depression, and are best summarized in the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised.29 They include feelings of hopelessness, helplessness, and sadness. Other common symptoms are difficulty concentrating, irritability, fatigue, and anxiety. Sleep disturbance may take the form of either insomnia or hypersomnia. The patient may have persistent negative thoughts about herself or the newborn. These thoughts may include thoughts of hurting herself or the baby, and this possibility must be investigated adequately.

To make the diagnosis of major depression or postpartum depression, the symptoms must continue for a minimum of 2 weeks. The evaluation also must exclude progression to a depression with psychotic features. In this case, additional manifestations might include guilty delusions, lack of reality testing, and inability of the patient to respond to conventional reassurance and support. At this point, the patient may be difficult and frustrating for the obstetrician to handle, and referral to a psychiatrist is indicated.

Mention must be made here of bipolar affective disorder, better known as manic-depressive disorder. The occurrence of a postpartum depression sometimes is the first episode of this disorder. A woman who has bipolar affective disorder and becomes pregnant is at especially high risk because she is at increased risk for exacerbation of her illness during and after pregnancy. Coordinated treatment by both psychiatrist and obstetrician is needed to monitor and intervene throughout this time. Schou30 reported an eightfold increase in hospitalizations of bipolar patients in the first month after delivery.

Treatment of a depressive disorder in the postpartum period is fairly straightforward. Such patients should be referred to a psychiatrist. In the treatment of major depression, a combination of psychotherapy and antidepressant medication clearly is superior to either therapy alone.31

Antidepressants, either the standard tricyclic agents or the newer serotonin blockade agents (e.g., bupropion and fluoxetine), have been effective in the treatment of major depression. The dilemma that arises during the postpartum period is that these medications are excreted in breast milk.32,33 Therefore, the new mother should avoid breast-feeding if she is taking these medications.34 Untreated depression will have a deleterious effect on mother-infant bonding, especially during the first 3 months after delivery.35,36,37

Psychotherapy, either supportive or more insight oriented, is equally valuable in the treatment of depression. Depending on the patient's level of dysfunction and her psychological curiosity about her condition, the appropriate therapy can be chosen.

Psychiatric hospitalization is less common, but can be indicated, especially in the treatment of depression with psychotic features. In the United States, there is often a reluctance to hospitalize the new mother because of the enforced separation of mother and infant that occurs. In Great Britain, this problem has been circumvented by the admission of mother-infant dyads to specially designed units.38

Psychotic Disorders

Psychosis during pregnancy is rare. In most cases, there is a preexisting psychiatric condition such as schizophrenia or manic-depressive disorder. Treatment by a psychiatrist throughout the pregnancy is advisable.39 Because of the nature of schizophrenia, dilemmas may arise in assessing the ability of the patient to care for the child after delivery. In addition, during pregnancy, especially the first trimester, antipsychotic medications should be avoided if possible. The pregnant psychotic patient may require intensive support, including psychiatric hospitalization if she has severe symptoms.

Postpartum psychosis is slightly more common, although much less so than postpartum depression. The incidence is believed to be approximately 1 to 2 per 1000 births.40 The onset of psychosis usually is within the first 3 weeks after delivery.

The clinical features that would alert the obstetrician to such disorders are bizarre behavior, irrational thinking, delusions, and paranoia. The chief concerns in these patients is the potential for harm to the infant and the disabling effect on the mother. Most cases of infanticide probably are the result of psychotic delusions that the mother enacts. This dynamic often is ignored by the criminal justice system in the United States, whereas in Great Britain, psychiatric treatment rather than incarceration is more common.41

The patient who is noncompliant and overtly mistrustful of the physician may have a masked psychotic disorder. Usually, it is necessary to enlist the help of a reliable family member, especially in ensuring that the patient follows through on psychiatric referral. When no such support system is available through the family, as in the cases of the pregnant, homeless, psychotic patient, then appropriate community social service agencies must be contacted. Unfortunately, in most urban areas, these agencies are grossly underfunded and overburdened, so adequate interventions are not always available.

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Like most other medications, psychiatric medications have not been proven safe during pregnancy. Although few drugs have been identified as clear developmental hazards to the fetus, few are completely safe.42 For this reason, most experts agree that administration of psychotropics is best avoided, especially during the first trimester.43

Nevertheless, 35% of pregnant women reported receiving at least one psychotropic medication during pregnancy.44 An Australian study found that between 10% and 20% of women of child-bearing age take antidepressant medication.45

For ethical reasons, prospective double-blind controlled studies of these drugs are unavailable, but retrospective studies and case reports have been published.46,47 More current, large-scale studies of the incidence of congenital malformations after maternal psychotropic drug use are needed.

Antidepressant Medications

Tricyclic antidepressants have not been associated with congenital malformations in literature reviews. Calabrese and Gulledge,43 in 1985, provided an excellent review of these studies. Mattison,42 in a 1992 report on drug effects on the fetus, listed tricyclic antidepressants as having no known effect on the fetus in first-, second-, or third-trimester use. Little is known about the potential effects of the newer, nontricyclic antidepressants.

Because of the half-life of these drugs, it is advisable to discontinue their use approximately 1 week to 10 days before the estimated date of delivery. The anticholinergic side effects of the drugs can cause neurologic symptoms in the newborn that include slowed, jerky movements; seizures; and urinary retention.48,49,50 Symptoms of withdrawal also have been noted, including tachypnea, irritability, cyanosis, and problems with feeding.49

The tricyclic antidepressants are excreted in the breast milk, although the concentration has varied from study to study.51,52 Clear data on the newer antidepressants (e.g. fluoxetine, bupropion) are not available. The most cautious recommendation is to avoid breast-feeding when antidepressants are taken.

Antipsychotic Medications

Antipsychotic medications (specifically, chlorpromazine, haloperidol, trifluoperazine, and perphenazine) were studied in the 1960s, and were not associated with an increased incidence of teratogenicity.53,54,55 However, other large-scale studies suggested possible connections between phenothiazine use during the first trimester and congenital malformations.46,56 Edlund and Craig reviewed epidemiologic data in California and concluded that the most dangerous period, the toxic window for phenothiazines, seems to be between 4 and 10 weeks after fertilization.56

Antipsychotic medication should not be administered at all during the first trimester. This recommendation includes the phenothiazine antiemetic drugs, such as prochlorperazine (Compazine, Smith Kline, Philadelphia, PA). Meclizine is listed as one of the drugs with suspected developmental toxicity (orofacial abnormalities) by Mattison.42

Anxiolytic Medications

Benzodiazepines were linked with an increased incidence of cleft palate in several studies.57,58 Other large-scale studies, reviewed by Calabrese and Gulledge,43 showed no increase in congenital malformations.43 Because the indications for benzodiazepine use rarely are acute, it is best to avoid their use during pregnancy, and especially during the first trimester.

These medications can cause withdrawal symptoms in newborns.59,60 The neonate's liver cannot metabolize benzodiazepines quickly, leading to greater toxicity of these drugs in the infant.43 Discontinuing benzodiazepines 2 to 3 weeks before delivery is recommended.

Lithium Carbonate

Lithium is the psychiatric drug that is most noted for its teratogenic potential. Its usual indication is for the treatment of bipolar affective disorder. Animal studies with lithium showed a teratogenic effect in rats, invertebrates, and nonmammalian embryos.61 Retrospective data in humans were collected in a lithium baby register in 1979, which recorded that 25 of 225 lithium babies (11%) had congenital malformations.62 There were six cases of Ebstein's anomaly, a rare cardiac anomaly, in babies born to mothers who had taken lithium during the first trimester.31,63 However, another retrospective study of the mothers of 59 children with Ebstein's anomaly showed that none of them had taken lithium.64

Lithium is excreted in the breast milk in approximately 50% of the concentration found in the maternal bloodstream.62 The effects of lithium in the newborn are hypothermia, cyanosis, bradycardia, and poor sucking reflex.43 Case reports of lithium toxicity in the newborn indicate further need for caution.65,66

If the drug is given during the third trimester, lithium levels should be monitored closely as renal clearance increases. At delivery, renal clearance drops, and the combination of this effect with dehydration can precipitate sudden toxicity. Seizures, tachycardia, and electrolyte imbalance can ensue unless lithium administration is reduced substantially or discontinued several days before delivery.30 After delivery, however, lithium administration should be resumed in the manic-depressive patient as soon as possible.

Other Psychotropic Medications

Other psychiatric medications include monoamine oxidase inhibitors for depression, carbamazepine for manic-depressive illness, and some of the newer agents for depression, such as fluoxetine (Prozac, Dista, Indianapolis, IN), sertraline (Zoloft, Roerig, New York, NY), and clomipramine (Anafranil, Ciba, Summit, NJ). Little is known about most of these agents during pregnancy, and their use generally is avoided. In a recent study by Jones and colleagues,67 carbamazepine (Tegretol, Geigy, Summit, NJ), however, was used in pregnant women with seizure disorders. It was significantly associated with craniofacial defects, fingernail hypoplasia, and developmental delay. Current recommendations are to avoid the use of this drug in pregnant patients.

Any pregnant patient who has serious psychiatric symptoms should be treated under the joint care of an obstetrician and a psychiatrist.

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For the mother, the discovery that the fetus may be sick or damaged may stimulate anxiety, guilt, disappointment, and other intense emotional reactions. She may feel ambivalence about the pregnancy, and the obstetrician must be able to anticipate this reaction and help the parents to appraise the danger to the fetus realistically. Termination of the pregnancy may be considered in certain high-risk conditions, and it is important for the obstetrician to remain objective in such difficult, emotional situations.

Other problems of maternal-fetal conflicts of interest were reviewed by Rosenthal.68 One common conflict is exemplified by the pregnant patient who is noncompliant with the recommended medical regimen (e.g., the woman who obtains no prenatal care whatsoever). This situation can occur when a grossly psychotic woman has delusional denial of her pregnancy as a result of her psychosis. Such patients need immediate psychiatric referral and treatment.

For the pregnant woman with two or more fetuses, issues of termination for one or more of them may produce anxiety, guilt, and the need to cope with stresses well beyond those of a normal pregnancy. The decision to terminate a fetus selectively so that one or more can be carried more viably to term may create significant stress. While the woman continues the pregnancy with the remaining fetus, she may be assailed with feelings of responsibility for the death of the other fetus. Feelings of sadness, grief, and mourning coexist with the more expected and positive anticipatory feelings. She also may have increasing anxiety over the fate of the continuing fetus.

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Adolescents are an especially high-risk group.69 Recent studies by Stiffman and associates70 suggested that pregnant adolescents, especially those from lower socioeconomic groups, generally come from the most unstable, dysfunctional, and psychologically disadvantaged environments,70 but may not have more mental health problems. Interestingly, these pregnant adolescents had fewer anxiety and conduct disorders compared with their nonpregnant adolescent peers. It was thought that the pregnancy actually may have improved their behavior.

Many adolescents who are not psychotic deny that they are pregnant, and thus obtain no prenatal care. For some adolescents, obtaining prenatal care may force an unwanted confrontation with parental anger, disapproval, and rejection, especially when the pregnancy has resulted from incest or date rape.71 For other pregnant adolescents, attention to prenatal care causes the girl to acknowledge her own sexuality, an issue that may be threatening for her.

For the impulsive, acting-out, or substance-abusing pregnant adolescent who has not exercised appropriate impulse control, the prenatal care regimen may be seen as another type of authority against which the girl has been rebelling. However, it also represents an opportunity for the obstetrician to set limits and show nurturant caring; unconsciously, such adolescents may yearn for an accepting, parent-like figure. In forming a caring, limit-setting, yet consistent relationship with the pregnant adolescent, the obstetrician may be in a unique position to help the girl obtain treatment for alcohol and substance abuse and other problems, while aiding her in complying with the needed prenatal regimen.

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The suddenness of premature labor and delivery leaves little time for the parents to prepare for the problems associated with the impending birth. When a previous pregnancy has ended in a premature birth, the parents may become more apprehensive about a similar birth experience.7 Whenever pregnancy, labor, or delivery results in a distressed infant, the parents experience a sudden reversal of their expectations for a normal, healthy child. This outcome disrupts parental coping mechanisms in a variety of ways. The parents, who have anticipated holding and nurturing their child in the delivery room, are faced instead with the immediate removal of the baby from the delivery room to an intensive care nursery. In this setting, the parents may feel that they have become superfluous observers in the technologic care of their child.72

If the baby has been transferred to a nursery far from the parental home, the disruption of the lives and feelings of the parents is enormous. What was to have been a joyful moment has been transformed suddenly and unexpectedly into an anxiety-producing, catastrophic event for the parents. Often, the father must make decisions quickly, and even accompany the child, while the mother remains a patient in the hospital where delivery took place. In such cases, the mother, who may have had a cesarean or otherwise difficult delivery, has little time to tend to her own physical needs before she must cope with feelings of loss for her absent child. She cannot begin bonding physically with her child. In addition, the mother is separated from the father at a time when both parents need each other for support. The mother, too, is alone with her feelings of apprehension, bewilderment, and confusion about the child, who the mother may not have seen before the transfer took place.

If there are older siblings, the parents may feel even more torn: they want to be with their newborn baby at this critical time, yet they may be worried about the effect of their absence on their other children. Financial considerations often exacerbate the psychological strains on the parents as their plans for returning to work are disrupted or deferred. Their employers may be understanding about parental needs for a short period, but usually not for the length of time that the baby may be hospitalized. Equally pressing may be the expense of the baby's hospital care, which may not be covered adequately by parental health insurance plans. All of these factors further exacerbate parental apprehension and distress.

The baby's appearance, especially when premature, often distresses parents because it differs from their expectations. When the baby is surrounded by technical equipment, the parental ambivalence intensifies. On the one hand, they are relieved that their baby is being supervised and treated by trained, skillful nursery personnel. On the other hand, their immediate feelings of anxiety, helplessness, loss of control, diminished self-esteem, and guilt are heightened because they, the parents, are not the primary caregivers for their own baby, and must depend on others.

Parents may blame themselves whenever something abnormal occurs, regardless of whether there is any basis for this guilt.7 These feelings will be exacerbated if there has been significant ambivalence about the pregnancy, particularly if this ambivalence was expressed behaviorally (e.g., if the mother was noncompliant with medical care, did not obtain prenatal care, or abused alcohol or other substances while pregnant).

If the child has an obvious genetic or congenital disorder, the parents may experience grief over the impairment, along with feelings of guilt, anger, and blame for the disability. Sometimes, parents blame each other and each other's family for the baby's problem. When this blame is rooted in genetic reality, the parents need maximal support.

Parents whose babies have congenital infections, especially acquired immune deficiency syndrome, will have strong emotional responses. The source of the mother's infection, her overall state of health, and her feelings about the baby influence her mental status and the responses of extended family members. If the mother has been abusing alcohol or other substances, even more complex problems about the mother's status and the future care of the baby are involved. In such cases, psychiatric and social work consultation are urgently needed.

Mothers and fathers may respond differently to the problems of their newborn. Fathers often appear less affected because they may be less verbal and less communicative about their feelings.73 The mother, along with others, may misinterpret the paternal silence as indifference, aloofness, unconcern, and withdrawal. One or both parents may distance themselves from the intensive care nursery and the baby in an effort to cope with the grief and distress. Sometimes only one parent will visit routinely, despite the ability of both parents to come. In some cases, both parents visit, but pay less attention to their own baby than to the other babies there. In this way, they may be trying to shield themselves from their feelings of grief over the possible or probable death of the baby.

Some parents abuse substances in their efforts to deal with their feelings.73 Others focus on the numerous procedures and laboratory studies performed on their baby, with insistent demands to hospital staff for frequent recitations of the baby's symptoms or laboratory results. They may focus on one specific, technical aspect of the baby's condition. They may insist that maximum technical interventions be given to the baby, when the hospital staff may know that doing so will not help the outcome. Parents may hover over the baby, questioning everything that is being done, to the point of interfering with the necessary routines of the nursery.

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Parental anger and guilt may be displaced onto certain nursery staff members, with resultant splitting of the staff and disruption of nursery staff functioning, especially in the areas of setting adequate limits for parental behavior in the nursery. These complex feelings and behaviors are commonly faced by staff members in intensive care nurseries, and obstetrics and fetal medicine personnel must be alert to their own varying responses to the parents of their patients. Social workers should be assigned to work with the nursery staff and the parents, and psychiatric consultation should be available.

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Parents who have a stillborn baby are devastated, and look to the obstetrician initially for help.74 Kirkley-Best and Kellner75 reviewed parental responses to stillbirths when the fetus died in utero, but delivery was not immediate. In such cases, the mother often hoped that the baby was still alive. Some women may not have experienced anticipatory grief. Stringham and associates76 consider this situation one of the most difficult stresses for the pregnant woman. They quoted one of their patients, who called herself a “walking coffin.”76 More often, the baby's death becomes apparent during labor or delivery, and the mother's grieving process is ushered in by the baby's birth. The normal grieving process applies to parents who have had a stillborn child, and it is important that obstetricians and hospital personnel recognize this process.74,75,76,77,78,79,80,81 Initially, the mother is stunned, and hopes that an error has been made, that the baby is still alive. This wish is followed by a phase of “yearning and searching,”75 during which the parents, especially the mother, become preoccupied with thoughts about the baby, about his or her appearance. The mother often reports still feeling the baby move. Especially when the mother has not seen or held her stillborn baby, this phase is particularly difficult.

Thereafter, mothers often feel guilty about the stillbirth, and they blame themselves. If the baby had any congenital defects or other abnormalities, mothers often feel ashamed and devalued.77 Comments by hospital personnel on the abnormal appearance of the baby, or suggestions that it would be preferable for the mother not to see the baby, only intensify the mother's feelings.

The difficulties attendant with stillbirths are exacerabated by the problems that many obstetricians and obstetric personnel experience with the loss. For many reasons, stillbirths often are treated as nonevents, thereby preventing the mother from talking about her loss, sense of failure, and feelings of grief.76,78,82 A mother may be discouraged from seeing, feeling, and holding her stillborn baby, which contributes to the feelings of distress and unreality, and disrupts the usual progression of the mourning process. Often, mothers of stillborn babies are not returned to the obstetric area, and they may not receive much attention afterward. Thus, the parents, especially the mother, are left to grieve in silence.78

Kirkley-Best and associates82 studied some of the attitudes of obstetricians toward stillbirths. Half of the obstetricians in the sample realized that mothers would be sad after a stillbirth, and that these mothers should see and hold their infants.82 Yet, most of the obstetricians questioned did not think that fathers of stillborn infants would be grief stricken, or that mothers would grieve for a specific child. Kirkley-Best and colleagues82 suggested that many obstetricians considered stillbirth as a “serious medical crisis rather than … the death of a son or a daughter.” Indeed, Condon stated that one third of parents with stillborn children did not feel adequately supported by their obstetrician.79

To aid the parents of stillborn children, the obstetric staff must acknowledge the reality of the loss of the child and give the mother and father the opportunity to see and hold the child and make adequate funeral arrangements.76,77 If an autopsy is performed, the parents should be informed of the results promptly. Most importantly, the obstetrician should meet again with the parents to provide support because the parents must be able to mourn and grieve in an atmosphere of empathic understanding and support.78 This support is of even greater importance for future pregnancies, during which maternal anxiety is to be anticipated because of the previous stillbirth. Maternal anxiety during succeeding pregnancies may intensify if the mourning process for the stillborn child has not been experienced adequately. Prolonged or pathologic grief reactions after a stillbirth have been reported79; such parents need a psychiatric referral for evaluation and treatment.

Parents grieve in the same way for a child who has died during the perinatal period as for an older child or an adult who has died. Although more pronounced in mothers than in fathers, mourning occurred in both parents, even during succeeding pregnancies.83

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