Dr Robert London

Psychiatry and Pregnancy

Clinical Psychiatry News - Volume 33, Issue 7, Page 22 (July 2005)

Relaxation and meditation techniques may indeed have a place in contemporary obstetrics. Those strategies offer methods of dissociation and focused concentration that not only help pregnant women with pain control, but also can provide relief from stress and anxiety.

And that's where we come in. As psychiatrists, we can offer to women who are fearful of childbirth a reasonable, safe method to control those emotions during pregnancy. Furthermore, teaching pain control techniques for birthing can go hand in hand with teaching stress and anxiety control techniques.

As far back as the 19th century, Franz Anton Mesmer used hypnotic inductions as a method of pain control in delivery. In the 1930s, Dr. Grantly Dick-Read in England saw the advantages of having a patient collaborate with a partner in birthing. That partner could explain what was occurring to the patient and add a measure of confidence. In addition, Dr. Dick-Read noticed that such partnerships in birthing made the experience less painful (“Childbirth Without Fear,” New York: Harper & Bros., 1953).

Meanwhile, in the United States in the 1930s, Americans began to use hospitals and medications in childbirth more and more. As new medications, anesthetics, and surgical techniques revolutionized childbirth, a certain amount of sterility and mechanization began to surround the entire experience of giving birth. While obstetrical care improved, the experience of giving birth got lost.

In the 1940s, a French obstetrician, Fernand Lamaze, went to the Soviet Union to learn a technique called “psychoprophylaxis.” This was a pain alleviation technique derived from Pavlovian methods and used by Russian midwives. The technique allowed the patient to divert her attention from pain through a series of rapid breaths.

Dr. Lamaze's method of focused breathing was used not only for real pain but also for the way in which pain is perceived. He developed exercises for muscle relaxation as the various stages of labor progressed.

The methods Dr. Lamaze developed were embraced in Europe, but not in the United States. The human dimension—especially in the context of women's specific needs—was missing. The Lamaze method didn't reach the United States until 1959, when Marjorie Karmel, who had given birth earlier in a Lamaze clinic in France, brought it here.

A few obstetricians, psychiatrists, and psychologists were suggesting and practicing relaxation and hypnosis in the United States during the period in which Dr. Lamaze became popular in Europe, but their work was not well recognized. Often their approaches appeared without clear guidelines. Furthermore, American psychiatry was so dominated by the psychoanalytic movement that little else besides the introduction of medications in the 1950s was readily accepted.

In working with women who sought help other than that offered by their obstetricians, I identified two issues: One focused on the anxiety and stress of pregnancy; the other centered around the pain of childbirth. Sometimes both issues were present in the same patient. The learning, philosophizing, and action (LPA) technique that I developed over the years while directing the short-term psychotherapy program at NYU Medical Center/Bellevue Hospital proved applicable to helping women through pregnancy and childbirth.

Clearly, making learning part of the process helps relieve the stress and anxiety that many women experience during pregnancy. Reviewing the wonders of conception, gestation, and birth with the patient reduces her stress. As education and philosophizing continue, her pain is reduced during the final hours and moments of childbirth: The pain is reprocessed and placed in the context of the impending event's being a joyous milestone.

As is the case with the Lamaze method, a period of time is needed to learn the LPA technique. By using a straightforward relaxation technique with deep, slow breathing as the focus in the early weeks of training, the patient becomes an expert on how to quickly enter a relaxed state. Specifically, the patient is told to breathe slowly. She learns to relax her muscles as she gently floats into a restful state. She should practice this technique for 1–2 minutes as many as 10 times a day. After the patient develops expertise in achieving relaxation, I offer several strategies aimed at alleviating her anxiety and stress.

Teaching the patient to project her fears and concerns onto a large movie screen—namely, seeing the fears on the screen but not experiencing them, all the while continuing to take deep, easy breaths—appealed greatly to those patients who were willing to use a psychiatric approach to conquering anxiety and stress. Other approaches might include having the patient imagine activities she would be doing with her child as the child develops.

Some of my patients combined this technique with the Lamaze method. From my point of view, it made no difference. If a person wanted to use more than one method to make the pregnancy and delivery better, so be it.

In some situations, a more serious psychiatric disorder might underlie the anxiety and stress of pregnancy, and the diagnosis of a person's problems by a psychiatrist would then be necessary to present the patient with an appropriate therapy. Not every pregnant woman is a candidate for a relaxation/hypnosis approach. In some cases, patients' mental difficulties make it impossible for them to remain stable, even in a Lamazelike program.

The simplest approach to pain control that I have used with patients who are close to delivery is the “glove anesthesia” method, as follows:

1. The patient goes into a relaxed state by using the deep-breathing exercises.

2. The patient makes a fist and squeezes the fist tightly.

3. As the fist gets tighter and tighter, the patient continues to take deep breaths and becomes more relaxed. The fist will start to feel numb. (This is not hypnotic suggestion in my view. Rather, it is a way of going along with the physiology of making a tight fist, squeezing it tighter, and experiencing numbness.)

4. Once the numbness in the hand is established (glove anesthesia), the patient touches her abdomen with the numb hand.

5. The numbness in the hand can then spread to the abdomen, creating a numbed, pain-free area.

It is important to note that this technique should be used for pain control in the end stages of labor and delivery. In other words, patients should allow themselves to feel and experience contractions so as to follow the process of labor.

Glove anesthesia should be used just at the time of late labor and delivery, but it is a process that a patient should learn early in the pregnancy. That approach and others give women choices in a mode that is consistent with natural childbirth. These techniques work best when the patient works with the obstetrical team.

Fernand Lamaze, the obstetrician, went to Russia to learn the techniques originated by a giant in the history of psychiatry and then applied those techniques to the process of childbearing. Psychiatrists can get on board contemporaneously as our specialty continues to change, grow, and address more diverse issues in mental health.

Send me your thoughts about mental health interventions in pregnancy and delivery, and I will try to share them with my readers.

PII: S0270-6644(05)70505-1


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