SECTION XI
PSYCHOTHERAPY IN OBSTETRICS
CHAPTER I
SUGGESTION IN OBSTETRICS
In no department of medicine is favorable or unfavorable mental influence more important than in obstetrics. Unfortunately, unfavorable suggestion has here played a serious rôle and must be controlled, modified, neutralized. Suggestion is valuable in its every phase, during the course of pregnancy, in labor itself, in post-partum convalescence, and with regard to nursing. Many women in our time are prone to persuade themselves that labor is a more serious incident than it usually proves to be and the consequence is an unfortunate suggestion of pain to come that so exaggerates sensitiveness as to make the actual suffering seem more than it really is. Sympathy expressed for women in pregnancy and in anticipation of their labor is sure to do more harm than good. Pain instead of being lessened by sympathy is increased and capacity to bear it is diminished. Anything that calls attention more particularly to the pain removes distracting conditions that might modify it favorably. Animals have the admirable instinct of withdrawing to some quiet corner when they are in pain, preferring to be alone. In this they follow nature and imitation of them is worthy of consideration, at least so far as the avoidance of opportunities for the expression of sympathy is concerned.
PREGNANCY
Maintenance of Health.—Women must keep up their normal health and strength during pregnancy. By not taking sufficient exercise and by being too much indoors, many women develop a morbid mental state in which every discomfort is less bearable than it was before. Lack of air and of exercise, furthermore, makes them prone to constipation, makes their sleep less restful, and reduces the appetite. For the sake of the being within them, they force themselves to eat, but this often serves only to make them obese, without improving their general health. If a woman in her ordinary condition, who was accustomed to going out-of-doors several hours every day and having reasonable diversion of mind and exercise of body, were to adopt the habits of life that many pregnant women form, she, too, would become morbidly introspective, fearful of the future, irritable over little things, restless at night, and even have certain physical symptoms, such as constipation, tired feelings, loss of [{454}] appetite, etc. Many of the discomforts and symptoms of which women complain during pregnancy are really due to unfortunate habits and to their mental attitude toward their conditions, rather than to any specific influence of pregnancy on the general health. As a rule, women who live naturally are in somewhat better physical health during pregnancy that at other times.
Obesity and Pregnancy.—It is important that women should not become obese during pregnancy. The woman who is taking too much fat in her diet and accumulating fat is likely to have a fat baby, and with these there is more difficulty in labor itself, and the infants have less resistive vitality than if they were unencumbered with useless adipose tissue. Her will must overcome the tendency to lassitude and the proneness to inactivity that comes over her, and she must feel that labor and her condition after it are dependent on normal, healthy life at this time.
Delayed Labor and Suggestion.—One phase of maternal impressions or of suggestion for the mother's mind that I have always been interested in has been that of the possibility of preventing delay in parturition by frequent suggestion of the time that delivery should be expected. There seems to be no doubt that expectation has some influence on the time of delivery. We do not know just why, after the uterus has tolerated the presence of the fetus for nine calendar months, it should then refuse to do so any longer and contract and expel it. Any number of theories have been suggested and even now our best obstetricians are not agreed as to the reason for this action on the part of the uterus. In some cases this contraction does not take place normally. The due term of labor is past and as a consequence fetuses grow too large within the uterus, greatly increasing the difficulties of parturition and adding to the risk of both mother and child. It is the custom to announce with pride the birth of twelve- and fifteen-pound babies, but it is doubtful whether nature intended that growth to this extent should take place before birth. There is in this, as in other phases of pride with regard to children, a curiously perverted feeling.
Many obstetricians feel that the babies who weigh much more than the average of seven pounds have probably been delayed in the uterus for a lunar month beyond the time when they should, or at least could have been normally born. It is a question whether this delay would have occurred if the mother's expectation of the birth had been directed to a date a month ahead of that on which her mind became fixed as the time of labor. Parturition usually takes place about the period of the recurrence of the menstrual molimina, or at least of that monthly cyclic feeling which many women experience, though there is no flow. It is not always easy to say at which of two monthly periods the birth should be expected. While physicians have warned patients of the possibility of the child being born at the first of the two possible periods, they have been inclined to dwell on the fact that it will probably be delayed until the later term. Women themselves are more prone to take the later than the earlier termination of their pregnancy. Both physician and patient are timorous of the ridicule that may follow if they make premature announcements. Whether we have not in this way created a tradition tending to delay parturition by a lunar month in many cases, is a problem that requires careful study.
The suggestion of as early a period as is compatible with the data provided, so as to create a definite expectancy in the mother's mind, seems well worth [{455}] deliberate attention. This is a role that psychotherapy has to play in lessening the dangers and the difficulties of parturition. With most healthy women, as indeed with most sensible normal women in life as regards all things, no suggestion is needed and nature will take her course promptly and properly. It is the nervous women, over-anxious about themselves, often of lax physical fiber because of their nervous condition, that need this phase of psychotherapy. It is in them that the unfavorable or mistaken suggestion may be emphasized to such a degree as to delay labor for a lunar month or even more.
Vomiting of Pregnancy.—One of the dreaded complications of pregnancy is serious prolonged vomiting. We know now that this is of two kinds, toxic and neurotic. The toxic variety may be associated with kidney changes, but is more commonly the consequence of certain rare forms of degeneration of the liver. The pathological picture after death is not unlike that of phosphorus poisoning. These cases are due to some serious disturbance of metabolism or to the absorption of some little understood poison. They are probably always fatal. The cases of neurotic vomiting are rather common. They are exaggerations, of the ordinary familiar vomiting of pregnancy which is exhibited by nearly all women at the recurrence of the menstrual times in the early portion of pregnancy. In some of these cases, however, the vomiting is so persistent and so prolonged that the patient's nutrition suffers severely, and there seems to be danger of a fatal termination. The condition has received the unfortunate name of "pernicious vomiting." In these cases there is sometimes question of the advisability of terminating the pregnancy lest the woman should die. Unfortunately this question has been so commonly discussed that most prospective mothers are likely to know something about it, so that when vomiting begins they are fearful lest they should have to lose their child. This becomes an obsession in some minds and an unfavorable suggestion that helps to maintain the vomiting.