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Ask the Mental Health Expert Archives 2001-2004

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Schizophrenic in Labor

Q. We have a schizophrenic under commitment in our psych unit who'll be coming to the labor and delivery unit soon to have her baby. I would love to be involved and educate myself and my peers. What resources are there where I may find more information? Are there any particular precautions that need to be taken?

A. I think the first thing to keep in mind is that schizophrenic is an adjective, not a noun. I mean, of course, that every individual with schizophrenia is unique, and will respond differently to good and bad life stressors. Much may depend on the person's education, family and social support system, general coping skills, and the degree of severity of the illness. Still, pregnancy and childbirth can be stressful for anyone, and individuals with schizophrenia may be vulnerable to acute worsening of their illness after giving birth. This seems to be more likely in patients with more severe forms of schizophrenia (see Davies et al, Schizophrenia Research, July, 1995, pp. 25-31).

New mothers with schizophrenia usually also require counseling, education, and support, in order to help them cope with this new and difficult (for anybody!) situation (see Kumar et al, Journal of Affective Disorders, January 1995, pp. 11-22). Certainly, medical personnel should be alert to any signs that the mother is expressing delusional ideas surrounding the birth, or making statements of a self-injurious or threatening nature; e.g., "I'm a bad mother. I don't deserve a baby. Maybe I should end it all. The voices are saying the baby came from the Devil," etc. (By the way, post-partum psychosis is a risk in women with bipolar and other mood disorders, not just in those with schizophrenia).

There are a number of medication related issues that come up, as well. As Mary Seeman MD has written (http://womenshealth.medscape.com/Medscape/WomensHealth/journal/2000/v05.n02/wh7146.seem/wh7146.seem-01.html): "In a new mother being treated with antipsychotics, drug concentrations at delivery are similar in maternal serum and amniotic fluid but are twice as high in fetal serum. After delivery, the neuroleptic concentration in breast milk is about 3 times that of maternal serum, probably because of the high lipid content of breast milk. To prevent both infant toxicity and infant withdrawal reactions, it is important to taper neuroleptic dose 2 weeks before anticipated delivery. Because antipsychotic medication will need to be resumed immediately following childbirth to prevent postpartum psychosis, it is wisest to counsel against breast feeding. Also, because the postpartum period is such a vulnerable one, a larger than usual dose of antipsychotic drug may be required for the first 6 weeks to keep symptoms at bay.

Decisions about appropriate pharmacotherapy at this time are very difficult to make and may have serious consequences. On one hand, it is important to prevent psychotic symptoms. On the other hand, it is equally important to not oversedate the mother, because she is in the process of bonding with her infant and learning new parenting skills. Mothers are rightly concerned that their baby may be taken from them and, frequently enough, decide that it is better not to be perceived as requiring medication. Thus, at a time when they are most vulnerable to relapse, they are tempted to stop medication to prove to child-protection workers that they are illness-free. Close liaison between mental health workers and child-protection workers at this time is critical."

Finally, I think you may best prepare yourself by discussing the particular patient with those on the psychiatric unit who know her best.

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June 2001

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