It is only once in a long time that the obstetrical nurse has a patient who is suffering from such a marked mental disturbance that her condition is diagnosed and treated as a psychosis. But more often than not she has a patient who is secretly suffering a good deal of mental stress and pain, which is not recognized and not treated.

In fact, by virtue of the deep significance of the states of pregnancy and motherhood, and the long period of time through which they continue, it is scarcely possible for them not to produce a mental effect of some sort upon the average woman. Sometimes this effect is a very happy one; but all too often it is quite the reverse. It is safe to say that the majority of maternity patients are passing through deep waters, and the nurse’s usefulness to these charges will be greatly broadened if she has at least some understanding of the cause and character of these mental sufferings.

In the ordinary course of events, from birth to death, we all of us are being called upon continuously to adjust ourselves to all sorts of experiences, situations and emotional strains peculiar first to early childhood, then the school epoch, the period of emancipation from home and finally to the life work. And as we take our way, we develop habits of meeting the sorrow and disappointments that come; the anxiety, criticism, success, failure, illness, poverty and what not.

Some individuals habitually face the issues of life, whether large or small, and habitually overcome difficulties for themselves and for other people. They are described by the psychiatrists as being grown up, or psychologically evolved.

Others follow the course of least resistance; never face their problems; are thoughtless and inconsiderate in their demands; are unable to make decisions and accordingly live upon the mental and moral strength of others. Such people are referred to as being infantile, or psychologically undeveloped. They are not unlike the baby who gets “what he wants when he wants it” by the unreasoning method of screaming and pounding upon his high chair with a spoon. He is scarcely more irresponsible than the hysterical adult who gains her point by developing a headache or fainting, flying into a rage or tearing her clothes and smashing china. Such people make little or no adjustment to unsatisfactory conditions and have poor capacity for endurance or sacrifice.

With not a few women this poor capacity is a result of lifelong indulgence or protection by unwise parents, and they never reason out the question of obligation or responsibility because they never have to. Everything is done for them. All rough places are so consistently smoothed out that they never entertain the idea that effort or adaptation on their part could possibly be in order.

There are others who cherish trouble, make difficulty where there need be none and steadfastly refuse to acknowledge good fortune or see the silver lining. This is their method of securing attention, much as the baby cries or screams to the same end.

Between these extreme types are ranged people who display innumerable shadings and degrees of psychological development. Some cope satisfactorily with their life situation because that situation is neither difficult nor beyond their capacity for adjustment. Others need a little bolstering up now and then to bridge over the gap between the demands made upon them and their ability to meet these demands. Still others have to be literally carried when disaster overtakes them, or they break down.

As might be expected, our ability to stand the big tests or strains that may come to us; our manner of meeting them and their effect upon us depend very largely upon how we have habitually met the lesser trials that have come to us previously, how we have habitually adjusted ourselves to the experiences of life. For after all the test of life is a measure of one’s capacity for adaptation to these experiences and to surroundings.

The strain that measures our ability to adapt ourselves may be one big stroke or it may be a long drawn out trial which would be of small consequence were it of short duration. It is the persistency and the monotony of a lesser care that so often wears away the rock of our endurance.

If a strain proves to be too much for our adaptive capacity, and we break down under it, our manner of breaking will be characteristic of us, or an accentuation of what might have been called our bendings under lesser difficulties in the past.

The expectant mother is no exception to these general principles. She does not develop nervous breakdowns either more or less frequently than the non-pregnant woman who is under an equal strain. She is merely a human being whose adaptive capacity is being tested. But the test is severe for there is, perhaps, no greater strain upon the adaptive capacity of a human being than that to which a woman is subjected during pregnancy, confinement and the months directly following the birth of a child. She may be expected to meet this strain just as she would meet another equally great demand upon her adaptive capacity.

Otherwise, pregnancy of itself does not affect the brain or the mind, any more than it affects the kidneys, for example. But like the kidneys, the brain or the mentality may have difficulty in coping with the additional strain that is put upon it during pregnancy, and if the strain is greater than the ability to function in either case there is likely to be a breakdown.

It is now generally believed, therefore, that there is no psychosis which is typical of pregnancy. But that during pregnancy one may see all types of neuroses and psychoses which are frequently associated with other severe strains upon the individual. We see depressions, excitement, paranoid trends, delusional and hallucination states, hypochondriasis, obsessive fears, anxiety attacks, hysterical manifestations as well as the so-called “neurotic vomiting.”

Aside from the delirium-like experiences often associated with the toxemias of pregnancy, none of the above mentioned conditions are referable to any disturbance of the physiologic or metabolic functioning of the patient, so far as science can demonstrate. They are merely accentuations of poor habits of adjustment to difficulties, which the patient has betrayed all her life.

The psychoses of pregnancy and the puerperium require skilful handling and the nurse is not called upon to care for them except under the constant supervision of a physician.

She is, however, constantly brought face to face with facts of fear and worry and conflicting desires which play a tremendous rôle in the well-being of the patient during the months of pregnancy and confinement. The chief source of happiness and of unrest is the mother’s attitude toward the coming of the baby.

Just here it may be helpful to have a word about what is meant by “conflict” and the “mechanism” which produces it. As a starting point there must be a recognition of the fact that the deepest and most influential feminine instinct is maternal—the desire to have and care for a child. It is primal. It has been in women since the dawn of Creation and although in many women it is put down, stifled or complicated by other desires, it cannot be destroyed. Not a few women deny this instinct, but back of their denial is some reason, conscious or unconscious, which is not harmonious with the idea of motherhood. The woman may be selfish, for example; she may be vain and not want to lose her grace and charm through pregnancy.

When some such feeling is strong it conflicts with the deeper one of maternalism and there is a lack of harmony or a “conflict.” It is just that—a conflict or struggle between two emotions and the result is a state of mental unrest. A homely comparison might be found in the digestive disturbance which may follow an effort to cope with two incompatible articles of food at the same time. The patient may have nausea, vomiting, pain or even more severe symptoms. The severity of the symptoms and their effect upon the patient depend somewhat upon the average vigor or stability ordinarily displayed by the digestive tract under a lesser strain. People with so-called delicate digestions may be greatly upset by combinations of food which others are able to cope with and suffer little or no inconvenience.

When a well evolved individual has a desire which results from our culture or civilization (a wish to preserve her grace or her luxuries, for example), that is in conflict with a deeper primal instinct, she will often be able to reason out the situation, and in the case of approaching motherhood, decide that the baby is worth any sacrifice, any inconvenience, and go joyfully through her period of expectancy. She will glory in the consciousness of her ability to realize the supreme purpose of a woman’s creation. In other words she adjusts herself to the situation, harmonizes the discordant desires and is mentally undisturbed.

A less well evolved woman, like a person with a delicate, easily upset digestive tract, will have difficulty in making an adjustment—in harmonizing her instinctive desire for motherhood and her acquired desire for comfort, attention and the things demanded by convention. The conflict may be violent enough to greatly upset her. This is particularly true if the demands of our cultural state make it necessary for the patient to keep this turmoil below the surface with no safety valve to relieve the pressure.

This problem of the mother’s attitude toward the coming of the baby is very general and varied as well. The mothers of families already large and poverty stricken are usually quite frank in expressing their dismay over the expected birth and lament the prospect of this extra burden, but at the same time they decide to make the best of it and they succeed in making a pretty satisfactory adjustment. Moreover, they do not feel the necessity for concealing their feelings or do not “repress” them, and accordingly find some relief in being candid.

The mothers of the middle and upper classes, however, are often surrounded by an atmosphere of conventional codes that are stifling to mental honesty. Accordingly they are less genuine in expressing their true attitude toward the coming child. To many of them—the selfish, self-centered type—the new baby will bring inconvenience rather than hardship. The importance of their ego will be dimmed. There will be a cutting down of luxuries and of freedom for social activities, and increased responsibility with closer confinement to the home. And while they give utterance to joy and pleasure over the prospect of having a baby, this does not quite reflect their inmost feelings.

Not a few women find an outlet for the tension caused by their conflict by being fretful and irritable or through conduct which they would have displayed if annoyed or chagrined about something other than the approaching birth of a child. Because of this outlet they are not so likely to break down.

It is by no means the rôle of the nurse to pry into the affairs of her patients, but she can often become the avenue of ventilation for a patient suffering from a mental conflict, and with very happy results. For one of the most helpful things that such a person can do is to talk, and little by little bring out and put into words the buried thoughts, dreads or shame that may be causing the conflict. Very often the listener will say surprisingly little and will express no definite opinions, but by a sympathetic, responsive attitude encourage the worried person to pour out the content of her mind.

Another source of unrest in the mind of the expectant mother, especially during her first pregnancy, is the fear of death during labor, or the development of complications. She is reluctant to speak of these things to her husband, family or friends, lest they laugh at her or regard her as a coward at the prospect of pain. Or she may be unwilling to distress those who love her by admitting her fear.

Fear of death and disease are very common traits and equally common is the hesitancy we all have in acknowledging them. And so the patient keeps these things to herself and turns them over and over in her mind; buries them and tries to put them out of her thoughts. But they stick. Her fear and her dread color everything that she hears, and very often and unwittingly her friends and relatives make matters worse by recounting the unhappy experiences of other mothers that they have known. At the same time these communicative friends do not tell of the immeasurably greater number of women who have come through safely, nor does the patient dwell upon these in her mind. She remembers the women who had convulsions or fever or a hemorrhage, or the one who died.

The nurse who sees the human being beyond the obstetrical case will appreciate the pain which such a conflict causes and by being sympathetic and responsive will try to make it easy for her patient to talk it over. The patient should invariably find her nurse ready to listen and to give assurances of the proved value of the precautions that are being taken to safeguard her and her baby. For not a few women are torn, not alone by the fear that things will go wrong with themselves, but with the fear that harm may come to the baby that they long to take into their arms and keep.

Other women are upset because of a habitual inability to make decisions that will bring about a marked change in their lives. They find it difficult to accept pregnancy because its consummation will definitely alter their state. Life may prove to be more satisfactory because of the baby, or it may be less so. But in any event it cannot be the same and they dread making an irrevokable change.

Still another cause of distress is the current belief as to hereditary influence, and the possible effect upon the unborn child of unsuccessful attempts at abortion which the patient has made early in her pregnancy. Every family has its skeleton of a relative who is “queer,” feeble-minded, epileptic or who has died in a sanitarium or state hospital for the insane. The fear that the child may “strike back” to one of these individuals, and suffer retardation in his mental development, often amounts to little less than an obsession.

The nurse may often dispel such an anxiety by drawing upon even her slender knowledge of embryology and reassure her patient that we know very little about inheritance, but that the evidence is that environment and early training are such important determining factors, that a child is more likely to be affected by the example and guidance of his parents during his first few years than through transmission from their blood.

Attempted abortions during the early months of pregnancy are more common than is generally supposed. Of their effect upon the offspring we know very little. We do know, however, that an attempt to produce an abortion often gives rise to a good deal of secret worry on the part of the expectant mother. It is the nucleus of many a vague depression during pregnancy, not only because of remorse over wrong-doing, but also because of fear that the child who is coming, in spite of the attempt to destroy him, may suffer the consequences. This is another of the anxieties which the patient can seldom bring herself to discuss with her family or even with her physician. But it so occupies her mind that she may allude to it, in a roundabout way, to the nurse who becomes her constant companion, as though describing the act of a friend. The nurse who reads between the lines may often relieve a serious tension caused in this way by discussing the matter casually and impersonally. Above all she must not assume an attitude of disapproval, for it is not within her province to go into the ethics or morality of the act. Her function at this time is solely to give the patient an opportunity to ventilate her thoughts.

Another real cause of worry during pregnancy is the patient’s fear of her own inadequacy to care for and to rear a child in the best possible manner. The idea of assuming the physical care and the moral guidance of another human being is often little less than terrifying to a young woman whose responsibilities in the past have been shared or carried by some one else. Or to the one who has gone through life hunting for, and exaggerating, the difficulties in a situation, before attempting to meet it; and perhaps to the one who is habitually conscientious in all of her relations with other people.

Still another type, and one which presents a much simpler situation, is the expectant or young mother who is scarcely suffering from a mental strain, but has a little let-down in her customary poise and self-control, such as we so often see in convalescents and chronic invalids.

Pregnancy, labor, and the puerperium are normal physiological processes, it is true, but they impose a physical tax and the patient is sometimes physically tired and after labor may suffer something akin to surgical shock.

The physical weariness may be due to an insufficiency on the part of some one of the internal secretions. But in any event the patient feels tired and may show the same sensitiveness or irritability that any of us show when tired and exhausted and she will merit considerable forbearance on the part of those who surround her.

But when we understand, even faintly, the conflicts which are possible in the mental life of the expectant mother—the incompatibility of her age-old maternal instinct and the desires born of our culture and civilization, it is not difficult to see that her adaptive capacity may be sorely tested.

The cause of her trouble is not apparent to the patient’s associates but they are aware of its manifestations in the shape of moods, temper tantrums, strange conduct and all sorts of nervous and mental symptoms. If such a patient does not get relief through talking things over, but continues to brood and worry alone—to repress the cause of the conflict—she may not be sufficiently adaptive to endure its ravaging effects, and have a nervous or mental breakdown as a result.

It is hoped that the nurse may understand from this discussion that the conflicting thoughts which her patient does not discuss, but buries and keeps below the surface of her mind, are the factor that works harm in her mental life. If the nurse can get her patient to ventilate these thoughts, they will be robbed of much of their power to injure. But this patient, like any one else, will talk freely only when she talks spontaneously and she will do this only when she senses in her nurse a sympathy and a sincere concern over her troubles.

Accordingly, the nurse should try to so attune herself as to be receptive to evidences of the patient’s moods and impulses, and possibly from a chance remark get a clue to the repressed desires which are working harm. She will then be able to meet the patient on that ground.

It is not that the relief of the patient by means of mental catharsis is necessarily a nurse’s function. It is simply that a patient suffering from a conflict should talk freely to some one, it does not matter who, and by virtue of the long hours which they spend together, the nurse very often happens to be that some one. People do not ordinarily find it easy to lay bare their inmost thoughts before the members of their family and the patient may not discuss her conflict with her physician, which of course is the ideal, because his visits are relatively short and do not favor the ambling, desultory conversation into which the nurse and patient may so easily drift.

On the other hand, the nurse must not look for trouble, in order to be useful, nor by the slightest intimation give her patient an idea that it is a common practice among expectant mothers to worry, be fearful or alarmed. If the patient displays these emotions the nurse must be ready, but she must not be suggestive. Her attitude must be entirely passive for she is simply a receptacle into which the patient may pour her conflicting thoughts. But the receptacle must be always available.

The positive course which the nurse may take is to be unfailingly hopeful and courageous and take it for granted that her patient is filled with joy and pride over her pregnancy. The gratification is there by instinct, but it may be so buried and complicated by other emotions that the patient is not wholly aware of it. It may be surprisingly clarifying for the nurse to say quite simply, “But, after all, it is a wonderful thing to have a baby and you are proud and glad that he is coming. He will be worth any sacrifice.”

If the nurse will so far put herself in the patient’s place that she is glad, sincerely glad, that the baby is coming, this attitude will communicate itself to the expectant mother. Happiness and enthusiasm are very infectious.

To sum it all up: The expectant mother who habitually has not made satisfactory adjustments during her life may be bending under a mental burden that is a little heavier than her slender, unevolved powers can bear. The nurse’s part is to recognize this possibility and realize that while she cannot attempt to correct the difficulty she can be a prop by simply being optimistic and reassuring. A patient who may be suffering from a mental conflict is often saved from a breakdown by little more than a ready sympathy which is born of understanding.