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Healthy Beginnings for a New Psychiatrist: Page 2 of 2

Healthy Beginnings for a New Psychiatrist: Page 2 of 2

I was not prepared to hear what Sarah would communicate as her thoughts became less disorganized. Although she wished to remain pregnant, Sarah described the sadness, confusion, and worry she felt surrounding her pregnancy. She described feeling pressured to have sex with a friend. She did not have romantic feelings for the child’s father and, furthermore, explained he did not seem to care about her or their unborn baby. Sarah lived with her mother and several siblings in a lower income area. Although money was tight at home, Sarah felt supported by her mother. Her mother told me she would help Sarah raise her child, and had actually helped several of Sarah’s older siblings raise their children. The patient did not endorse symptoms of PTSD; however, her psychotic symptoms began to take on new meaning for me as I learned more of Sarah’s history. I could not help but wonder, “What is Sarah trying to get rid of with her spitting? Are the bugs she is spitting out symbols for her unborn baby?”

Over the course of several months, paranoia diminished. Something had shifted in Sarah during this time period. She began to spit with reduced vigor and frequency, no longer carrying a sippy cup with her at all times. Sarah also began to ask questions regarding the changes in her body during pregnancy and, although anxious, she began to get excited about becoming a mother. She also became interested in learning how to care for a baby.

I had completed my third-year medical school clerkships 6 years ago, and I did not anticipate I would have to revisit the field of obstetrics as a psychiatric fellow. Although Sarah was closely followed by the obstetrics service at the hospital, many additional questions arose for her at times in between their visits. Being Sarah’s primary provider, and having the luxury of spending time with her daily, I reviewed my medical school textbook on pregnancy and delivery. I searched for pregnancy workbooks and other materials to educate Sarah about her pregnancy and to prepare her as well as I could to help to care for her baby.

Sarah enthusiastically participated in discussions about nutritious eating in pregnancy and she was relieved to learn the body changes she was experiencingsuch as increased need to urinate and low back painwere normal in pregnancy. Together we practiced caring for a baby, and Sarah exhibited pride when she learned to place a diaper on a baby doll successfully. The patient was notably less anxious. She was preparing to be a mother, and she and her baby were doing relatively well.

Late one night I received a call from the nursing station on the inpatient ward. Sarah had gone into labor at approximately 37 weeks’ gestation. I rushed to the hospital to be at Sarah’s side for the delivery. Sarah’s mother and an older sister were also present in the delivery room, and I felt welcomed by the family. There were no complications during delivery and, although fatigued the next morning, the patient reported that she was happy and proud to be the mother of a healthy baby girl. During my assessment the following morning, I did not observe Sarah spitting—intriguing, in light of my dynamic interpretation that this symptom may represent her feelings about the pregnancy.

Sarah’s treatment required me to step out of a more traditional role of a psychiatrist and incorporate services generally provided by obstetricians, nutritionists, nurse educators, and social workers. The therapeutic act for Sarah included not only medication management and therapy, but also education and preparation for delivering and nurturing a baby.

I think of Sarah and her beautiful baby girl often. I am thankful they were both healthy on discharge and hope they may be a little more prepared for the challenges that lie ahead as a result of healthy beginnings.

The details of this case were changed in order to preserve patient anonymity.



Dr Jeffrey is a Child and Adolescent Psychiatry Fellow at the Resnick Neuropsychiatric Hospital, UCLA, in Los Angeles.

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