Explaining tokophobia, the phobia of pregnancy and childbirth

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anxiety, birth, childbirth, distress, fear, hyperarousal, labour, media, negative birth experience, panic, positive birth experience, post-birth PTSD, pregnancy, PTSD, social media, symptoms, tokophobia, trauma, treatment

Explaining tokophobia, the phobia of pregnancy and childbirth

For expectant mothers, it’s very normal to approach birth with a feeling of trepidation, particularly for the first baby. From the moment a pregnancy is announced, the average pregnant woman is inundated with horror stories of pain and long labours by supposed well-meaning friends, and it can be hard to focus on a positive birth experience when you don’t know what to expect.

But for some women, the fear of childbirth goes beyond trepidation into full-blown anxiety, panic and fear. Known as tokophobia, this phobia of childbirth affects somewhere between 3-8 per cent of pregnant women.

Symptoms include worries specifically about the pregnancy and birth, a fear of harm or death related to the birth, poor sleep, and a sense of hyper-arousal (rapid heartbeat and breathing, difficulty winding down). The fear of childbirth is a common non-medical reason for requesting a caesarean section, and women with this fear have a much higher rate of both caesarean delivery and use of epidural anaesthesia.

There is no clear path to developing fear of childbirth, but there are some risk factors that we know about. A history of anxiety or depression is one risk factor, as is a history of childhood abuse, be it sexual, physical or emotional abuse.

Some studies have also identified patterns with age, suggesting younger mums are more vulnerable, as are those with less education, and mums without a strong social network.

However, a recent study found that one of the biggest influences women reported on their fear of childbirth was the media. Hospital-based reality television programs and medical dramas often feature storylines with dramatic emergency situations during childbirth and this may be all women know of giving birth prior to the event.

We also know that around 95 per cent of pregnant European women report searching for pregnancy and birth information online, and social media and blogs hold the potential for the circulation of misinformation that may heighten fears rather than allay them.

There is another group of women who may find pregnancy and childbirth frightening due to related fears. One of the most common phobias in adults is blood/injury phobia, often including a fear of injections. Pregnancy and childbirth is hence very confronting for these women, who may faint or experience extreme distress at even routine blood tests throughout their pregnancy.

Researchers have found that for first time mothers, a positive birth experience can often relieve the fear of childbirth so that it is no longer an issue for future pregnancies. However, whether or not women start with a fear of childbirth, a negative birth experience can make them up to five times more likely to develop tokophobia for future pregnancies.

A negative experience of birth may be due to complications, feeling out of control, dissatisfaction with care providers, or just not having the birth that was expected. Between 2-6 per cent of women report post-traumatic stress syndrome (PTSD) following a difficult birth experience. PTSD is the disorder once known as ‘shell shock’ for its affliction of soldiers following war, and is characterised by nightmares and re-experiencing of the birth trauma, avoidance of all reminders of the birth, and hyper-arousal. Without treatment, PTSD can limit family size and cause problems in women’s relationships with their partner and their child.

While we may not hear much about tokophobia and post-birth PTSD, their prevalence suggests we do need to look out for women who may be suffering both before and after birth. In addition to the distress at the time, stress and anxiety during pregnancy are linked to a higher rate of preterm birth and later behavioural problems in children.

The good news is that like all anxiety disorders, the fear of childbirth and PTSD can be addressed and treatments are available. One of the most vital elements of treatment is education on birth, whether through the obstetric care provider, midwives, or antenatal classes. Knowing what to expect and having an agreed plan with your care provider can assist to overcome some of the irrational fears.

Linked to this, a supportive and trusting relationship with the care providers who will manage the birth is essential. This is not always possible as some obstetric settings do not allow for repeated contact with the same provider, but a relationship of trust will be more likely to create a positive birth experience.

When problems do occur in pregnancy and birth, a post-birth debriefing can be useful and may help prevent the development of PTSD symptoms. Understanding what went wrong and why things happened the way they did can help with processing the events and accompanying trauma.

As with other anxiety disorders, relaxation, light exercise and slow breathing can help to calm the body and relieve the hyper-arousal that comes with the fear of childbirth. A psychologist can assist with other anxiety management techniques that can help to minimise fears.

For those who find the idea of pregnancy and birth overwhelming, it is important to know that help is available and such symptoms can be successfully treated. The first step is confiding your fears so that those around you can start to support you through what could be a wonderful journey.

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Awareness during surgery can cause long-term harm, says report

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anaesthesia, awareness, consciousness, dissociation, muscle-relaxing drugs, operations, paralysis, sensations, surgery

Awareness during surgery can cause long-term harm, says report

At least 150 and possible several thousand patients a year are conscious while they are undergoing surgery in the operating theatre, according to a report which warns that some people suffer long-term psychological damage as a result.

In the vast majority of cases, patients have been given muscle-relaxing drugs that temporarily paralyse them, preventing them from warning theatre staff that they are awake. It happens most often during caesarean sections under general anaesthetic and during heart surgery.

A three-year investigation carried out by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland found that usually the experience of awareness was short-lived, at the beginning or end of the operation.

Half of those who were aware of what was happening to them were distressed by the experience, and 41% said they suffered long-term psychological harm. The sensations they experienced included tugging, stitching, pain, paralysis and choking.

Patients described feelings of dissociation, panic, extreme fear and suffocation. Some said they feared they had been entombed, buried alive or were dead.

Prof Jaideep Pandit, consultant anaesthetist at the John Radcliffe hospital in Oxford and one of the authors of the report, said the Royal College and Association had “recognised the problem officially for the first time”.

He said: “For a long time it has been a discussion on the periphery. This is real. We need to understand it and tackle it.”

Not all experiences were traumatising, he said. Some patients spoke of feeling removed from what was happening. The drugs did not cause unconsciousness but made them feel detached. Sometimes they felt this was acceptable, and Pandit said there was an unanswered question as to whether all patients would want oblivion during surgery or whether some might prefer pain-free awareness.

It was vital, however, he said, that patients are told before they have surgery that there is a possibility, however remote, of having some consciousness of what is going on.

Estimates of how often this happens vary, says the report. When patients are asked after surgery whether they had any awareness, one in 600 say yes. But only one in 19,000 will come forward to talk about it voluntarily after the surgery. That would put the numbers at between 150 and 4,500 a year.

The team looked at three million episodes where a general anaesthetic was given in a hospital and reviewed in detail 300 cases of awareness reported by patients.

In 97% of cases, patients received muscle-relaxing drugs as well as the general anaesthetic. This makes it harder for an anaesthetist to be sure the patient is unconscious.

Around 10% of cases were caused by drug errors. In some, the muscle relaxant had been given without the general anaesthetic, which meant the patient was fully conscious but paralysed throughout their operation.

Where that happened, says the report, there were organisational as well as individual errors. “These included ill-considered policies for drug management, similar-looking ampoules, poorly organised operating lists, high workload, distraction and hurriedness,” says the report.

“These patients were severely distressed and severely harmed in the long term,” said Pandit. The report recommends a checklist before surgery, which would require the anaesthetist to line up the drugs they intend to administer and point to each one in turn. Pandit said mistakes “seem to occur in a highly pressured environment”.