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Friday, November 13, 2020

Northwest Passage

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Northwest_Passage

Northwest Passage routes

The Northwest Passage (NWP) is the sea route between the Atlantic and Pacific oceans through the Arctic Ocean, along the northern coast of North America via waterways through the Canadian Arctic Archipelago.  The eastern route along the Arctic coasts of Norway and Siberia is accordingly called the Northeast Passage (NEP).

The various islands of the archipelago are separated from one another and from the Canadian mainland by a series of Arctic waterways collectively known as the Northwest Passages or Northwestern Passages.

For centuries, European explorers sought a navigable passage as a possible trade route to Asia. An ice-bound northern route was discovered in 1850 by the Irish explorer Robert McClure; it was through a more southerly opening in an area explored by the Scotsman John Rae in 1854 that Norwegian Roald Amundsen made the first complete passage in 1903–1906. Until 2009, the Arctic pack ice prevented regular marine shipping throughout most of the year. Arctic sea ice decline has rendered the waterways more navigable for ice navigation.

The contested sovereignty claims over the waters may complicate future shipping through the region: the Canadian government maintains that the Northwestern Passages are part of Canadian Internal Waters, but the United States and various European countries claim that they are an international strait and transit passage, allowing free and unencumbered passage. If, as has been claimed, parts of the eastern end of the Passage are barely 15 metres (49 ft) deep, the route's viability as a Euro-Asian shipping route is reduced. In 2016 a Chinese shipping line expressed a desire to make regular voyages of cargo ships using the passage to the eastern United States and Europe, after a successful passage by Nordic Orion of 73,500 tonnes deadweight tonnage in September 2013. Fully loaded, Nordic Orion sat too deep in the water to sail through the Panama Canal.

Overview

The fabled Strait of Anián, shown in the upper left corner of the map. (Hugo Allard, 1685)

Early expeditions

Before the Little Ice Age (late Middle Ages to the 19th century), Norwegian Vikings sailed as far north and west as Ellesmere Island, Skraeling Island and Ruin Island for hunting expeditions and trading with the Inuit and people of the Dorset culture who already inhabited the region. Between the end of the 15th century and the 20th century, colonial powers from Europe dispatched explorers in an attempt to discover a commercial sea route north and west around North America. The Northwest Passage represented a new route to the established trading nations of Asia.

England called the hypothetical northern route the "Northwest Passage." The desire to establish such a route motivated much of the European exploration of both coasts of North America, also known as the New World. When it became apparent that there was no route through the heart of the continent, attention turned to the possibility of a passage through northern waters. There was a lack of scientific knowledge about conditions; for instance, some people believed that seawater was incapable of freezing. (As late as the mid-18th century, Captain James Cook had reported that Antarctic icebergs had yielded fresh water, seemingly confirming the hypothesis). Explorers thought that an open water route close to the North Pole must exist. The belief that a route lay to the far north persisted for several centuries and led to numerous expeditions into the Arctic. Many ended in disaster, including that by Sir John Franklin in 1845. While searching for him the McClure Arctic Expedition discovered the Northwest Passage in 1850.

In 1906, the Norwegian explorer Roald Amundsen first successfully completed a passage from Greenland to Alaska in the sloop Gjøa. Since that date, several fortified ships have made the journey.

From east to west, the direction of most early exploration attempts, expeditions entered the passage from the Atlantic Ocean via the Davis Strait and through Baffin Bay, both of which are in Canada. Five to seven routes have been taken through the Canadian Arctic Archipelago, via the McClure Strait, Dease Strait, and the Prince of Wales Strait, but not all of them are suitable for larger ships. From there ships passed through waterways through the Beaufort Sea, Chukchi Sea, and Bering Strait (separating Russia and Alaska), into the Pacific Ocean.

Potential as a shipping lane

Map of the Arctic region showing the Northeast Passage, the Northern Sea Route within it, and the Northwest Passage.

In the 21st century, major changes to the ice pack due to climate change have stirred speculation that the passage may become clear enough of ice to permit safe commercial shipping for at least part of the year. On August 21, 2007, the Northwest Passage became open to ships without the need of an icebreaker. According to Nalan Koc of the Norwegian Polar Institute, this was the first time the Passage has been clear since they began keeping records in 1972. The Northwest Passage opened again on August 25, 2008. It is usually reported in mainstream media that ocean thawing will open up the Northwest Passage (and the Northern Sea Route) for various kind of ships, making it possible to sail around the Arctic ice cap and possibly cutting thousands of miles off shipping routes. Warning that the NASA satellite images indicated the Arctic may have entered a "death spiral" caused by climate change, Professor Mark Serreze, a sea ice specialist at the U.S. National Snow and Ice Data Center (NSIDC) said: "The passages are open. It's a historic event. We are going to see this more and more as the years go by."

On the other hand, some thick sections of ice will remain hard to melt in the shorter term. Such drifting and large chunks of ice, especially in springtime, can be problematic as they can clog entire straits or severely damage a ship's hull. Cargo routes may therefore be slower and uncertain, depending on prevailing conditions and the ability to predict them. Because a plurality of containerized traffic operates in a just-in-time mode (which does not tolerate delays well) and the relative isolation of the passage (which impedes shipping companies from optimizing their operations by grouping multiple stopovers on the same itinerary), the Northwest Passage and other Arctic routes are not always seen as promising shipping lanes by industry insiders, at least for the time being. The uncertainty related to physical damage to ships is also thought to translate into higher insurance premiums, especially because of the technical challenges posed by Arctic navigation (as of 2014, only 12 percent of Canada's Arctic waters have been charted to modern standards).

The Beluga group of Bremen, Germany, sent the first Western commercial vessels through the Northern Sea Route (Northeast Passage) in 2009. Canada's Prime Minister Stephen Harper announced that "ships entering the North-West passage should first report to his government."

Map of the route followed by the US ship SS Manhattan in 1969.

The first commercial cargo ship to have sailed through the Northwest Passage was SS Manhattan in August 1969. SS Manhattan, of 115,000 deadweight tonnage, was the largest commercial vessel ever to navigate the Northwest Passage.

The largest passenger ship to navigate the Northwest Passage was the cruise liner Crystal Serenity of gross tonnage 69,000. Starting on August 10, 2016, the ship sailed from Vancouver to New York City with 1,500 passengers and crew, taking 28 days.

In 2018, two of the freighters leaving Baffinland's port in the Milne Inlet, on Baffin Island's north shore, were bound for ports in Asia. Those freighters did not sail west through the remainder of the Northwest Passage, they sailed east, rounded the tip of Greenland, and transitted Russia's Northern Sea Route.

Routes

Lancaster Sound at the north end of Baffin Island. Parry Channel runs directly west.
 
9 August 2013
9 August 2013
 
9 August 2016
9 August 2016
 
The Northwest Passage is increasingly ice-free.

The Northwest Passage includes three sections:

Many attempts were made to find a salt water exit west from Hudson Bay, but the Fury and Hecla Strait in the far north is blocked by ice. The eastern entrance and main axis of the northwest passage, the Parry Channel, was found in 1819. The approach from the west through Bering Strait is impractical because of the need to sail around ice near Point Barrow. East of Point Barrow the coast is fairly clear in summer. This area was mapped in pieces from overland in 1821–1839. This leaves the large rectangle north of the coast, south of Parry Channel and east of Baffin Island. This area was mostly mapped in 1848–1854 by ships looking for Franklin's lost expedition. The first crossing was made by Amundsen in 1903–1905. He used a small ship and hugged the coast.

Extent

The International Hydrographic Organization defines the limits of the Northwestern Passages as follows:

On the West. The Eastern limit of Beaufort Sea from Lands End through the Southwest coast of Prince Patrick Island to Griffiths Point, thence a line to Cape Prince Alfred, the Northwestern extreme of Banks Island, through its West coast to Cape Kellet, the Southwestern point, and thence a line to Cape Bathurst on the mainland (70°36′N 127°32′W).
On the Northwest. The Arctic Ocean between Lands End, Prince Patrick Island, and Cape Columbia, Ellesmere Island.
On the Northeast. The Coast of Ellesmere Island between C. Columbia and C. Sheridan the Northern limit of Baffin Bay.
On the East. The East Coast of Ellesmere Island between C. Sheridan and Cape Norton Shaw (76°29′N 78°30′W), thence across to Phillips Point (Coburg Island) through this Island to Marina Peninsula (75°55′N 79°10′W) and across to Cape Fitz Roy (Devon Island) down the East Coast to Cape Sherard (Cape Osborn) (74°35′N 80°30′W) and across to Cape Liverpool, Bylot Island (73°44′N 77°50′W); down the East coast of this island to Cape Graham Moore, its southeastern point, and thence across to Cape Macculloch (72°29′N 75°08′W) and down the East coast of Baffin Island to East Bluff, its Southeastern extremity, and thence the Eastern limit of Hudson Strait.
On the South. The mainland coast of Hudson Strait; the Northern limits of Hudson Bay; the mainland coast from Beach Point to Cape Bathurst.

Historical expeditions

Assumed route of the Strait of Anián

As a result of their westward explorations and their settlement of Greenland, the Vikings sailed as far north and west as Ellesmere Island, Skraeling Island for hunting expeditions and trading with Inuit groups. The subsequent arrival of the Little Ice Age is thought to have been one of the reasons that European seafaring into the Northwest Passage ceased until the late 15th century.

Strait of Anián

In 1539, Hernán Cortés commissioned Francisco de Ulloa to sail along the Baja California Peninsula on the western coast of North America. Ulloa concluded that the Gulf of California was the southernmost section of a strait supposedly linking the Pacific with the Gulf of Saint Lawrence. His voyage perpetuated the notion of the Island of California and saw the beginning of a search for the Strait of Anián.

The strait probably took its name from Ania, a Chinese province mentioned in a 1559 edition of Marco Polo's book; it first appears on a map issued by Italian cartographer Giacomo Gastaldi about 1562. Five years later Bolognino Zaltieri issued a map showing a narrow and crooked Strait of Anian separating Asia from the Americas. The strait grew in European imagination as an easy sea lane linking Europe with the residence of Khagan (the Great Khan) in Cathay (northern China).

Cartographers and seamen tried to demonstrate its reality. Sir Francis Drake sought the western entrance in 1579. The Greek pilot Juan de Fuca, sailing from Acapulco (in Mexico) under the flag of the Spanish crown, claimed he had sailed the strait from the Pacific to the North Sea and back in 1592. The Spaniard Bartholomew de Fonte claimed to have sailed from Hudson Bay to the Pacific via the strait in 1640.

Northern Atlantic

The first recorded attempt to discover the Northwest Passage was the east–west voyage of John Cabot in 1497, sent by Henry VII in search of a direct route to the Orient. In 1524, Charles V sent Estêvão Gomes to find a northern Atlantic passage to the Spice Islands. An English expedition was launched in 1576 by Martin Frobisher, who took three trips west to what is now the Canadian Arctic in order to find the passage. Frobisher Bay, which he first charted, is named after him.

As part of another expedition, in July 1583 Sir Humphrey Gilbert, who had written a treatise on the discovery of the passage and was a backer of Frobisher, claimed the territory of Newfoundland for the English crown. On August 8, 1585, the English explorer John Davis entered Cumberland Sound, Baffin Island.

The major rivers on the east coast were also explored in case they could lead to a transcontinental passage. Jacques Cartier's explorations of the Saint Lawrence River in 1535 were initiated in hope of finding a way through the continent. Cartier became persuaded that the St. Lawrence was the Passage; when he found the way blocked by rapids at what is now Montreal, he was so certain that these rapids were all that was keeping him from China (in French, la Chine), that he named the rapids for China. Samuel de Champlain renamed them Sault Saint-Louis in 1611, but the name was changed to Lachine Rapids in the mid-19th century.

In 1602, George Weymouth became the first European to explore what would later be called Hudson Strait when he sailed Discovery 300 nautical miles (560 km) into the Strait. Weymouth's expedition to find the Northwest Passage was funded jointly by the British East India Company and the Muscovy Company. Discovery was the same ship used by Henry Hudson on his final voyage.

John Knight, employed by the British East India Company and the Muscovy Company, set out in 1606 to follow up on Weymouth's discoveries and find the Northwest Passage. After his ship ran aground and was nearly crushed by ice, Knight disappeared while searching for a better anchorage.

In 1609, Henry Hudson sailed up what is now called the Hudson River in search of the Passage; encouraged by the saltiness of the water in the estuary, he reached present-day Albany, New York, before giving up. On September 14, 1609, the explorer Henry Hudson entered the Tappan Zee while sailing upstream from New York Harbor. At first, Hudson believed the widening of the river indicated that he had found the Northwest Passage. He proceeded upstream as far as present-day Troy before concluding that no such strait existed there. He later explored the Arctic and Hudson Bay.

In 1611, while in James Bay, Hudson's crew mutinied. They set Hudson and his teenage son John, along with seven sick, infirm, or loyal crewmen, adrift in a small open boat. He was never seen again. Cree oral legend reports that the survivors lived and traveled with the Cree for more than a year.

A mission was sent out in 1612, again in Discovery, commanded by Sir Thomas Button to find Henry Hudson and continue through the Northwest Passage. After failing to find Hudson, and exploring the west coast of Hudson Bay, Button returned home due to illness in the crew. In 1614, William Gibbons attempted to find the Passage, but was turned back by ice. The next year, 1615, Robert Bylot, a survivor of Hudson's crew, returned to Hudson Strait in Discovery, but was turned back by ice. Bylot tried again in 1616 with William Baffin. They sailed as far as Lancaster Sound and reached 77°45′ North latitude, a record which stood for 236 years, before being blocked by ice.

On May 9, 1619, under the auspices of King Christian IV of Denmark–Norway, Jens Munk set out with 65 men and the king's two ships, Einhörningen (Unicorn), a small frigate, and Lamprenen (Lamprey), a sloop, which were outfitted under his own supervision. His mission was to discover the Northwest Passage to the Indies and China. Munk penetrated Davis Strait as far north as 69°, found Frobisher Bay, and then spent almost a month fighting his way through Hudson Strait. In September 1619, he found the entrance to Hudson Bay and spent the winter near the mouth of the Churchill River. Cold, famine, and scurvy destroyed so many of his men that only he and two other men survived. With these men, he sailed for home with Lamprey on July 16, 1620, reaching Bergen, Norway, on September 20, 1620.

René-Robert Cavelier, Sieur de La Salle built the sailing ship, Le Griffon, in his quest to find the Northwest Passage via the upper Great Lakes. Le Griffon disappeared in 1679 on the return trip of her maiden voyage. In the spring of 1682, La Salle made his famous voyage down the Mississippi River to the Gulf of Mexico. La Salle led an expedition from France in 1684 to establish a French colony on the Gulf of Mexico. He was murdered by his followers in 1687.

Ellis expedition: Voyage to Hudson Bay, in 1746 and 1747

Henry Ellis, born in Ireland, was part of a company aiming to discover the Northwest Passage in May 1746. After the difficult extinction of a fire on board the ship, he sailed to Greenland, where he traded goods with the Inuit peoples on July 8, 1746. He crossed to the town of Fort Nelson and spent the summer on the Hayes River. He renewed his efforts in June 1747, without success, before returning to England.

In 1772, Samuel Hearne travelled overland northwest from Hudson Bay to the Arctic Ocean, thereby proving that there was no strait connecting Hudson Bay to the Pacific Ocean.

Northern Pacific

1765 globe by Guillaume Delisle, showing a fictional Northwest Passage.

Most Northwest Passage expeditions originated in Europe or on the east coast of North America, seeking to traverse the Passage in the westbound direction. Some progress was made in exploring the western reaches of the imagined passage.

In 1728 Vitus Bering, a Danish Navy officer in Russian service, used the strait first discovered by Semyon Dezhnyov in 1648 but later accredited to and named after Bering (the Bering Strait). He concluded that North America and Russia were separate land masses by sailing between them. In 1741 with Lieutenant Aleksei Chirikov, he explored seeking further lands beyond Siberia. While they were separated, Chirikov discovered several of the Aleutian Islands while Bering charted the Alaskan region. His ship was wrecked off the Kamchatka Peninsula, as many of his crew were disabled by scurvy.

The Spanish made several voyages to the northwest coast of North America during the late 18th century. Determining whether a Northwest Passage existed was one of the motives for their efforts. Among the voyages that involved careful searches for a Passage included the 1775 and 1779 voyages of Juan Francisco de la Bodega y Quadra. The journal of Francisco Antonio Mourelle, who served as Quadra's second in command in 1775, fell into English hands. It was translated and published in London, stimulating exploration.

Captain James Cook made use of the journal during his explorations of the region. In 1791 Alessandro Malaspina sailed to Yakutat Bay, Alaska, which was rumoured to be a Passage. In 1790 and 1791 Francisco de Eliza led several exploring voyages into the Strait of Juan de Fuca, searching for a possible Northwest Passage and finding the Strait of Georgia. To fully explore this new inland sea, an expedition under Dionisio Alcalá Galiano was sent in 1792. He was explicitly ordered to explore all channels that might turn out to be a Northwest Passage.

Cook and Vancouver

In 1776, Captain James Cook was dispatched by the Admiralty in Great Britain on an expedition to explore the Passage. A 1745 act, when extended in 1775, promised a £20,000 prize for whoever discovered the passage. Initially the Admiralty had wanted Charles Clerke to lead the expedition, with Cook (in retirement following his exploits in the Pacific) acting as a consultant. However, Cook had researched Bering's expeditions, and the Admiralty ultimately placed their faith in the veteran explorer to lead, with Clerke accompanying him.

After journeying through the Pacific, to make an attempt from the west, Cook began at Nootka Sound in April 1778. He headed north along the coastline, charting the lands and searching for the regions sailed by the Russians 40 years previously. The Admiralty's orders had commanded the expedition to ignore all inlets and rivers until they reached a latitude of 65°N. Cook, however, failed to make any progress in sighting a Northwestern Passage.

Various officers on the expedition, including William Bligh, George Vancouver, and John Gore, thought the existence of a route was 'improbable'. Before reaching 65°N they found the coastline pushing them further south, but Gore convinced Cook to sail on into the Cook Inlet in the hope of finding the route. They continued to the limits of the Alaskan peninsula and the start of the 1,200 mi (1,900 km) chain of Aleutian Islands. Despite reaching 70°N, they encountered nothing but icebergs.[17]

From 1792 to 1794, the Vancouver Expedition (led by George Vancouver who had previously accompanied Cook) surveyed in detail all the passages from the Northwest Coast. He confirmed that there was no such passage south of the Bering Strait. This conclusion was supported by the evidence of Alexander MacKenzie, who explored the Arctic and Pacific Oceans in 1793.

19th century

Das Eismeer (The Sea of Ice), 1823–1824, a painting by Caspar David Friedrich, inspired by William Edward Parry's account from the 1819–1820 expedition. Kunsthalle Hamburg, Germany.

In the first half of the 19th century, some parts of the Northwest Passage (north of the Bering Strait) were explored separately by many expeditions, including those by John Ross, Elisha Kent Kane, William Edward Parry, and James Clark Ross; overland expeditions were also led by John Franklin, George Back, Peter Warren Dease, Thomas Simpson, and John Rae. In 1826 Frederick William Beechey explored the north coast of Alaska, discovering Point Barrow.

Sir Robert McClure was credited with the discovery of the Northwest Passage in 1851 when he looked across McClure Strait from Banks Island and viewed Melville Island. However, this strait was not navigable to ships at that time. The only usable route linking the entrances of Lancaster Sound and Dolphin and Union Strait was discovered by John Rae in 1854.

Franklin expedition

In 1845, a lavishly equipped two-ship expedition led by Sir John Franklin sailed to the Canadian Arctic to chart the last unknown swaths of the Northwest Passage. Confidence was high, as they estimated there was less than 500 km (310 mi) remaining of unexplored Arctic mainland coast. When the ships failed to return, relief expeditions and search parties explored the Canadian Arctic, which resulted in a thorough charting of the region, along with a possible passage. Many artifacts from the expedition were found over the next century and a half, including notes that the ships were ice-locked in 1846 near King William Island, about halfway through the passage, and unable to break free. Records showed Franklin died in 1847 and Captain Francis Rawdon Moira Crozier took over command. In 1848 the expedition abandoned the two ships and its members tried to escape south across the tundra by sledge. Although some of the crew may have survived into the early 1850s, no evidence has ever been found of any survivors. In 1853 explorer John Rae was told by local Inuit about the disastrous fate of Franklin's expedition, but his reports were not welcomed in Britain.

Starvation, exposure and scurvy all contributed to the men's deaths. In 1981 Owen Beattie, an anthropologist from the University of Alberta, examined remains from sites associated with the expedition. This led to further investigations and the examination of tissue and bone from the frozen bodies of three seamen, John Torrington, William Braine and John Hartnell, exhumed from the permafrost of Beechey Island. Laboratory tests revealed high concentrations of lead in all three (the expedition carried 8,000 tins of food sealed with a lead-based solder). Another researcher has suggested botulism caused deaths among crew members. New evidence, confirming reports first made by John Rae in 1854 based on Inuit accounts, has shown that the last of the crew resorted to cannibalism of deceased members in an effort to survive.

McClure expedition

The North-West Passage (1874), a painting by John Everett Millais representing British frustration at the failure to conquer the passage.
Tate Britain, London.

During the search for Franklin, Commander Robert McClure and his crew in HMS Investigator traversed the Northwest Passage from west to east in the years 1850 to 1854, partly by ship and partly by sledge. McClure started out from England in December 1849, sailed the Atlantic Ocean south to Cape Horn and entered the Pacific Ocean. He sailed the Pacific north and passed through the Bering Strait, turning east at that point and reaching Banks Island.

McClure's ship was trapped in the ice for three winters near Banks Island, at the western end of Viscount Melville Sound. Finally McClure and his crew—who were by that time dying of starvation—were found by searchers who had travelled by sledge over the ice from a ship of Sir Edward Belcher's expedition. They rescued McClure and his crew, returning with them to Belcher's ships, which had entered the Sound from the east. McClure and his crew returned to England in 1854 on one of Belcher's ships. They were the first people known to circumnavigate the Americas and to discover and transit the Northwest Passage, albeit by ship and by sledge over the ice. (Both McClure and his ship were found by a party from HMS Resolute, one of Belcher's ships, so his sledge journey was relatively short.)

This was an astonishing feat for that day and age, and McClure was knighted and promoted in rank. (He was made rear-admiral in 1867.) Both he and his crew also shared £10,000 awarded them by the British Parliament. In July 2010 Canadian archaeologists found his ship, HMS Investigator, fairly intact but sunk about 8 m (26 ft) below the surface.

John Rae

The expeditions by Franklin and McClure were in the tradition of British exploration: well-funded ship expeditions using modern technology, and usually including British Naval personnel. By contrast, John Rae was an employee of the Hudson's Bay Company, which operated a far-flung trade network and drove exploration of the Canadian North. They adopted a pragmatic approach and tended to be land-based. While Franklin and McClure tried to explore the passage by sea, Rae explored by land. He used dog sleds and techniques of surviving in the environment which he had learned from the native Inuit. The Franklin and McClure expeditions each employed hundreds of personnel and multiple ships. John Rae's expeditions included fewer than ten people and succeeded. Rae was also the explorer with the best safety record, having lost only one man in years of traversing Arctic lands. In 1854, Rae returned to the cities with information from the Inuit about the disastrous fate of the Franklin expedition.

Amundsen expedition

Norwegian polar explorer Roald Amundsen was the first to sail through the Northwest Passage in 1903–1906.
 
Amundsen's Gjøa was the first vessel to transit the passage.

The first explorer to conquer the Northwest Passage solely by ship was the Norwegian explorer Roald Amundsen. In a three-year journey between 1903 and 1906, Amundsen explored the passage with a crew of six. Amundsen, who had sailed to escape creditors seeking to stop the expedition, completed the voyage in the converted 45 net register tonnage (4,500 cu ft or 130 m3) herring boat Gjøa. Gjøa was much smaller than vessels used by other Arctic expeditions and had a shallow draft. Amundsen intended to hug the shore, live off the limited resources of the land and sea through which he was to travel, and had determined that he needed to have a tiny crew to make this work. (Trying to support much larger crews had contributed to the catastrophic failure of John Franklin's expedition fifty years previously). The ship's shallow draft was intended to help her traverse the shoals of the Arctic straits.

Amundsen set out from Kristiania (Oslo) in June 1903 and was west of the Boothia Peninsula by late September. Gjøa was put into a natural harbour on the south shore of King William Island; by October 3 she was iced in. There the expedition remained for nearly two years, with the expedition members learning from the local Inuit people and undertaking measurements to determine the location of the North Magnetic Pole. The harbour, now known as Gjoa Haven, later developed as the only permanent settlement on the island.

After completing the Northwest Passage portion of this trip and having anchored near Herschel Island, Amundsen skied 800 kilometres (500 mi) to the city of Eagle, Alaska. He sent a telegram announcing his success and skied the return 800 kilometres (500 mi) to rejoin his companions. Although his chosen east–west route, via the Rae Strait, contained young ice and thus was navigable, some of the waterways were extremely shallow (3 ft (0.91 m) deep), making the route commercially impractical.

Later expeditions

The first traversal of the Northwest Passage via dog sled was accomplished by Greenlander Knud Rasmussen while on the Fifth Thule Expedition (1921–1924). Rasmussen and two Greenland Inuit travelled from the Atlantic to the Pacific over the course of 16 months via dog sled.

Canadian Royal Canadian Mounted Police officer Henry Larsen was the second to sail the passage, crossing west to east, leaving Vancouver on June 23, 1940 and arriving at Halifax on October 11, 1942. More than once on this trip, he was uncertain whether St. Roch, a Royal Canadian Mounted Police "ice-fortified" schooner, would survive the pressures of the sea ice. At one point, Larsen wondered "if we had come this far only to be crushed like a nut on a shoal and then buried by the ice." The ship and all but one of her crew survived the winter on Boothia Peninsula. Each of the men on the trip was awarded a medal by Canada's sovereign, King George VI, in recognition of this feat of Arctic navigation.

Later in 1944, Larsen's return trip was far more swift than his first. He made the trip in 86 days to sail back from Halifax, Nova Scotia, to Vancouver, British Columbia. He set a record for traversing the route in a single season. The ship, after extensive upgrades, followed a more northerly, partially uncharted route.

In 1954, HMCS Labrador completed the east-to-west transit, under the command of Captain O.C.S. Robertson, conducting hydrographic soundings along the route. She was the first warship (and the first deep draft ship) to transit the Northwest Passage and the first warship to circumnavigate North America. In 1956, HMCS Labrador again completed the east-to-west transit, this time under the command of Captain T.C. Pullen.

On July 1, 1957, the United States Coast Guard Cutter Storis departed in company with USCGC  Bramble and USCGC Spar to search for a deep-draft channel through the Arctic Ocean and to collect hydrographic information. The US Coast Guard Squadron was escorted through Bellot Strait and the Eastern Arctic by HMCS Labrador. Upon her return to Greenland waters, Storis became the first U.S.-registered vessel to circumnavigate North America. Shortly after her return in late 1957, she was reassigned to her new home port of Kodiak, Alaska.

In 1960, USS Seadragon completed the first submarine transit of the Northwest Passage, heading east-to-west.

In 1969, SS Manhattan made the passage, accompanied by the Canadian icebreakers CCGS John A. Macdonald and CCGS Louis S. St-Laurent. The U.S. Coast Guard icebreakers Northwind and Staten Island also sailed in support of the expedition.

Manhattan was a specially reinforced supertanker sent to test the viability of the passage for the transport of oil. While Manhattan succeeded, the route was deemed not to be cost-effective. The United States built the Alaska Pipeline instead.

In June 1977, sailor Willy de Roos left Belgium to attempt the Northwest Passage in his 13.8 m (45 ft) steel yacht Williwaw. He reached the Bering Strait in September and after a stopover in Victoria, British Columbia, went on to round Cape Horn and sail back to Belgium, thus being the first sailor to circumnavigate the Americas entirely by ship.

In 1981 as part of the Transglobe Expedition, Ranulph Fiennes and Charles R. Burton completed the Northwest Passage. They left Tuktoyaktuk on July 26, 1981, in the 18-foot (5.5 m) open Boston Whaler and reached Tanquary Fiord on August 31, 1981. Their journey was the first open-boat transit from west to east and covered around 3,000 miles (4,800 km; 2,600 nmi), taking a route through Dolphin and Union Strait following the south coast of Victoria and King William islands, north to Resolute Bay via Franklin Strait and Peel Sound, around the south and east coasts of Devon Island, through Hell Gate and across Norwegian Bay to Eureka, Greely Bay and the head of Tanquary Fiord. Once they reached Tanquary Fiord, they had to trek 150 miles (240 km) via Lake Hazen to Alert before setting up their winter base camp.

In 1984, the commercial passenger vessel MV Explorer (which sank in the Antarctic Ocean in 2007) became the first cruise ship to navigate the Northwest Passage.

In July 1986, Jeff MacInnis and Mike Beedell set out on an 18-foot (5.5 m) catamaran called Perception on a 100-day sail, west to east, through the Northwest Passage. This pair was the first to sail the passage, although they had the benefit of doing so over a couple of summers.

In July 1986, David Scott Cowper set out from England in a 12.8-metre (42 ft) lifeboat named Mabel El Holland, and survived three Arctic winters in the Northwest Passage before reaching the Bering Strait in August 1989. He continued around the world via the Cape of Good Hope to return to England on September 24, 1990. His was the first vessel to circumnavigate the world via the Northwest Passage.

On July 1, 2000, the Royal Canadian Mounted Police patrol vessel Nadon, having assumed the name St Roch II, departed Vancouver on a "Voyage of Rediscovery." Nadon's mission was to circumnavigate North America via the Northwest Passage and the Panama Canal, recreating the epic voyage of her predecessor, St. Roch. The 22,000-mile (35,000 km) Voyage of Rediscovery was intended to raise awareness concerning St. Roch and kick off the fund-raising efforts necessary to ensure the continued preservation of St. Roch. The voyage was organized by the Vancouver Maritime Museum and supported by a variety of corporate sponsors and agencies of the Canadian government. Nadon is an aluminum, catamaran-hulled, high-speed patrol vessel. To make the voyage possible, she was escorted and supported by the Canadian Coast Guard icebreaker Simon Fraser. The Coast Guard vessel was chartered by the Voyage of Rediscovery and crewed by volunteers. Throughout the voyage, she provided a variety of necessary services, including provisions and spares, fuel and water, helicopter facilities, and ice escort; she also conducted oceanographic research during the voyage. The Voyage of Rediscovery was completed in five and a half months, with Nadon reaching Vancouver on December 16, 2000.

On September 1, 2001, Northabout, an 14.3-metre (47 ft) aluminium sailboat with diesel engine, built and captained by Jarlath Cunnane, completed the Northwest Passage east-to-west from Ireland to the Bering Strait. The voyage from the Atlantic to the Pacific was completed in 24 days. Cunnane cruised in Northabout in Canada for two years before returning to Ireland in 2005 via the Northeast Passage; he completed the first east-to-west circumnavigation of the pole by a single sailboat. The Northeast Passage return along the coast of Russia was slower, starting in 2004, requiring an ice stop and winter over in Khatanga, Siberia. He returned to Ireland via the Norwegian coast in October 2005. On January 18, 2006, the Cruising Club of America awarded Jarlath Cunnane their Blue Water Medal, an award for "meritorious seamanship and adventure upon the sea displayed by amateur sailors of all nationalities."

On July 18, 2003, a father-and-son team, Richard and Andrew Wood, with Zoe Birchenough, sailed the yacht Norwegian Blue into the Bering Strait. Two months later she sailed into the Davis Strait to become the first British yacht to transit the Northwest Passage from west to east. She also became the only British vessel to complete the Northwest Passage in one season, as well as the only British sailing yacht to return from there to British waters.

In 2006, a scheduled cruise liner (MS Bremen) successfully ran the Northwest Passage, helped by satellite images telling the location of sea ice.

On May 19, 2007, a French sailor, Sébastien Roubinet, and one other crew member left Anchorage, Alaska, in Babouche, a 7.5-metre (25 ft) ice catamaran designed to sail on water and slide over ice. The goal was to navigate west to east through the Northwest Passage by sail only. Following a journey of more than 7,200 km (4,474 mi), Roubinet reached Greenland on September 9, 2007, thereby completing the first Northwest Passage voyage made in one season without engine.

Northwest Passage Drive Expedition (NWPDX) (2009–2011)

In April 2009, planetary scientist Pascal Lee and a team of four on the Northwest Passage Drive Expedition drove the HMP Okarian Humvee rover a record-setting 496 km (308 mi) on sea-ice from Kugluktuk to Cambridge Bay, Nunavut, the longest distance driven on sea-ice in a road vehicle. The HMP Okarian was being ferried from the North American mainland to the Haughton–Mars Project (HMP) Research Station on Devon Island, where it would be used as a simulator of future pressurized rovers for astronauts on the Moon and Mars. The HMP Okarian was eventually flown from Cambridge Bay to Resolute Bay in May 2009, and then driven again on sea-ice by Lee and a team of five from Resolute to the West coast of Devon Island in May 2010. The HMP Okarian reached the HMP Research Station in July 2011. The Northwest Passage Drive Expedition is captured in the motion picture documentary film Passage To Mars (2016).

In 2009, sea ice conditions were such that at least nine small vessels and two cruise ships completed the transit of the Northwest Passage. These trips included one by Eric Forsyth on board the 42-foot (13 m) Westsail sailboat Fiona, a boat he built in the 1980s. Self-financed, Forsyth, a retired engineer from the Brookhaven National Laboratory, and winner of the Cruising Club of America's Blue Water Medal, sailed the Canadian Archipelago with sailor Joey Waits, airline captain Russ Roberts and carpenter David Wilson. After successfully sailing the Passage, the 77-year-old Forsyth completed the circumnavigation of North America, returning to his home port on Long Island, New York.

Cameron Dueck and his crew aboard the 40-foot sailing yacht Silent Sound also transited in the summer of 2009. Their voyage began in Victoria, BC on June 6 and they arrived in Halifax on October 10.

Dueck wrote a book about the voyage called The New Northwest Passage.

On September 9, 2010, Bear Grylls and a team of five completed a point-to-point navigation between Pond Inlet and Tuktoyaktuk in the Northwest Territories on a rigid inflatable boat (RIB). The expedition drew attention to how the effects of global warming made this journey possible and raised funds for the Global Angels charity.

On August 30, 2012 Sailing yacht Billy Budd, 110 feet (34 m), an English SY, successfully completed the Northwest Passage in Nome, Alaska, while sailing a northern route never sailed by a sailing pleasure vessel before. After six cruising seasons in the Arctic (Greenland, Baffin Bay, Devon Island, Kane Basin, Lancaster Sound, Peel Sound, Regent Sound) and four seasons in the South (Antarctic Peninsula, Patagonia, Falkland Islands, South Georgia), SY Billy Budd, owned by and under the command of an Italian sporting enthusiast, Mariacristina Rapisardi. Crewed by Marco Bonzanigo, five Italian friends, one Australian, one Dutch, one South African, and one New Zealander, it sailed through the Northwest Passage. The northernmost route was chosen. Billy Budd sailed through the Parry Channel, Viscount Melville Sound and Prince of Wales Strait, a channel 160 nautical miles (300 km; 180 mi) long and 15 nautical miles (28 km; 17 mi) wide which flows south into the Amundsen Gulf. During the passage Billy Budd – likely a first for a pleasure vessel – anchored in Winter Harbour in Melville Island, the very same site where almost 200 years ago Sir William Parry was blocked by ice and forced to winter.

On August 29, 2012, the Swedish yacht Belzebub II, a 31-foot (9.4 m) fibreglass cutter captained by Canadian Nicolas Peissel, Swede Edvin Buregren and Morgan Peissel, became the first sailboat in history to sail through McClure Strait, part of a journey of achieving the most northerly Northwest Passage. Belzebub II departed Newfoundland following the coast of Greenland to Qaanaaq before tracking the sea ice to Grise Fiord, Canada's most northern community. From there the team continued through Parry Channel into McClure Strait and the Beaufort Sea, tracking the highest latitudes of 2012's record sea ice depletion before completing their Northwest Passage September 14, 2012. The expedition received extensive media coverage, including recognition by former U.S. Vice President Al Gore. The accomplishment is recorded in the Polar Scott Institute's record of Northwest Passage Transits and recognized by the Explorers Club and the Royal Canadian Geographic Society.

At 18:45 GMT on September 18, 2012, Best Explorer, a steel cutter 15.17 metres (49.8 ft), skipper Nanni Acquarone, passing between the two Diomedes, was the first Italian sailboat to complete the Northwest Passage along the classical Amundsen route. Twenty-two Italian amateur sailors took part of the trip, in eight legs from Tromsø, Norway, to King Cove, Alaska, totalling 8,200 nautical miles (15,200 km; 9,400 mi). Later in 2019 Best Explorer skppered again by Nanni Acquarone became the first Italian sailboat to circumnavigate the Arctic sailing north of Siberia from Petropavlovsk-Kamchatsky to Tromsø and the second ever to do it clockwise.

Setting sail from Nome, Alaska, on August 18, 2012, and reaching Nuuk, Greenland, on September 12, 2012, The World became the largest passenger vessel to transit the Northwest Passage. The ship, carrying 481 passengers, for 26 days and 4,800 nmi (8,900 km; 5,500 mi) at sea, followed in the path of Captain Roald Amundsen. The World's transit of the Northwest Passage was documented by National Geographic photographer Raul Touzon.

In September 2013, MS Nordic Orion became the first commercial bulk carrier to transit the Northwest Passage. She was carrying a cargo of 73,500 short tons (66,700 t) of coking coal from Port Metro Vancouver, Canada, to the Finnish Port of Pori, 15,000 short tons (14,000 t) more than would have been possible via the traditional Panama Canal route. The Northwest Passage shortened the distance by 1,000 nautical miles (1,900 km; 1,200 mi) compared to traditional route via the Panama Canal.

In August and September 2016 a cruise ship was sailed through the Northwest Passage. The ship Crystal Serenity, (with 1,000 passengers, and 600 crew) left Seward, Alaska, used Amundsen's route and reached New York on September 17. Tickets for the 32-day trip started at $22,000 and were quickly sold out. The trip was repeated in 2017. In 2017 33 vessels made a complete transit, breaking the prior record of 20 in 2012.

In September 2018, sailing yacht Infinity (a 36·6 m ketch) and her 22-person crew successfully sailed through the Northwest Passage. This was part of their mission to plant the Flag of Planet Earth on the remaining Arctic ice. Supported by the initiative, EarthToday, this voyage was a symbol for future global collaboration against climate change. The Flag of Planet Earth was planted on September 21, 2018, the International Day of Peace.

International waters dispute

The Canadian government classifies the waters of the Northwest Passage in the Canadian Arctic Archipelago, as internal waters of Canada as per the United Nations Convention on the Law of the Sea and by the precedent in the drawing of baselines for other archipelagos, giving Canada the right to bar transit through these waters. Some maritime nations, including the United States and some of the European Union, claim these waters to be an international strait, where foreign vessels have the right of "transit passage." In such a regime, Canada would have the right to enact fishing and environmental regulation, and fiscal and smuggling laws, as well as laws intended for the safety of shipping, but not the right to close the passage. If the passage's deep waters become completely ice-free in summer months, they will be particularly enticing for supertankers that are too big to pass through the Panama Canal and must otherwise navigate around the tip of South America.

The dispute between Canada and the United States arose in 1969 with the trip of the U.S. oil tanker SS Manhattan through the Arctic Archipelago. The prospect of more American traffic headed to the Prudhoe Bay Oil Field made the Canadian government realize that political action was required.

In 1985, the U.S. Coast Guard icebreaker Polar Sea passed through from Greenland to Alaska; the ship submitted to inspection by the Canadian Coast Guard before passing through, but the event infuriated the Canadian public and resulted in a diplomatic incident. The United States government, when asked by a Canadian reporter, indicated that they did not ask for permission as they insist that the waters were an international strait. The Canadian government issued a declaration in 1986 reaffirming Canadian rights to the waters. The United States refused to recognize the Canadian claim. In 1988 the governments of Canada and the United States signed an agreement, "Arctic Cooperation," that resolved the practical issue without solving the sovereignty questions. Under the law of the sea, ships engaged in transit passage are not permitted to engage in research. The agreement states that all U.S. Coast Guard and Navy vessels are engaged in research, and so would require permission from the Government of Canada to pass through.

However, in late 2005, it was reported that U.S. nuclear submarines had travelled unannounced through Canadian Arctic waters, breaking the "Arctic Cooperation" agreement and sparking outrage in Canada. In his first news conference after the 2006 federal election, Prime Minister-designate Stephen Harper contested an earlier statement made by the U.S. ambassador that Arctic waters were international, stating the Canadian government's intention to enforce its sovereignty there. The allegations arose after the U.S. Navy released photographs of USS Charlotte surfaced at the North Pole.

On April 9, 2006, Canada's Joint Task Force (North) declared that the Canadian Forces will no longer refer to the region as the Northwest Passage, but as the Canadian Internal Waters. The declaration came after the successful completion of Operation Nunalivut (Inuktitut for "the land is ours"), which was an expedition into the region by five military patrols.

In 2006 a report prepared by the staff of the Parliamentary Information and Research Service of Canada suggested that because of the September 11 attacks, the United States might be less interested in pursuing the international waterways claim in the interests of having a more secure North American perimeter. This report was based on an earlier paper, The Northwest Passage Shipping Channel: Is Canada's Sovereignty Really Floating Away? by Andrea Charron, given to the 2004 Canadian Defence and Foreign Affairs Institute Symposium. Later in 2006 former United States Ambassador to Canada, Paul Cellucci agreed with this position; however, the succeeding ambassador, David Wilkins, stated that the Northwest Passage was in international waters.

On July 9, 2007, Prime Minister Harper announced the establishment of a deep-water port in the far North. In the press release Harper said, "Canada has a choice when it comes to defending our sovereignty over the Arctic. We either use it or lose it. And make no mistake, this Government intends to use it. Because Canada's Arctic is central to our national identity as a northern nation. It is part of our history. And it represents the tremendous potential of our future."

On July 10, 2007, Rear Admiral Timothy McGee of the U.S. Navy and Rear Admiral Brian Salerno of the U.S. Coast Guard announced that the United States would be increasing its ability to patrol the Arctic.

In June 2019, the U.S. State Department spokesperson Morgan Ortagus said the United States "believes that Canada's claim of the Northwest Passage are internal waters of Canada as inconsistent with international law" despite historical precedent regarding archipelago baselines.

Thinning ice cover and the Northwest Passage

Arctic shrinkage as of 2007 compared to previous years

In the summer of 2000, two Canadian ships took advantage of thinning summer ice cover on the Arctic Ocean to make the crossing. It is thought that climate change is likely to open the passage for increasing periods, making it potentially attractive as a major shipping route. However, the passage through the Arctic Ocean would require significant investment in escort vessels and staging ports, and it would remain seasonal. Therefore, the Canadian commercial marine transport industry does not anticipate the route as a viable alternative to the Panama Canal within the next 10 to 20 years (as of 2004).

On September 14, 2007, the European Space Agency stated that ice loss that year had opened up the historically impassable passage, setting a new low of ice cover as seen in satellite measurements which went back to 1978. According to the Arctic Climate Impact Assessment, the latter part of the 20th century and the start of the 21st had seen marked shrinkage of ice cover. The extreme loss in 2007 rendered the passage "fully navigable." However, the ESA study was based only on analysis of satellite images and could in practice not confirm anything about the actual navigation of the waters of the passage. ESA suggested the passage would be navigable "during reduced ice cover by multi-year ice pack" (namely sea ice surviving one or more summers) where previously any traverse of the route had to be undertaken during favourable seasonable climatic conditions or by specialist vessels or expeditions. The agency's report speculated that the conditions prevalent in 2007 had shown the passage may "open" sooner than expected. An expedition in May 2008 reported that the passage was not yet continuously navigable even by an icebreaker and not yet ice-free.

Scientists at a meeting of the American Geophysical Union on December 13, 2007, revealed that NASA satellites observing the western Arctic showed a 16% decrease in cloud coverage during the summer of 2007 compared to 2006. This would have the effect of allowing more sunlight to penetrate Earth's atmosphere and warm the Arctic Ocean waters, thus melting sea ice and contributing to the opening the Northwest Passage.

In 2006 the cruise liner MS Bremen successfully ran the Northwest Passage, helped by satellite images telling where sea ice was.

On November 28, 2008, the Canadian Broadcasting Corporation reported that the Canadian Coast Guard confirmed the first commercial ship sailed through the Northwest Passage. In September 2008, MV Camilla Desgagnés, owned by Desgagnés Transarctik Inc. and, along with the Arctic Cooperative, is part of Nunavut Sealift and Supply Incorporated (NSSI), transported cargo from Montreal to the hamlets of Cambridge Bay, Kugluktuk, Gjoa Haven, and Taloyoak. A member of the crew is reported to have claimed that "there was no ice whatsoever." Shipping from the east was to resume in the fall of 2009. Although sealift is an annual feature of the Canadian Arctic this is the first time that the western communities have been serviced from the east. The western portion of the Canadian Arctic is normally supplied by Northern Transportation Company Limited (NTCL) from Hay River, and the eastern portion by NNSI and NTCL from Churchill and Montreal.

In January 2010, the ongoing reduction in the Arctic sea ice led telecoms cable specialist Kodiak-Kenai Cable to propose the laying of a fiberoptic cable connecting London and Tokyo, by way of the Northwest Passage, saying the proposed system would nearly cut in half the time it takes to send messages from the United Kingdom to Japan.

In September 2013, the first large ice strengthened sea freighter, Nordic Orion, used the passage.

In 2016 a new record was set when the cruise ship Crystal Serenity transited with 1,700 passengers and crew. Crystal Serenity is the largest cruise ship to navigate the Northwest Passage. Starting on August 10, 2016, the ship sailed from Vancouver to New York City, taking 28 days for the journey.

Transfer of Pacific species to North Atlantic

Scientists believe that reduced sea ice in the Northwest Passage has permitted some new species to migrate across the Arctic Ocean. The gray whale Eschrichtius robustus has not been seen in the Atlantic since it was hunted to extinction there in the 18th century, but in May 2010, one such whale turned up in the Mediterranean. Scientists speculated the whale had followed its food sources through the Northwest Passage and simply kept on going.

The plankton species Neodenticula seminae had not been recorded in the Atlantic for 800,000 years. Over the past few years, however, it has become increasingly prevalent there. Again, scientists believe that it got there through the reopened Northwest Passage.

In August 2010, two bowhead whales from West Greenland and Alaska respectively, entered the Northwest Passage from opposite directions and spent approximately 10 days in the same area.

Postpartum psychosis

From Wikipedia, the free encyclopedia
 
Postpartum psychosis
Other namespuerperal psychosis
Figure 1. Incidence of Psychoses among Swedish First-Time Mothers.png
Rates of psychoses among Swedish first-time mothers
SpecialtyPsychiatry Edit this on Wikidata
SymptomsHallucinations, delusions, mood swings, confusion, restlessness, personality changes
CausesGenetic and environmental
Risk factorsFamily history, bipolar disorder, schizophrenia, difficult pregnancy
TreatmentAnti-psychotics, mood stabilizers , anti-depressants

Early in the history of medicine, it was recognized that severe mental illness sometimes started abruptly in the days after childbirth, later known as puerperal or postpartum psychosis. Gradually, it became clear that this was not a single and unique entity, but a group of at least twenty distinct disorders.

Psychosis implies the presence of manic symptoms, stupor or catatonia, perplexity, confusion, disorders of the will and self, delusions and/ or hallucinations. Psychiatric disorders that lack these symptoms are excluded; depression, however severe, is not included, unless there are psychotic features.

Of this group of psychoses, postpartum bipolar disorder is overwhelmingly the most common in high-income nations.

Postpartum Bipolar disorder

Signs and symptoms

Almost every symptom known to psychiatry occurs in these mothers – every kind of delusion including the rare delusional parasitosis, delusional misidentification syndrome, Cotard delusion, erotomania, and the changeling delusion, denial of pregnancy or birth, command hallucinations, disorders of the will and self, catalepsy and other symptoms of catatonia, self-mutilation and all the severe disturbances of mood. In addition, the literature also describes symptoms not generally recognized, such as rhyming speech, enhanced intellect, and enhanced perception.

As for collections of symptoms (syndromes), about 40% have puerperal mania, with increased vitality and sociability, reduced need for sleep, rapid thinking and pressured speech, euphoria and irritability, loss of inhibition, violence, recklessness and grandiosity (including religious and expansive delusions); puerperal mania is considered to be particularly severe, with highly disorganized speech, extreme excitement and eroticism.

Another 25% have an acute polymorphic (cycloid) syndrome. This is a changing clinical state, with transient delusions, fragments of other syndromes, extreme fear or ecstasy, perplexity, confusion and motility disturbances. In the past some experts regarded this as pathognomonic (specific) for puerperal psychosis, but this syndrome is found in other settings, not just the reproductive process, and in men. These psychoses are placed in the World Health Organization's ICD-10 under the rubric of acute and transient psychotic disorders. In general psychiatry, manic and cycloid syndromes are regarded as distinct, but, studied long-term among childbearing women, the bipolar and cycloid variants are intermingled in a bewildering variety of combinations, and, in this context, it seems best to regard them as members of the same ‘bipolar/cycloid’ group. Together the manic and cycloid variants make up about two thirds of childbearing psychoses.

Diagnosis

Postpartum bipolar disorders must be distinguished from a long list of organic psychoses that can present in the puerperium, and from other non-organic psychoses; both of these groups are described below. It is also necessary to distinguish them from other psychiatric disorders associated with childbirth, such as anxiety disorders, depression, post-traumatic stress disorder, complaining disorders and bonding disorders (emotional rejection of the infant), which occasionally cause diagnostic difficulties.

Clinical assessment requires obtaining the history from the mother herself and, because she is often severely ill, lacking in insight and unable to give a clear account of events, from at least one close relative. A social work report and, in mothers admitted to hospital, nursing observations are information sources of great value. A physical examination and laboratory investigations may disclose somatic illness complicating the obstetric events, which sometimes provokes psychosis. It is important to obtain the case records of previous episodes of mental illness, and, in patients with multiple episodes, to construct a summary of the whole course of her psychiatric history in relation to her life.

In the 10th edition of the International Classification of Diseases, published in 1992, the recommendation is to classify these cases by the form of the illness, without highlighting the postpartum state. There is, however, a category F53.1, entitled 'severe mental and behavioural disorders associated with the puerperium', which can be used when it is not possible to diagnose some variety of affective disorder or schizophrenia. The American Psychiatric Association's Diagnostic and Statistical Manual, whose 5th edition was published in May 2013, allows the use of a 'peripartum onset specifier' in episodes of mania, hypomania or major depression if the symptoms occur during pregnancy or the first four weeks of the puerperium. The failure to recognize postpartum psychosis, and its complexity, is unhelpful to clinicians, epidemiologists, and other researchers.

Onset groups

Postpartum bipolar disease belongs to the bipolar spectrum, whose disorders exist in two contrasting forms – mania and depression. They are highly heritable, and sufferers (rather less than 1% of the population) have a lifelong tendency (diathesis) to develop psychotic episodes in certain circumstances. The ‘triggers’ include a number of pharmaceutical agents, surgical operations, adrenal corticosteroids, seasonal changes, menstruation and childbearing. Research into puerperal mania is, therefore, not the study of a ‘disease-in-its-own right’, but an investigation into the childbearing triggers of bipolar disorder.

Psychoses triggered in the first two weeks after the birth - between the first postpartum day (or even during parturition until about the 15th day – complicate approximately 1/1,000 pregnancies. The impression is sometimes given that this is the only trigger associated with childbearing. But there is evidence of four other triggers – late postpartum, prepartum, post-abortion and weaning. Marcé, widely considered an authority on puerperal psychoses , claimed that they could be divided into early and late forms; the late form begins about six weeks after childbirth, associated with the return of the menses . His view is supported by the large number of cases in the literature with onset 4-13 weeks after the birth, mothers with serial 4-13 week onsets and some survey evidence. The evidence for a trigger acting in pregnancy is also based on the large number of reported cases, and particularly on the frequency of mothers suffering two or more prepartum episodes. There is evidence, especially from surveys, of bipolar episodes triggered by abortion (miscarriage or termination). The evidence for a weaning trigger rests on 32 cases in the literature, of which 14 were recurrent. The relative frequency of these five triggers is given by the number of cases in the literature – just over half early postpartum onset, 20% each late postpartum and prepartum onset, and the rest post-abortion and weaning onset.

In addition, episodes starting after childbirth may be triggered by adrenal corticosteroids, surgical operations (such as Caesarean section) or bromocriptine as an alternative to, or in addition to, the postpartum trigger.

Course of the illness

With modern treatment, a full recovery can be expected within 6-10 weeks. After recovery from the psychosis, some mothers suffer from depression, which can last for weeks or months. About one third suffer a relapse, with a return of psychotic symptoms a few weeks after recovery; these relapses are not due to a failure to comply with medication, because they were often described  before pharmaceutical treatment was discovered . A minority have a series of periodic relapses related to the menstrual cycle. Complete recovery, with a resumption of normal life and a normal mother-infant relationship is the rule.

Many of these mothers suffer from other bipolar episodes, on the average about one every six years. Although suicide is almost unknown in an acute puerperal manic or cycloid episode, depressive episodes later in life carry an increased risk, and it is wise for mothers to maintain contact with psychiatric services in the long term.

In the event of a further pregnancy, the recurrence rate is high - in the largest series, about three quarters suffered a recurrence, but not always in the early puerperium; the recurrence could occur during pregnancy, or later in the postpartum period. This suggests a link between early onset and other onset groups.

Management, treatment and prevention

Pre-conception counselling

It is known that women with a personal or family history of puerperal psychosis or bipolar disorder are at risk of a puerperal episode. The highest risk of all (82%) is a combination of a previous postpartum episode and at least one earlier non-puerperal episode. There is a need to counsel women at high risk before they embark on pregnancy, especially those on prophylactic treatment. The issues include the teratogenic risk, the frequency of recurrence and the risks and benefit of various treatments during pregnancy and breast-feeding; a personal analysis should be made for each individual, and is best shared with close family members. The teratogenic risks of antipsychotic agents are small, but are higher with lithium and anti-convulsant agents. Carbamazepine, when taken in early pregnancy, has some teratogenic effects, but valproate is associated with spina bifida and other major malformations, and a foetal valproate syndrome; it is contra-indicated in women who may become pregnant. Given late in pregnancy, antipsychotic agents and lithium can have adverse effects on the infant. Stopping mood-stabilisers has a high risk of recurrence during pregnancy.

Pre-birth planning

If a mother at high risk becomes pregnant, it is essential to convene a planning meeting. This is urgent because the diagnosis of pregnancy may be late, and the birth may be premature. The meeting should be attended by primary care, obstetric and psychiatric staff, together (if possible) with the expectant mother and her family and (if appropriate) a social worker. There are many issues – pharmaceutical treatment, antenatal care, early signs of a recurrence, the management of the puerperium, and the care and safety of the infant. It is important that the psychiatric team is notified as soon as the infant is born.

Home treatment and hospitalization

It has been recognized since the 19th century that it is optimal for a mother with puerperal psychosis to be treated at home, where she can maintain her role as homemaker and mother to her other children, and develop her relationship with the new-born. But there are many risks, and it is essential that she is monitored by a competent adult round the clock, and visited frequently by professional staff. Home treatment is a counsel of perfection and most mothers will be admitted to a psychiatric hospital, many as an emergency, and usually without their babies. In a few countries, especially Australia, Belgium, France, India, the Netherlands, Switzerland and the United Kingdom, special units allow the admission of both mother and infant. Conjoint admission has many advantages, but the risks to the infant of admission to a ward full of severely ill mothers should not be understated, and the high ratio of nursing staff, required to safeguard the infants, make these among the most expensive psychiatric units.

Treatment of the acute episode

These mothers require sedation with anti-psychotic (neuroleptic) agents, but are liable to extrapyramidal symptoms, including the neuroleptic malignant syndrome. Since the link with bipolar disorder was recognized (about 1970), treatment with mood-stabilizing agents, such as lithium and anti-convulsant drugs, has been employed with success. Electroconvulsive therapy has the reputation of efficacy in this disorder, and it can be given during pregnancy (avoiding the risk of pharmaceutical treatment), with due precautions. But there have been no trials, and Dutch experience has shown that almost all mothers recover quickly without it. After recovery the mother may need antidepressant treatment and/or prophylactic mood stabilizers; she will need counselling about the risk of recurrence and will often appreciate psychotherapeutic support.

Prevention

There is much evidence that lithium can at least partly prevent episodes in mothers at high risk. It is dangerous during parturition, when pressure in the pelvis can obstruct the ureters and raise blood levels. Started after the birth its adverse effects are minimal, even in breast-fed infants.

But these are early days in the control of this malady. The ambition of medicine is to eradicate disease through understanding its causes, and dealing with them. To eliminate the risk of puerperal psychosis in the daughters and descendants of present sufferers, we need to know much more about the bipolar diathesis, and how, in each onset group, episodes are triggered.

Causes

The cause of postpartum bipolar disorder breaks down into two parts – the nature of the brain anomalies that predispose to manic and depressive symptoms, and the triggers that provoke these symptoms in those with the bipolar diathesis. The genetic, anatomical and neurochemical basis of bipolar disorder is at present unknown, and is one of the most important projects in psychiatry; but is not the main concern here. The challenge and opportunity presented by the childbearing psychoses is to identify the triggers of early postpartum onset and other onset groups.

Considering that these psychoses have been known for centuries, little effort has so far been made to understand the underlying biology. Research has lagged far behind other areas of medicine and psychiatry. There is a dearth of knowledge and of theories. There is a much evidence of heritability, both from family studies and molecular genetics. Early onset cases occur more frequently in first time mothers, but this is not true of late postpartum or pregnancy onset. There are not many other clues. Sleep deprivation has been suggested. Inhibition of steroid sulphatase caused behavioural abnormalities in mice. A recent hypothesis, supported by collateral studies, invokes the re-awakening of auto-immunity after its suppression during pregnancy, on the model of multiple sclerosis or autoimmune thyroiditis; a related hypothesis has proposed that abnormal immune system processes (regulatory T cell biology) and consequent changes in myelinogenesis may increase postpartum psychosis risk. The other promising lead is based on the similarity of bipolar-cycloid puerperal and menstrual psychosis; many women have suffered from both. Late-onset puerperal psychoses, and relapses may be linked to menstruation. Since almost all reproductive onsets occur when the menstrual cycle is released from a long period of inhibition, this may be a common factor, but it can hardly explain episodes starting in the 2nd and 3rd trimesters of pregnancy.

History

Between the 16th and 18th centuries about 50 brief reports were published; among them is the observation that these psychoses could recur, and that they occur both in breast-feeding and non-lactating women. In 1797, Osiander, an obstetrician from Tübingen, reported two cases at length - masterly descriptions which are among the treasures of medical literature. In 1819, Esquirol conducted a survey of cases admitted to the Salpêtrière, and pioneered long-term studies. From that time, puerperal psychosis became widely known to the medical profession. In the next 200 years over 2,500 theses, articles and books were published. Among the outstanding contributions were Delay's unique investigation using serial curettage and Kendell's record-linkage study comparing 8 trimesters before and 8 trimesters after the birth. In the last few years, two monographs reviewed over 2,400 works, with more than 4,000 cases of childbearing psychoses from the literature and a personal series of more than 320 cases.

Research directions

The lack of a formal diagnosis in the DSM and ICD has hindered research . Research is needed to improve the care and treatment of afflicted mothers, but it is of paramount importance to investigate the causes, because this can lead to long term control and elimination of the disease. The opportunities come under the heading of clinical observation, the study of the acute episode, long-term studies, epidemiology, genetics and neuroscience. If mothers, who have suffered from puerperal psychosis, are concerned to encourage research this is a contact. In a disorder with a strong genetic element and links to the reproductive process, costly imaging, molecular-genetic and neuroendocrinological investigations will be decisive. These depend on expert laboratory methods. It is important that the clinical study is also ‘state-of-the-art’– that scientists understand the complexity of these psychoses, and the need for multiple and reliable information sources to establish the diagnosis.

Other non-organic postpartum psychoses

It is much less common to encounter other acute psychoses in the puerperium.

Psychogenic psychosis

This is the name given to a psychosis whose theme, onset and course are all related to an extremely stressful event. The psychotic symptom is usually a delusion. Over 50 cases have been described, but usually in unusual circumstances, such as abortion. or adoption or in fathers at the time of the birth of one of their children. They are occasionally seen after normal childbirth.

Paranoid and schizophrenic psychoses

These are so uncommon in the puerperium that it seems reasonable to regard them as sporadic events, not puerperal complications.

Early postpartum stupor

Brief states of stupor have rarely been described in the first few hours or days after the birth. They are similar to parturient delirium and stupor, which are among the psychiatric disorders of childbirth.

Organic postpartum psychoses

There are at least a dozen organic (neuropsychiatric) psychoses that can present in pregnancy or soon after childbirth. The clinical picture is usually delirium – a global disturbance of cognition, affecting consciousness, attention, comprehension, perception and memory – but amnesic syndromes and a mania-like state also occur. The two most recent were described in 1980 and 2010, and it is quite likely that others will be described. Organic psychoses, especially those due to infection, may be more common in nations with high parturient morbidity.

Infective delirium

The most common organic postpartum psychosis is infective delirium. This was mentioned by Hippocrates: there are 8 cases of puerperal or post-abortion sepsis among the 17 women in the 1st and 3rd books of epidemics, all complicated by delirium. In Europe and North America the foundation of the metropolitan maternity hospitals, together with instrumental deliveries and the practice of attending necropsies, led to epidemics of streptococcal puerperal fever, resulting in maternal mortality rates up to 10%. The peak was about 1870, after which antisepsis and asepsis gradually brought them under control. These severe infections were often complicated by delirium, but it was not until the nosological advances of Chaslin and Bonhöffer that they could be distinguished from other causes of postpartum psychosis. Infective delirium hardly ever starts during pregnancy, and usually begins in the first postpartum week. The onset of sepsis and delirium are closely related, and the course parallels the infection, although about 20% of patients continue to suffer from chronic confusional states after recovery from the infection. Recurrences after another pregnancy are rare. Their frequency began to decline at the end of the 19th century, and fell steeply after the discovery of the sulphonamides. Puerperal sepsis is still common in Bangladesh, Nigeria and Zambia. Even in Britain, cases are still occasionally seen. It would be a mistake to forget this cause of puerperal psychosis.

Eclamptic and Donkin psychoses

Eclampsia is the sudden eruption of convulsions in a pregnant woman, usually around the time of delivery. It is the late complication of pre-eclamptic toxaemia (gestosis). Although its frequency in nations with excellent obstetric services has fallen below 1/500 pregnancies, it is still common in many other countries. The primary pathology is in the placenta, which secretes an anti-angiogenic factor in response to ischaemia, leading to endothelial dysfunction. In fatal cases, there are arterial lesions in many organs including the brain. This is the second most frequent organic psychosis, and the second to be described. Psychoses occur in about 5% of cases, and about 240 detailed cases have been reported. It particularly affects first time mothers. Seizures may begin before, during or after labour, but the onset of psychosis is almost always postpartum. These mothers usually suffer from delirium but some have manic features. The duration is remarkably short, with a median duration of 8 days. This, together with the absence of a family history and of recurrences, contrasts with puerperal bipolar/cycloid psychoses. After recovery, amnesia and sometimes retrograde memory loss may occur, as well as other permanent cerebral lesions such as dysphasia, hemiplegia or blindness.

A variant was described by Donkin. He had been trained by Simpson (one of those who first recognized the importance of albuminuria) in Edinburgh, and recognized that some cases of eclamptic psychosis occurred without seizures; this explains the interval between seizures (or coma) and psychosis, a gap that has occasionally exceeded 4 days: seizures and psychosis are two different consequences of severe gestosis. Donkin psychosis may not be rare: a British series included 13 possible cases; but clarifying its distinction from postpartum bipolar disorder requires prospective investigations in collaboration with obstetricians.

Wernicke-Korsakoff psychosis

This was described by Wernicke and Korsakoff. The pathology is damage to the core of the brain including the thalamus and mamillary bodies. Its most striking clinical feature is loss of memory, which can be permanent. It is usually found in severe alcoholics, but can also result from pernicious vomiting of pregnancy (hyperemesis gravidarum), because the requirement for thiamine is much increased in pregnancy; nearly 200 cases have been reported. The cause is vitamin B1 (thiamine) deficiency. This has been available for treatment and prevention since 1936, so the occurrence of this syndrome in pregnancy should be extinct. But these cases continue to be reported – more than 50 in this century – from all over the world, including some from countries with advanced medical services; most are due to rehydration without vitamin supplements. A pregnant woman who presents in a dehydrated state due to pernicious vomiting urgently needs thiamine, as well as intravenous fluids.

Vascular disorders

Various vascular disorders occasionally cause psychosis, especially cerebral venous thrombosis. Puerperal women are liable to thrombosis, especially thrombophlebitis of the leg and pelvic veins; aseptic thrombi can also form in the dural venous sinuses and the cerebral veins draining into them. Most patients present with headache, vomiting, seizures and focal signs such as hemiplegia or dysphasia, but a minority of cases have a psychiatric presentation. The incidence is about 1 in 1,000 births in Europe and North America, but much higher in India, where large series have been collected. Psychosis is occasionally associated with other arterial or venous lesions: epidural anaesthesia can, if the dura is punctured, lead to leakage of cerebrospinal fluid and subdural haematoma. Arterial occlusion may be due to thrombi, amniotic fragments or air embolism. Postpartum cerebral angiopathy is a transitory arterial spasm of medium caliber cerebral arteries; it was first described in cocaine and amphetamine addicts, but can also complicate ergot and bromocriptine prescribed to inhibit lactation. Subarachnoid haemorrhage can occur after miscarriage or childbirth. All these usually present with neurological symptoms, and occasionally with delirium.

Epilepsy

Women with a lifelong epileptic history are liable to psychoses during pregnancy, labour and the puerperium. Women occasionally develop epilepsy for the first time in relation to their first pregnancy, and psychotic episodes have been described. There are over 30 cases in the literature.

Hypopituitarism

Pituitary necrosis following postpartum haemorrhage (Sheehan's syndrome) leads to failure and atrophy of the gonads, adrenal and thyroid. Chronic psychoses can supervene many years later, based on myxoedema, hypoglycaemia or Addisonian crisis. But these patients can also develop acute and recurrent psychoses, even as early as the puerperium.

Water intoxication

Hyponatraemia (which leads to delirium) can complicate oxytocin treatment, usually when given to induce an abortion. By 1975, 29 cases had been reported, of which three were severe or fatal.

Urea cycle disorders

Inborn errors of the Krebs-Henseleit urea cycle lead to hyperammonaemia. In carriers and heterozygotes, encephalopathy can develop in pregnancy or the puerperium. Cases have been described in carbamoyl phosphate synthetase 1, argino-succinate synthetase and ornithine carbamoyltransferase deficiency.

Anti-NMDA receptor encephalitis

The most recent form of organic childbearing psychosis to be described is encephalitis associated with antibodies to the NMDA receptor; these women often have ovarian teratomas. A Japanese review found ten reported during pregnancy and five after delivery.

Other organic psychoses with a specific link to childbearing

Sydenham's chorea, of which chorea gravidarum is a severe variant, has a number of psychiatric complications, which include psychosis. This usually develops during pregnancy, and occasionally after the birth or abortion. Its symptoms include severe hypnagogic hallucinations (hypnagogia), possibly the result of the extreme sleep disorder. This form of chorea was caused by streptococcal infections, which at present respond to antibiotics; it still occurs as a result of systemic lupus or anti-phospholipid syndromes. Only about 50 chorea psychoses have been reported, and only one this century; but it could return if the streptococcus escapes control. Alcohol withdrawal states (delirium tremens) occur in addicts whose intake has been interrupted by trauma or surgery; this can happen after childbirth. Postpartum confusional states have also been reported during withdrawal from opium and barbiturates. 

One would expect acquired immunodeficiency syndrome (HIV/AIDS) encephalitis to present in pregnancy or the puerperium, because it is a venereal disease that can progress rapidly; one case of AIDS encephalitis, presenting in the 28th week of gestation, has been reported from Haiti, and there may be others in countries where AIDS is rife. Anaemia is common in pregnancy and the puerperium, and folate deficiency has been linked to psychosis.

Incidental organic psychoses

The psychoses, mentioned above, all had a recognized connection with childbearing. But medical disorders with no specific link have presented with psychotic symptoms in the puerperium; in them the association seems to be fortuitous. They include neurosyphilis, encephalitis including von Economo's, meningitis, cerebral tumours, thyroid disease and ischaemic heart disease.

Society and culture

Support

In the UK, a series of workshops called "Unravelling Eve" were held in 2011, where women who had experienced postpartum depression shared their stories.

Notable cases in history and fiction

Harriet Sarah, Lady Mordaunt (1848–1906), formerly Harriet Moncreiffe, was the Scottish wife of an English baronet and Member of Parliament, Sir Charles Mordaunt. She was the defendant in a sensational divorce case in which the Prince of Wales (later King Edward VII) was embroiled; after a controversial trial lasting seven days, the jury determined that Lady Mordaunt was suffering from “puerperal mania” and her husband's petition for divorce was dismissed, while Lady Mordaunt was committed to an asylum.

Andrea Yates suffered from depression and, four months after the birth of her 5th child, relapsed, with psychotic features. Several weeks later she drowned all five children. Under the law in Texas, she was sentenced to life imprisonment, but, after a retrial, was committed to a mental hospital.

Guy de Maupassant, in his novel Mont-Oriol (1887) described a brief postpartum psychotic episode.

Charlotte Perkins Gilman, in her short story The Yellow Wallpaper (1892) described severe depression with psychotic features starting after childbirth, perhaps similar to that experienced by the author herself.

Stacey Slater, a fictional character in the long-running BBC soap-opera EastEnders suffered from postpartum psychosis in 2016, and was one of the show's biggest storylines that year.

Legal status

Postpartum psychosis, especially when there is a marked component of depression, has a small risk of filicide. In acute manic or cycloid cases, this risk is about 1%. Most of these incidents have occurred before the mother came under treatment, and some have been accidental. Several nations including Canada, Great Britain, Australia, and Italy recognize postpartum mental illness as a mitigating factor in cases where mothers kill their children. In the United States, such a legal distinction was not made as of 2009, and an insanity defense is not available in all states.

Britain has had the Infanticide Act since 1922.

Psychiatric disorders of childbirth

From Wikipedia, the free encyclopedia
 
This article covers the complications of childbirth (parturition, labour, delivery,) not those of pregnancy or the postpartum period. Even with modern obstetrics and pain control, childbirth is still an ordeal for many women. During delivery, or immediately afterwards, dramatic complications are occasionally seen - delirium, stupor, rage, acts of desperation or neonaticide. These complications will be briefly reviewed in turn. With the great improvement in obstetric care, most of them have become rare. There is, however, a great contrast between Europe, North America, Australia, Japan and some other countries with advanced medical care, and the rest of the world. The wealthiest nations produce only 10 million children each year, from a total of 135 million. They have a maternal mortality rate (MMR) of 6–20/100,000. Some poorer nations with high birth rates have an MMR more than 100 times as high, and, presumably, a corresponding prevalence of severe morbidity. In Africa, India & South East Asia, and Latin America, these complications of parturition may still be as important as they have been throughout human history.

Three settings for childbirth

Modern childbirth

In nations with state-of-the-art obstetric services, childbirth is always supervised by a midwife or obstetrician. Pain can be relieved by nitrous oxide, pethidine or an epidural anaesthetic, and complications can be dealt with promptly, if necessary by emergency Caesarean section. These services are now standard procedure in many countries. Even so, parturition can still be a severe ordeal, and at least one third find it a traumatic experience. Although women spend only a few days, sometimes only a few hours, in labour, it is often an extreme experience, as shown by the frequency of post-traumatic stress disorder. The complications listed below, though rare, can still occur.

Historic childbirth

This is a term used here to describe the birth of children before the introduction (in 1847) of effective pain relief. During that time psychiatric complications were clearly described, well recognized and common in countries with the best health services. Those conditions still exist in nations with high birth rates and a dearth of trained staff. At the beginning of this century only about one third of births in tropical Africa and South-East Asia were attended by doctors or midwives. Although there has been some improvement since then, it is still true that about half the births in many nations are not supervised by skilled attendants.

Clandestine labour

The third setting is concealed labour, endured by a woman who has dissembled her pregnancy. Not only is there no analgesia or skilled attendance, but there is no emotional support; on the contrary, the mother’s mental state is disturbed by anger, fear, shame or despair. Most neonaticides occur in this setting. Perpetrators have rarely given a personal account, but experienced obstetricians have attempted a graphic description of their state of mind. There is objective evidence that complications are much more common.

Tocophobia

The word comes from the Greek tokos, meaning parturition. Early authors like Ideler wrote about this fear, and, in 1937, Binder drew attention to a group of women who sought sterilization because of tocophobia. In the last 40 years there have been a series of papers published mainly from Scandinavia. Tocophobia can be primary (before the first child is born) or secondary (typically after extremely traumatic deliveries). Elective Caesarean section is one solution, but psychotherapy can also help these women to give birth vaginally.

Obstetric factitious disorder

Factitious disorder (self-induced illness) can take many forms, and, during pregnancy, they include obstetric complications such as antepartum bleeding and hyperemesis. They also include simulation of labour by contractions of the abdominal muscles or manipulation of tocodynamometry. Other women have induced premature labour by rupture of the membranes or by prostaglandin suppositories or both. These extreme cases illustrate the strong wish that some women have to bring pregnancy to an end; occasionally they importunately demand premature delivery, whatever the risk to the infant.

Delirium during labour

Under the name ‘parturient delirium’, this is defined  as an acute (usually sudden) clouding of consciousness, lasting minutes or hours, with full recovery. Onset is usually towards the end of labour, and recovery after the birth. Any of the following may be observed – incoherent speech, misidentification of persons, visual hallucinations, inappropriate behaviour such as singing, or memory loss for the episode. A phasic course, with alternate delirium and clarity, continuation into the puerperium, and recurrence after another pregnancy have been described in a few cases.

It was one of the first psychiatric disorders, related to childbearing, to be described, and its importance in the early 19th century is indicated by an early classification, stating that it was one of two recognized forms of puerperal insanity. More than 50 cases have been described, most of them in the epoch when parturition was endured without effective pain relief. The disorder has almost disappeared in nations with advanced obstetrics, with only two early 20th century reports. But, within the last ten years, there were 28 nations in which fewer than half the births were attended by skilled birth attendants; they included Nigeria, Pakistan, Ethiopia and Bangladesh, each with more than 3 million births/year. In 2012, it was estimated that 130-180 million infants would be delivered in the quinquennium 2011-2015 without skilled birth attendance. There are still many countries where parturition in the 21st century is like that in Europe in the early 19th century, and women are at risk of becoming delirious during labour.

Unconscious delivery

Childbirth can occur during natural sleep, and under excessively heavy sedation, including alcohol intoxication. A diverse list of medical disorders have led to delivery during coma, including head injury, antepartum bleeding, severe hypotension and hypothermia. Of these the commonest is eclampsia. There are ten cases in the literature of unexplained stupor or coma, including cases with features of catatonia.

Acts of desperation

In women facing death during obstructed labour, panic or despair can drive them to take desperate remedies. There are about twenty cases of suicide attempts or completed suicide. The suicidal motive is not depression or shame, but unbearable pain and despair. The methods – throwing themselves out of the window, hanging or drowning – show the extremity of the mother’s suffering.

There are more than 20 descriptions of auto-Caesarean section. In a few cases the apparent motive has been the destruction of an unwanted child, or psychiatric illness, but the majority have been desperate remedies when the infant cannot be delivered and the nearest obstetric unit was beyond reach. Most of these cases have been reported from poor countries, where contributions to literature are scarce, and they may be more common there. The mother usually survives, but few infants survive.

Psychosis during labour

Various psychoses can start during labour. Of the organic psychoses, eclamptic, Donkin, epileptic and infective psychoses have all started during labour, although postpartum onset is usual. These differ from parturient delirium in their duration, lasting at least a few days, not a few hours. In addition, there are 19 cases of bipolar episodes with onset during labour; they differ from parturient delirium in their symptomatology (mania rather than delirium) and a duration measured in weeks. These cases are evidence that, on the balance of probability, the trigger of bipolar/cycloid episodes is already active during parturition.

Parturient rage

During the final painful contractions which lead to the expulsion of the infant, some women have become extremely angry. Before the introduction of effective pain relief (1847), obstetricians were familiar with this, and referred to it under names like parturient rage, furor uterinus, Wut der Gebärenden and colère d’accouchées. Some mothers lost control and attacked their husband, obstetricians, midwives or other attendants. At one time it was common, and clearly described. It still occurs occasionally under modern obstetric conditions.

The infant is at risk, because angry mothers have reached down to haul the baby out, or made a dangerous assault on the new-born; for example, a 40-year old mother, at the end of her 1st pregnancy, kicked away the midwife, tore out the infant, and killed it by striking its head against the bedpost. In most neonaticides, the infant is killed by suffocation, drowning or exposure. But in a minority there is extraordinary brutality – the head smashed with multiple fractures or splintering of bone, the head cut or torn off, the infant stabbed many times, or a combination of these. The pathology bears witness to the mother’s mental state. Nowadays, this phenomenon would not be regarded as a mental illness, and the only diagnosis could be ‘unspecified disorder of adult personality and behaviour. But this has not always been so. In France, Esquirol mentioned a mother who stabbed her infant 26 times with a pair of scissors; she was acquitted because the judges considered that she was suffering from mental derangement. There is an insoluble judicial problem, because violence is sometimes a feature of delirium; in a clandestine birth, it is impossible to know whether consciousness was clouded or not.

Pathological mental states immediately after the birth

Immediately after the birth, an exhausted mother, fainting or in shock, may not be able to care for the new-born, who often needs resuscitation, and can suffocate in mucus or blood. Exhaustion alone, without syncope or delirium, can prevent a mother from helping a dying infant; in clandestine labours, it can be fatal to the new-born, without mens rea.

Brief states of delirium have been described with onset after the birth, less common but similar to those that occur during parturition. There are about 20 in the literature. Several of them have been accompanied by violence, and, after recovery a few hours later, followed by amnesia. Occasionally mothers have had recurrent episodes.

Postpartum stupor has been described, beginning immediately or very shortly after the birth. The mother remains speechless, immobile and unresponsive to any stimuli for hours or even a day or more. These stupors differ in duration and clinical features from postpartum bipolar disorder. They have been phasic, with recovery and relapse. Their cause is unknown.

Childbirth-related post-traumatic stress disorder (PTSD)

Postpartum PTSD was first described in 1978. Since then more than 100 papers have been published. After excessively painful labours, or those with a disturbing loss of control, fear of death or infant loss, or complications requiring forceps delivery or emergency Caesarean section, some mothers suffer symptoms similar to those occurring after other harrowing experiences; these include intrusive memories (flashbacks), nightmares, and a high-tension state, with avoidance of triggers such as hospitals or words associated with parturition. The frequency depends on criteria and severity, but figures of 2-4% are representative; these symptoms can last for many months. Some avoid further pregnancy (secondary tocophobia), and those who become pregnant again may experience a return of symptoms, especially in the last trimester. These mothers can be helped by counseling soon after the birth or a variety of trauma-focused psychological therapies.

Complaining reactions

Another reaction to a severe experience of childbirth is pathological complaining (paranoia querulans in the International Classification of Diseases). These mothers complain bitterly about perceived mismanagement. The complaints, directed at midwives or other staff members, vary from lack of pain relief, unnecessary epidural anaesthesia, poor condition of the baby, humiliation or ‘dehumanization’, excessive use of technology, student examinations, or lack of explanation and sympathy. Occasionally the content is truly absurd – one mother’s intense resentment was her husband suggesting the wrong name for the infant. In response to these ‘outrages’, mothers may harangue the midwives repeatedly or write critical letters, and are preoccupied with fantasies of revenge – ‘beating the midwives to pulp’, ‘smashing the doctor’s head in’, ‘burning the hospital down’. Angry rumination may continue for weeks, months or more than a year. The frequency is similar to post-traumatic stress disorder, and there is an association between the two complications. The effect on child care is like that of severe depression, but the emotional state (furious anger, not sadness and despair) and treatment strategy are different. Psychotherapy is directed at distracting the mother from her grievances, and reinforcing productive child-centered activity; a diary is a useful focus – the therapist listens with sympathy to her complaints, then turns to the written record, expressing pleasure and interest in the mother’s achievements in spite of them.

Cryogenics

From Wikipedia, the free encyclopedia https://en.wikipedia.org/wiki/Cryogenics...