Links update: August 2019
This is a guest post by Elizabeth Ford who is based in the UK so is writing from a UK perspective. Elizabeth explored birth trauma for her PhD and generously agreed to write a post for MidwifeThinking. There are lots of references for students and/or those who like to access original sources of information.
Artwork by Amanda Greavette: http://amandagreavette.com
For most women, birth is not the blissful event of three easy pushes and welcoming their precious baby into the world. Even for those women who have a short straightforward vaginal birth, it can be a tough slog and a real test of the depth of their resources. However, for some women, birth is much more than that. It is a physical and psychological trauma. The aftermath of a traumatic birth can affect a woman for months or years and impact on her bond with her baby, her relationship with her partner, her decision to have another baby and even her willingness to engage with future health care.
Birth as a trauma
Childbirth is a common event in society so is viewed by most people as “normal”. It may therefore be difficult to understand how it can be traumatic for some women. However, case studies and other research make it clear that women can suffer extreme distress as a consequence of their experiences during childbirth. A small proportion of pregnancies and births involve events that most people would agree are potentially traumatic, such as stillbirth, severe complications, or undergoing invasive medical interventions without effective pain relief. Other women may have a seemingly normal birth but feel traumatized by aspects such as loss of control, loss of dignity, or the dismissive, hostile or negative attitudes of people around them.
Post-Traumatic Stress Disorder
Recently it has become recognised that women who experienced a traumatic birth can develop post-traumatic stress disorder (PTSD). Some women experience childbirth as threatening and frightening and go on to develop PTSD symptoms.
The American Psychiatric Association defines the symptoms of PTSD as (1):
- Persistently re-experiencing the event, by flashbacks, nightmares, intrusive thoughts, and intense distress at reminders of the event.
- Persistent avoidance of reminders of the event, and emotional numbing and estrangement from others
- Persistent symptoms of increased arousal. This means difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance or an exaggerated startle response
For a diagnosis, patients must report experiencing all three types of symptoms for longer than one month. Many women (around 30%) experience these symptoms in the days or weeks following birth, and this is a normal way of coming to terms with a stressful or overwhelming event. It is only when symptoms do not get better that PTSD is diagnosed (in 1 to 5% of women).
What causes trauma & PTSD?
Research has been carried out into what makes someone more likely to develop PTSD following childbirth. These risk factors fall into three categories: those that exist before the birth; aspects of the birth itself; and the type of support and care women get after birth.
Some women will be more vulnerable to a traumatic birth because of pre-existing problems. For example women with a history of psychiatric problems and previous trauma are more likely to be traumatised by their experience of birth. In particular, a history of sexual trauma or abuse is associated with PTSD after birth. There is some evidence that women with a history of trauma will be more vulnerable to PTSD following birth if they have inadequate support and care during the birth (2-5).
During the birth, certain complications and events may be more stressful to women than others. Broadly speaking, women are more likely to get PTSD if they have an emergency caesarean or assisted delivery (forceps or ventouse). However, women who have a vaginal birth are still at risk (4, 6). Other stressful aspects of birth, such as blood loss, a long labour, a high level of pain, or a large number of interventions are not clearly related to getting PTSD. Importantly, women who feel out of control during birth or who have poor care and support from midwives and doctors are more likely to get PTSD (3, 5, 7). Furthermore, if a woman is overwhelmed by the experience and copes by dissociating (feeling like she is mentally “not there any more”, or having an “out of body experience”), she will be at higher risk of PTSD (8, 9).
Following the birth, support from friends and family, and possibly that from health professionals, may help women resolve their experiences and recover from a traumatic birth (5, 10). Conversely, a lack of support may prevent recovery or possibly cause more stress and thereby increase symptoms.
Feeling angry when birth is mismanaged
In some cases births are mismanaged and a woman can feel unable to get past her experience. She may go over and over the events in her head and feel angry that she was denied the experience she could potentially have had (11). This can form part of the symptoms of PTSD (intrusive thoughts, irritability & anger). However, PTSD is considered to be an anxiety disorder, and so for this anger and preoccupation to be diagnosed as PTSD, the other symptoms listed above must also be experienced. A woman who feels very angry is struggling with a valid emotional response to being discounted or not listened to during the birth, or even being mistreated or assaulted. Even when women don’t fit into the “PTSD box” (fulfilling all the symptom criteria), they may have a spectrum of subclinical trauma reactions which would benefit from support, counselling, or psychotherapy.
Is PTSD the same as postnatal depression?
PTSD has different symptoms to depression. Depression symptoms encompass a depressed mood i.e. feeling sad, empty, tearful or irritable, in addition to diminished interest or pleasure in activities; significant weight loss or weight gain or decrease or increase in appetite; insomnia or hypersomnia; fatigue or loss of energy; feelings of worthlessness or excessive or inappropriate guilt; and a diminished ability to think or concentrate, or indecisiveness.
In contrast, trauma symptoms are focussed on the traumatic event (re-experiencing it, avoiding reminders of it) and a diagnosis of PTSD is not possible without having experienced a traumatic event. This is not the case with depression. However, in practice symptoms overlap and a majority of women who have PTSD will also have depression (3, 4). Effective treatments for PTSD and depression differ. Recommended treatment for PTSD is psychotherapy, and only long-lasting or complex cases of PTSD benefit from anti-depressants.
Do women expect too much from childbirth?
A question that is often asked by health professionals is whether women have too high expectations of achieving a natural or drug-free birth, contributing to them being traumatised when birth does not go as expected. The answer to this is rather complicated but research studies point towards it not being the case. Firstly women’s expectations are found, on average, to be similar to their experiences (12, 13). That is, if a woman has broadly positive expectations she is more likely to have a positive experience. Secondly, if unrealistic expectations were linked to PTSD we might expect to find more trauma responses in first time mothers. This has been found, but subsequent analysis suggests it is due to the higher rate of intervention in these women (14). Finally, one study looked at this question directly and found that a difference between expectations and experience in the level of pain, length of labour, medical interventions and level of control was not associated with PTSD symptoms. However, a difference between expected support from health professionals and the level of care experienced was predictive of PTSD symptoms (13). Women don’t seem necessarily to be traumatised by the events of birth not happening as they expected, but may be affected when they do not receive the care they expect.
Implications for maternity care
Research in this field is at an early stage and more needs to be done before making policy recommendations. However, the body of evidence points towards several considerations. Firstly, some women enter pregnancy and birth with existing risk factors for PTSD, and these women may need particular care. Health professionals should be aware that women with a history of trauma, abuse (particularly sexual abuse) and psychiatric problems are at higher risk of PTSD following birth. There is some evidence that a lack of support during the birth may put these women at particular risk (5).
Secondly, interactions with other people have a strong effect on trauma reactions. For example, PTSD is more likely following events which are perceived to have been intentionally perpetrated rather than following accidents (15). This effect of personal relationships and care is particularly relevant to childbirth (16). There is substantial research showing support during labour and birth improves both physical and psychological outcomes (17), and that perceptions of inadequate support and care are predictive of traumatic stress responses. Women who are traumatised often describe negative interactions with staff such as feeling rushed, bullied, judged, ignored or put off when asking for pain relief.
Understanding the importance of support helps explain why, for example, level of pain is not consistently associated with PTSD symptoms. It may not be the level of pain per se which is traumatising for women, but the experience of unbearable pain in combination with the perception of being denied pain-relief by an uncooperative caregiver. Women also report caregivers proceeding with interventions, such as forceps deliveries or episiotomies, without consent, and sometimes even when the woman has clearly expressed her wish not to have the intervention. Negligent care such as leaving women naked in stirrups with the door open can be intensely degrading and stressful. Many of the traumatising aspects of childbirth could be reduced with consistent and considerate care from maternity staff.
What to do if this has happened to you
If you have had a traumatic birth and don’t know how to get help, the first step is to contact the Birth Trauma Association (BTA; www.birthtraumaassociation.org.uk) who give information and support. They produce a leaflet which you can print out and take to your GP explaining the condition (your GP may not have heard of postnatal PTSD), and you can ask for a referral to specialist psychotherapy services. If you’re in the UK, you can also contact the hospital where you gave birth and ask for a debriefing session with a midwife or consultant to go through your birth notes. This is not a counselling session but may help you to understand what happened during the birth and why events proceeded as they did. If you have physical problems following the birth you can also ask for a referral to a gynaecologist or physiotherapist. If you do not feel able to go back to the hospital where you gave birth, because memories are too painful or it causes you too much anxiety, you could ask your GP for a counselling referral or you could consider contacting a private psychotherapist. Make sure they are registered with the relevant professional association (BACP or BABCP in the UK). Recently in the UK you can “self-refer” to psychotherapy on the NHS through your local IAPT service (www.iapt.nhs.uk). Talking to other women who have been through similar experiences may help, the BTA can put you in touch with other mothers.
And Dads…
It can be traumatic watching a partner go through a harrowing experience while feeling helpless and horrified. The information on PTSD above can also apply to partners. The BTA has a section on their website for dads or partners. It is worth reading this and seeking help for yourself if you feel this applies to you.
More resources and support
I’ve added some links below (this is MidwifeThinking). Please let me know if you have any other links or resources that you think should be included.
- Birthtalk (Australia)
- AIMS (UK) – article and list of support networks
- Solace for Mothers (US)
References
- APA. Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC; 2000.
- Wijma K, Soderquist J, Wijma B. Posttraumatic stress disorder after childbirth: A cross sectional study. Journal of Anxiety Disorders. 1997;11(6):587-97.
- Czarnocka J, Slade P. Prevalence and predictors of post-traumatic stress symptoms following childbirth. British Journal of Clinical Psychology. 2000;39:35-51.
- Ayers S, Harris R, Sawyer A, Parfitt Y, Ford E. Posttraumatic stress disorder after childbirth: Analysis of symptom presentation and sampling. Journal of Affective Disorders. 2009;119:200-4.
- Ford E, Ayers S. Support during birth interacts with prior trauma and birth intervention to predict postnatal post-traumatic stress symptoms. Psychology and Health. in press.
- Soet J, Brack G, Dilorio C. Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth. 2003;30:36-46.
- Cigoli V, Gilli G, Saita E. Relational factors in psychopathological responses to childbirth. Journal of Psychosomatic Obstetrics and Gynecology. 2006 Jun;27(2):91-7.
- Kennedy HP, MacDonald EL. “Altered consciousness” during childbirth: potential clues to post traumatic stress disorder? Journal of Midwifery & Women’s Health. 2002 2002/0;47(5):380-2.
- Olde E, Van der Hart O, Kleber RJ, Van Son M, Wijnen HAA, Pop VJM. Peritraumatic Dissociation and Emotions as Predictors of PTSD Symptoms Following Childbirth. Journal of Trauma & Dissociation. 2005;6(3):125-42.
- Soderquist J, Wijma B, Wijma K. The longitudinal course of post-traumatic stress after childbirth. Journal of Psychosomatic Obstetrics and Gynecology. 2006 Jun;27(2):113-9.
- Brockington I. Postpartum Psychiatric Disorders. The Lancet. 2004 January 24;363:303-10.
- Slade P, MacPherson S, Hume A, Maresh M. Expectations, experiences and satisfaction with labour. British Journal of Clinical Psychology. 1993;32:469-83.
- Ayers S. Post-traumatic Stress Disorder Following Childbirth Unpublished Ph.D Thesis, University of London; 1999.
- Soderquist J, Wijma K, Wijma B. Traumatic Stress after Childbirth: the role of obstetric variables. Journal of Psychosomatic Obstetrics and Gynecology. 2002;23:31-9.
- Charuvastra A, Cloitre M. Social Bonds and Posttraumatic Stress Disorder. Annual Review of Psychology. 2008;59:301-28.
- Ford E, Ayers S. Stressful events and support during birth: The effect on anxiety, mood and perceived control. Journal of Anxiety Disorders. 2009;23:260-8.
- Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. The Cochrane Database of Systematic Reviews. 2003(3):Art No.: CD003766. DOI:10.1002/14651858.CD003766.
Thanks for this post. This is an issue that is very neglected. Provision of a known carer who will listen to, support and ensure that the woman is heard becomes even more important if we want to prevent PTSD or support a woman who has experienced it. As a midwife I have witnessed the healing power of a woman previously traumatised, going through a subsequent birth, heard and supported, to a place where she can move on from the past trauma.
You know, I’m actually angrier and more upset about the birth of my perfectly healthy daughter than I ever was about my stillborn son’s. I’m thankfully not traumatized by it, but it was a horrible experience 🙁
I really appreciate the thorough treatment of this topic, and especially the inclusion of literature probing the link between “high expectations” of the childbirth experience and subsequent trauma/PTSD (having been accused of having set myself up for a traumatic experience by having too high/too specific standards for my daughter’s birth).
If I may be nitpicky for a second, I wouldn’t say that society views birth as normal, as much as society views potentially traumatizing aspects of most maternity care as normal and something one needs to endure in order to ‘earn’ a healthy baby. I don’t have a good sense of what it is like in the UK, but it seems like the institutionalized maternity care system in a number of countries (most notably the US) is set up in such a way that continually threatens the autonomy, human rights, physical and emotional integrity of birthing women. In other words, maternity care providers get away with practices that would be considered illegal if not criminal in most other contexts.
Until we reach for higher standards than “all that matters is a healthy baby” at the institutional level, women will continue to be victimized and risk traumatizing experiences at unacceptable levels.
VW, birth in the UK is far different from the US, not that it is perfect or this article wouldn’t have been written by a Brit! We have better rates of intervention than the US, I’ve not fully gone into the statistics but I can imagine they do look better here.
Women are looked after by MWs through their pregnancies and only see a doctor if there is something wrong (for example I see an obstetrician and a rheumatologist because I’m autoimmune but they look after me from the autoimmune side of it, MWs still look after the pregnancy) and the same is true of birth. I am having a VBA2C following a full inverse T (I have a classical and a transverse incision) but my birth will still be cared for by a MW who will call a doctor if she needs my trace to be looked at or if there’s something that’s concerning her etc otherwise they will come around on their rounds.
I have suffered from Birth Trauma after the birth of my eldest. This article was like reading a check list of things that caused it! It wasn’t anyone’s fault though. My daughter was footling breech at 31 weeks and I was in labour. I was put on the drip and given steroids. When they checked me I was delivering the membranes but not her. I had a crash section with GA and when they opened me up they couldn’t see her so they had to make the classical incision. When I was in labour I was quite happy thinking they were going to stop it and I had plenty of time. I woke up with the contractions stopped and couldn’t even remember what had gone on. Mum was talking to me and I didn’t understand why she was sitting on my bed waking me up! My brain couldn’t fit in the gap where I had been asleep, it couldn’t accept that I had had a baby in that time. She was five hours old before I could see her, I hadn’t even had a photo of her and when I saw her I didn’t believe she was mine, she was HUGE 4lb 2oz at 31 weeks! It didn’t help that for a month I wasn’t allowed to be her parent, that was the nurses and MWs job, having to ask for permission to pick her up, nurse her, change a nappy etc didn’t help fill in the blanks in my head.
As far as I’m concerned the only thing the hospital did wrong was to not debrief me and to be defensive when I asked them to keeping the details of the section secret (I found out last week after almost 5 years).
PS: Solace for Mothers in the US is an excellent online support community for birth-related trauma.
Thanks for your comment and suggestion – I’ve added Solace for Mothers to the list 🙂
I was delighted to read this piece on such an important subject. One of my current concerns is the failure of the latest Confidential Enquiry into Maternal Deaths in the UK to mention PTSD as a potential cause of suicide. Chapter 11 on psychiatric deaths in the latest report (Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008) shows, like the previous two reports, that suicide is a leading cause of maternal death. Yet the clinical diagnoses mentioned (post partum psychosis and depression) do not include PTSD. On our helpline, the women I talk to who seem at most immediate risk of suicide (which often continues after the post partum year) almost invariably have PTSD rather than the “depression” they have been labelled with.
Unfortunately the screening of women to diagnose postnatal mental illness has resulted in clumsy child “”protection” action, and fear of losing children is associated with more suicides – as this, and the two previous reports show. One GP actually told a mother “well, we don’t have to worry about you because the baby is safe in foster care”.
Government policy has resulted in midwives and other health care staff prioritising child “safeguarding” rather than helping mothers. Not surprisingly , we find more and more mothers are concealing post-natal mental health problems.
Jean Robinson, President, Association for Improvements in the Maternity Services
I agree wholeheartedly with this article. I have PTSD because of how the hospital treated me. I was abused, emotionally manipulated (told I was going to kill my baby), coerced, talked down to, talked over, and just considered a nuisance. I was the single most unimportant person in that room and yet it was my body and my baby and my life they were affecting.
Our society considers birth to a scary, painful event and will not recognise when a woman is suffering because of how she was treated. I hate (with a passion) the comment ‘at least you have a healthy baby’. I was treated the way I was when the hospital thought my son was unhealthy.
Oh Melanie, my heart goes out to you. I hope you’ve found some way to work through this experience for yourself. Some of the resources suggested may be helpful to you. There is no excuse for treating women the way you were treated, even if the hospital thought your son was unhealthy. Your words “I was the single most unimportant person in that room and yet it was my body and my baby and my life they were affecting” sum up the situation completely. We have a long way to go, it seems from your story, for woman centred maternity care to be a reality everywhere.
Thank you for writing and sharing this valuable information. It is so bang on.
Thank you for bringing more light to this issue.
So many of the things you report were true for me. I felt denied the right to be involved in my care, misguided by distracted care providers, and watched as my care providers had heated, disrespectful conversations with each other. I also was told I was going to the OR for a forceps delivery or perhaps a cesarean then the doctor, with out any consultation or consent, went to the surgical option.
To top it all off, I spent 10 minutes thinking my son was in danger ,only to later learn that a medical student was practising a newborn exam on him before I’d even seen him.
I attached a link to my blog that describes my first hand account of the onset of P.S.T.D.
Thanks again for spreading the word that MOTHERS MATTER TOO!
I specialize in healing and preventing birth trauma and
just wrote a post about birth trauma and its cultural legacy:
http://www.mamamuse.com/2011/05/trust-love/
Glad this is getting air time.
~ Krista
Thanks Krista – I’ve added a link to your post 🙂
This article very much points the finger at medical personnel and how their treatment of a labouring mother is instrumental in how a woman views her birth experience.
As a midwife how do you feel about the concept of birth trauma when a women whose care you have been involved in reports that she is suffering from birth trauma?
I ask because the student midwife I had following my care was an employee of the hospital I was at, and she seems to struggle to accept my pain, and that it was her colleague’s treatment of me that have caused my problems. She isn’t even a main player in my birth trauma, rather she was there for some of it.
Melanie – If a woman reports she is suffering from birth trauma then she is. My perception of her birth or experience is not really relevant. I would be devastated to think I may have caused trauma but would want to explore what I did or didn’t do that caused her pain. I have certainly witnessed abuse in the hospital system but confronting colleagues about what they did often results in them thinking I am being ‘over the top’. I think the use and mis-use of power is so interwoven in the maternity system that it is almost invisible to those emerged in it. Students are effectively socialised into this and can struggle to see it. They have very little power themselves and it is easier to accept the system than fight it. Maybe you should point the student in the direction of the this blog post.
interesting. i have just written a letter to my erstwhile midwife as she heard i was unhappy with my birth via the grapevine and sent me a cold and snippy text message. she was cold and irritated during my failed homebirth and i wish that she would take to heart my very valid concerns. i wrote a letter a week ago and dropped it off and havent heard anything. all i can say is i truly hope she learns from this. too many other mothers have said the same thing to me about their birth with her. caregivers need to be exactly that – caring…
Not every Birth Trauma is caused by people doing things wrong or badly. Mine was the result of a situation that couldn’t have been handled any different. The only thing they did wrong was to not debrief me and to be defensive when I asked them to a few months later.
I am glad you included the paragraph for DADS too. I bet there are more men who care to admit it, who felt like helpless spectators, who could do nothing for their partners, while they were at the mercy of birthing technocrats!
I meant “more men THAN those who care to admit it…”.
These words:
“… a difference between expectations and experience in the level of pain, length of labour, medical interventions and level of control was not associated with PTSD symptoms. However, a difference between expected support from health professionals and the level of care experienced was predictive of PTSD symptoms”
are so important and foundational to the issues experienced by women chewed up by the ‘system’ as Melanie and MJ explain in their posts.
Women have every right to expect health care professionals to engage with them in every aspect of decision making in a way that is respectful, considerate and supportive of the woman’s wishes. We can see from Melanie’s and MJ’s comments, that to do otherwise can create long term distress for women and that is reprehensible. No one cares as much about a baby as the baby’s mother and all health care practitioners need to remember that in their interactions with mothers.
Hello, very nice article, I wish I could translate it into Spanish for publication in this web http://www.asistenciapiscologica.es dedicated to perinatal psychology. Of course indicate the original article, author and a link to this blog according to the license C.C.
I hope there is no porblem and await your response.
Greetings and congratulations on the web.
Sorry for my spelling mistakes.
That would be great! 🙂
Pingback: Cuando el nacimiento es un trauma
Entry is already posted, I leave the link. Thank you very much
http://asistenciapsicologica.es/?p=544
Delighted that you’ve managed to translate it so quickly. You can add my email to the post if you think anyone might like to ask questions.
emlford @ yahoo.co.uk
Thank you for this article, it is very good.
I was just wonder about this paragraph:
“Feeling angry when birth is mismanaged
In some cases births are mismanaged and a woman can feel unable to get past her experience. She may go over and over the events in her head and feel angry that she was denied the experience she could potentially have had. This overwhelming preoccupation can be mistaken for PTSD but it isn’t. The dominant emotion in this case is anger, whereas in PTSD the main emotion is anxiety (11).”
I would have to disagree with this statement. In my work with Solace for Mothers one major thing I see in women who have been traumatized is experiencing anger and rage. PTSD can insight many emotions, as you have noted depression is one recognized common emotion, but anger and irritability is another. Also, going “over and over the events in her head” is part of Criterion B: Intrusive Recollection (http://www.solaceformothers.org/PTSD_info.html): “The traumatic event is persistently re-experienced in at least one of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.” The anger is part of Criterion D: hyperarousal: “2. Irritability or outbursts of anger”.
It is very common for women with birth trauma or PTSD to go over and over the event in their heads and be angry about how they were treated. Being obsessed by the birth is generally an intrusive thought, not a controlled one. Being mistreated or abused is a very common cause of birth trauma, and anyone who has been assaulted in such a way is going to be angry about it. If they have all 9 criterion present including this one (which can be counted as two of the criterion as I highlighted above), they likely have PTSD. If this is the only symptom they have, they may not have full blown PTSD, but they definitely are struggling with a traumatic response to being mistreated or assaulted.
Thanks for this thoughtful comment. You are right about the anger thing in lots of ways and the viewpoint that anger alone does not constitute PTSD comes from a psychiatrist writing 7 years ago in the Lancet. I think more work needs to be done unpicking what is involved in women experiences and symptoms following a traumatic birth. It may be that some of the things women feel are different from what someone would feel after a different traumatic event such as a car crash. As I said in the part about how “intentially perpetrated” traumas are more potent then accidents, birth is all about the other people involved. Interactions (particularly negative/hostile/abusive ones) with other people can result in all sorts of emotions. There is no right or wrong way to feel.
I will have a think about how the section can be reworded and hopefully rewrite that bit 🙂
If you look at research on responses to rape, it is common to find that anger, irritability, or rage is very common. If a woman experiences the type of birth trauma that is due to being mistreated, her responses to the event may closely align with the responses of a person who has been raped. I have also read the idea that women who experience birth trauma go through something similar to the stages of grief. I have personally observed that it can be quite common for women to get stuck in the anger stage.
Also, I might question the findings of a singular psychiatrist. Birth trauma is not something anyone in the medical profession wants to admit exists. They especially don’t want to admit it exists as a result of the treatment that was given by other medical professionals. Symptoms of trauma go largely unnoticed in postpartum women. Most women with birth trauma or PTSD are instead diagnosed with postpartum depression and given a prescription of anti-depressants. So I would be really skeptical of that particular piece of research.
Your article really is very good, it’s just that one point I’m being picky about 🙂
I’ve reworded the paragraph slightly, and I think it better expresses both our points of view.
I suggest you look up the Lancet article referenced as it’s actually a great summary of various postpartum disorders to inform doctors, not a piece of research. Don’t be too quick to be suspicious of the entire medical profession, some are actually on the side of women and are working to change things within their institutions.
Having interviewed women following their births who were flagged up as possibly traumatised following a questionnaire survey, some women I found were not traumatised but were still very angry about what had happened. For example one woman whose waters broke at 33 weeks with twins, kept insisting she was having contractions, but the midwife insisted she wasn’t in labour. When she was finally checked she was at 10cm and an emergency c-section was needed with general anaesthetic. She wasn’t traumatised but she was very angry that she’d missed the birth of her babies because someone wouldn’t listen to her.
So in my experience the anger can exist without a traumatic response. These women might benefit from a debrief and an apology but counselling is possibly not appropriate to heal their (completely justified) anger and sense of loss.
Reading this makes me cringe. I have been through a full term stillbirth as well as 3 other births. My son birth, who was born in June, involved the doctor pushing the baby back inside of me as he tried to come out arm first, turning him, chord prolapse, hemorrage, and immediate c-section under general anesthesia. All the while I had no pain management. (this was my choice due to failures of epidurals in the past). I remember every little detail all the way to the nurse holding the baby inside of me while they rushed me down the hall to surgery. I’m sure my dignity wasn’t exactly the first thing they were thinking of as I was wisked away in all of my naked glory in front of any visitor of staff in the hall. My son from the c-section will be one in 2 weeks and I’m due with what will likely be my last child in Sept.
During our last experience both the baby and I were quite lucky to make it out alive and required some extra recovery. I think about our stillborn daughter daily and always will, but she nolonger haunts my days and nights. I even think I may have a bit of anxiety when I stop ignoring this pregnancy and prepare for my next c-section. (v-back is not an option) I say these things in complete awareness that time will heal and it’s a horrible shame that I do not cherish my birth experiences. It’s sad that even my good birth involved the use of suction to get my child out. It was even worse that my doctor at the time pre-empted the pain of my one and only push while he pulled the child out with a “now don’t be a wussy” (I hadn’t made a peep through any of this and wussy isn’t exactly who I am). I feel that in our modern society, if we expect to have the “safety” of a hospital setting, we are doomed to know that at some point someone will likely put your legs in stirrups for you and “help” you stay put while someone else intervenes for the sake of the baby. Perhaps twilight sleep isn’t such a bad idea.
I think in the healing process it’s best to remember that the people who handle our care do the best they can and we have an obligation to hand pick them. Forgiveness is paramount if you want to feel whole again. I am grateful to those who have helped my babies survive the trauma that has become my childbirth history. I prepare for the worst and hope for the best with my next. Thank you for the article. It’s good to know I am by no means the only one.
“Forgiveness is paramount if you want to feel whole again” – thank you for these wise words and for sharing your story.
Birth trauma is often caused by the lack of an understandable explanation, or worse not having one at all. It is so hard sometimes to give an adequate explanation and so often poor care after will exacerbate the problem.
My daughter has a severe postnatal haemorrhage, following an elective caesarian. It was the care after that was a problem, no call bell, the wall socket taped up, poor staffing levels, issues with caring for her baby, no one assisting with breast feeding or ensuring she had nourishment or fluids. IVI running out, left unattended in HDU with another patient, screaming for a midwife as her baby was choking, and my daughter in this environment, of demotivated midwives, every midwife telling her ‘please complain so that we can improve the care of women like you’.
She had a debrief, one of disbelief by the professionals debriefing her. It is even more sad that the response to her letter was one of sarcasm. She was stating her concern regarding staffing levels, lack of call bell, her distress at what happened whilst in a NHS hospital. It was suggested she may need assistance to use a call bell, her point was there was not one, not that she was unable to figure out how to press a button on the end of a cord. Every one of her friends who has read this letter have been shocked at the sarcasm.
It is really very sad that when a woman who is reaching out for some answers is greeted with such disbelieving and shocking responses. This is why the NHS is having to defend itself so much against bad press. They employ shockingly inadequate management in some trusts.
Sometimes a just a simple genuine ‘sorry’ could make all the difference. 🙁
I just wanted to add that it is perfectly normal to go through the stages of grieving for a birth that did not turn out how you expected. If anyone has read Elizabeth Kubler Ross , she pioneered this thought for death and dying ,but I have found it to be useful in many situations. Therefore, you will find denial, anger , bargaining , depression and acceptance. It’s when we can’t work past these emotions that we run into problems. I am working on a series of posts that address this model as it may apply to birth and helping women deal with a birth that does not turn out how they expected or was more traumatic. We are dealing with a loss here. Here’s my first post on this with more to come: http://thebeginningofmotherhood.blogspot.com/2011/06/elizabeth-kubler-ross-using-model-to.html
Thank you for highlighting the grief and loss cycle associated with birth trauma Rachel.
You said:
“It’s when we can’t work past these emotions that we run into problems”
very true!
I look forward to your up and coming posts on EKR model and birth trauma.
Thanks for the information and the link 🙂
“Other women may have a seemingly normal birth but feel traumatized by aspects such as loss of control, loss of dignity, or the dismissive, hostile or negative attitudes of people around them.”
My feelings about my “normal, healthy” birth make so much more sense now. Thank you.
Thank you so much for this post. My first pregnancy was so horrible and the labor and delivery was worse. I wanted nothing to do with my baby. I didn’t want another baby. I did and it was amazing and has helped me heal but I am still in therapy dealing with the PTSD from my first baby and learning to bond with him still. It’s been almost 3 years and I am still trying to bond with him. This was VERY great to read! 😀
I think that the most important thing my midwife did after my potentially traumatizing birth was sit down with me and say, “you will feel differently about this experience at different times. In six months you may be very angry with me. When that happens, call me and we will talk.”
She was open to my experience even if it was difficult for her to hear. She opened up the dialogue right away.
She earned my respect for that and taught me, as a midwife, how to be one.
Janelle
This is fascinating stuff. As an ex midwife, doula and now in my 4th year of psychotherapy training, I am looking at this subject for my dissertation. I am trying to decide exactly what angle to write it from. Suggestions gratefully received!
I am the subject in the painting featured in this post. It is a painting that hurt quite a bit to view, as it is a shot of a moment of avoidance for me. I am very thankful it has brought me to this article and has made me understand my trauma in a whole new way. I had a beautiful home birth and a traumatic post-birth experience which left me confused for months. Understanding the development of PTSD has allowed me to make sense of something I have previously never been able to sort out. Thank you!
Thank you so much for commenting. It is very special to have you (the woman in the painting) visiting the site and finding comfort. I chose the painting to illustrate the post because I could feel the disengagement and hurt oozing from it. I have seen this ‘look’ so many times. I wish you well in your journey of healing 🙂
Thank you for this article, I finally have an explanation for what I went through after the birth of my daughter 13 years ago, I just thought I was crazy. My daughter was born perfectly healthy and that, thankfully, was my prime focus and probably why I managed to cope and recover enough to function as a mother effectively but there was much long term emotional scarring that I have only gotten to the bottom of and dealt with recently. Medical professionals have NO idea the amount of harm they can do with their “routine procedural interventions”. Thank you again this article has allowed me to have a good old cathartic cry and I feel even better;)
A good cry is important every now and then *hug*
The birth of my 5th child was traumatic to me and since, I have had so many emotional issues, nightmares and extreme anxiety. Thank you for this article because it validates my experiences and feelings.
I was diagnosed with PTSD a few months after my daughter was born. I went to see a psychotherapist and thought for a while it was over, but when I think about the birth again, I can’t help crying and still have panic attacks. That was 3 years ago. We’ve been trying to have a second child for 6 months now, and I think I’m not yet pregnant because it’d mean giving birth, being violated again, disrespected, and I’m not sure I can stand it again. The midwife lied to me several times to make sure I’d do as she wanted. For instance, she said that if I didn’t agree to the injection, the next step was the C section. Which, according to the doctor I saw after the birth to talk about it, wasn’t true. But the most traumatic was, well, I don’t know what’s the English for that! (I’m French), in fact, the placenta wouldn’t come at all so they ripped it out and I felt everything. I shouted “stop it” again and again, they never stopped, never. They then said they had to do it because I was bleeding, that I could have bled to death. But the report I read later said clearly “no bleeding”. I don’t know how / if I’ll be able to give birth again, especially in a hospital. I thought about home birth, but no midwife agrees to do it where I live (insurance issue). Thank you for this article. Thank you for showing what birth trauma is.
I have to chime in with a note about the book “Survivor Moms” as a great resource on this topic! Julia Seng and Mickey Sperlich are experts on PTSD and though the book has a slightly different focus, it is so helpful to all of us who care about birth and birth traumas.
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It was never easy to carry a child inside you for 9 months. Every woman is prone to physical and emotional stress, it could be doubled when they’re pregnant. But at the end of the day, the pain is worth it when you see you those angels came out in the world. Nevertheless, it’s still important to take pre and post natal check up to ensure the health and safety of the mother and child.
Yet another excellent article thanks for the details and very good study.
I wrote a blog post after the stillbirth of my second daughter and one of the last paragraphs says
“When it comes to labour and birth, there are those that say that what matters most at the end of the day is a healthy baby. Those in the Positive Birth movement know that your labour and birth can have a profound impact on the aftermath, on how you bond with your baby. PTSD and postnatal depression can result with a poor birth experience. Based on my experience I would argue that having a positive birth experience is just as important as having a healthy baby – if Rowan’s labour and birth had been traumatic in any way then my ability to cope with the aftermath, to process the grief I’m feeling, would I believe, be deeply compromised. I’m not saying that grieving the loss of my baby girl, my youngest daughter, is easy – far from it – but if I was having to cope with the aftermath of a traumatic birth as well then I doubt I’d be able to write this blog. In fact, I very much doubt I’d be able to find the strength to get out of bed in the morning at all.”
That pretty much covers my take on it. A traumatic birth can do so much harm if you don’t have the right support afterwards.
Thank you for sharing your words – you can share the link if you’d like.
I wasn’t sure if it was relevant as it was mostly my birth story but it’s here http://sunny-view.blogspot.co.uk/2013/08/there-are-some-things-birth-plan-cant.html?m=1
Thank you… what a lovely birth story. And beautiful photos of Rowan.
Hello
I am writing on behalf of McIver Brown Traumatic Birth Injury Lawyer to request permission to write a guest post article for your website about the issue of birth injury.
Please let me know whether this would be something that you would consider for your site.
I would be happy to discuss further or answer any questions you may have over the phone.
Best regards
Soraya Sophia Moghadass
Thank you, I love this article, great to share for mamas, dads and support workers alike. I am adding a link to this page from my website http://www.elephantsneverforgetpts.wordpress.com
Warmly
Adela
Thank you for sharing this great article. I’d just like to point you in the direction of a similar one I wrote last year
http://homebirthersandhopefuls.com/birth-stories/other-stories/birth-trauma/
and also my own website (I’m a Birth Trauma psychotherapist in the UK)
http://lifeboost-uk.com/wp/birth-trauma/
I’ve always aimed to provide women with clear and sensitive information and welcome visitors to the site who are seeking information even if they are not looking for therapy or additional support.
It would be a great and good thing if we could bring all the information and help resources together one day to truly support women.
Warm regards, Lori Fitzgerald.
HI! I had 2 C-sections. With my son I had a very hard labor and he was in the birth canal for 4 hours not moving and I was trying to push him out but just couldn’t. I ended up having an emergency C-section. I already was drugged up so they were about to do it thinking I was still out of it. But I wasn’t and I could feel them starting to cut me open. So, they put me out with gas. My son came and wasn’t breathing and they had a hard time getting to breath I was still out. I had no idea what happen and after I woke up I was told that I couldn’t hold him until the next day. I felt like a bad mother for that. I wasn’t told about him not breathing until the next night and that made me feel even worse thinking he could have died. With my daughter I decided to have the C-section right from the start. She was perfect and healthy. But with her I had the “baby blues” I was so depressed and angry and I didn’t know why either. I would cry and get mad at the silliest things. That lastest about 6 months my hubby didn’t know what to do and tried his hardest . I did talk to a women on the phone and online who understood . But I wouldn’t have changed my decisions my kids are 11 months apart too. And yes it was and still is hard to have them that close in age.
Thanks for sharing your experience Kathleen. It is important that women know they are not the only ones working through depression following birth.
Reblogged this on Adela Stockton Counselling.
Thank you for this great article. Birth trauma is not as recognized as it should be. I’ve made it my life’s mission to help as many mothers as possible find deep healing, peace and resolution after a disappointing or traumatic birth experience. The stories of the women that I am working with are absolutely heart warming and transformational. Very rewarding work! EFT and Matrix Birth Reimprinting are some of the most powerful tools that I have found to work through the trauma after birth and release it on a physical and emotional level. If you’d like to check out my work (I see clients via Skype around the world) you can find me here: http://prenatalcoach.com
Thank your for this article (and for all your articles). I can’t find how to keep in touch with you, so I write here. I’m an italian blogger and an activiste mother in preserving human right in childbirth. I find you through Amanda Greavette (I feel so blessed); I love your blog! I would also ask your authorisation to translate this article in italian (obviously quoting the original author and source and sending you the link). Could it be possible?
Thank you so much.
Warmly
Marika Novaresio
Hi Marika
Thank you for your lovely feedback 🙂
I am happy for you to translate the article – my aim is for all women to be able to access information.
Oh, thank you so much!
Hi ! Great article ..
It’s sad though that traumatic births are so different in developed countries compared to developing countries where the issue is unheard of and even the loss of a child after birth is not addressed adequately .
I’m from Pakistan and about 5 weeks ago I gave birth to my first child who was unfortunately stillborn due to medical negligence – my doctor delayed my c section for about 15 hours after my water burst at 35 weeks. I was already suffering from prenatal anxiety and depression during pregnancy and now I’m a wreck .. I am going through dissociation at this point where I feel a complete sense on unreality and can’t fathom what happened . I’m going fr psychotherapy but I wish I could get some more help. Everything seems so unreal . Attached is my article which I wrote in a local newspaper regarding my birthing experience My baby would be alive if it wasn’t for medical negligence – http://www.dawn.com/news/1233990
I am so sorry for the loss of your precious baby. It is normal to be feeling how you do. You will need lots of support to process what happened and grieve for your baby. Take care x
I see that this post is an old one to comment on, but then, so am I, so here goes. Perhaps it will be a little different slant on this sad topic. I’m about to become a first-time grandmother in a few days. My daughter is 36, and, although we’re not enemies or estranged, we’re not especially close, either; just a casual friendliness but no real depth or sharing or intimacy. I’ve always attributed this to our very differing personalities, extrovert vs. introvert, optimist vs. depressive (me), etc. Imagine my shock when she said she wanted me in L&D with her. I’m really stumped on the role I’ll play. Her husband’s heart is in the right place, but he is the sort who can’t even watch a simple blood draw, so how realistic is it to count on him for very much?
To my regret, she has heard my birth horror story too many times over the years: Unremarkable labor, then being told time to push (which Lamaze in those days taught us meant 15-30 minutes till birth)– except it turned into 3 1/2 hrs. She became lodged at stage +2 or +3 presentation, posterior with chin turned up, and shoulder malpositioned. I’d had no anesthesia, but OB nevertheless attempted forceps rotation. That was unsuccessful as the head was too tight in the birth canal to get forceps around it. I was taken out of the stirrups and prepped for c-sect., calling in my regular OB to come in despite his day off. He assessed and said no, c-sect. would be worse. Fortunately, he was one of 2 MD’s trained in vaccuum extraction which was the cutting edge technology in those days. I was eventually given a pudendal block. 2 nurses were practically on the table w/me, arms locked across my belly to prevent her sliding back up. Unsurprisingly, a 4th degree episiotomy. The pediatrician was called in, expecting trouble. At shift change, the supervisor told the staff that weren’t otherwise occupied to go in and watch because mine was “an interesting one.” Much later, another pediatrician came into my room and gravely intoned to reassure me that “your daughter is not brain damaged” when that thought had not even begun to enter my mind.
To this day, I have difficulty grasping the modern ideas of empowerment, and consent, and discussion over every little thing in some ubiquitous quest for a perfect “positive birth experience.” I’ve never thought of this as PTSD exactly, but yet I still can’t describe my actual feelings, either. I definitely don’t blame the care providers and feel that in another era perhaps either my daughter or myself or both, would not have survived. I can’t imagine discussing the pros and cons of forceps, episiotomy, pudendals in the delivery room– sounds ridiculous to me.
And yet. . . . I am ashamed that I clearly remember at the time feeling that they could have thrown the baby in the garbage and that be fine with me– no rush of some great euphoria we’d been told would occur. There’s a picture of the doc showing her to me, bloody and misshapen, and I just stared, not reaching for her. And yet. . . I recall “rooming in” (the newest thing) being extremely important. I spent many hours alone, just staring at her in the bassinet, consciously making peace, coming to understand in some primal, private way that this little being didn’t do this to me intentionally. And yet. . . . there is a reason my 2 children are spaced 4 years apart, and when the parents’ “refresher course” did the hospital tour I freaked out when they came to the delivery room (separate in those days, no birthing suites) and fled the hospital. Later, I made the OB write in my chart that, providing there were no complications, I could birth in the small labor room if the hospital’s only “birthing room” was unavailable. . . . Trauma? I don’t know.
The 2nd birth was the polar opposite. I remember using my Phase I early labor Lamaze breathing, saving my transition breathing but never using it because I was waiting for things to get “really hard.” I got up and showered, alone, 20 minutes after he was born. And yes, I do feel more emotionally connected to him in some ways.
I apologize for the length of my story. But it circles back to the beginning. Now I am in this surprising position of attending my daughter. I’m not at all afraid of “wimping out” on her during L&D. Here is the twist: we just learned she is being induced at 37 wks due to obstetric intrahepatic chorestasis, a condition very difficult for laypeople to research. (Even though I do have a healthy skepticism for trusting internet research). We haven’t been discussing lots of details during a normal pregnancy (maybe that bonding issue?). And now I am learning at literally the very last moments, that she and her husband have done very, very little to prepare for L&D. Some cursory surface-level mass produced classes, nothing very in-depth (8-10 hrs.). Their lack of basic knowledge and motivation to dig and and face what’s coming astonishes me.
I believe knowledge is power and is an antidote to fear, and their intentional lack of it terrifies me. I realize I can’t– nor is it my role– to get them up to speed even if I could. There are so many issues to induction and the “cascade of interventions” but at some point it is appropriate to trust medical professionals also. It’s a delicate dance! Yet she seems content to do and passively accept whatever the docs decree virtually without question. She’s admitted to me she hasn’t thought about “99 percent of it and will just figure it out” despite being a very accomplished, level-headed professional person. I thought that the modern approach to health care was active participation and collaboration, not near-blind capitulation to authority figures?
I don’t think my experience is totally responsible for her fear, because she surely talks and relies upon her peer group much more than me. But I can’t help wondering if maybe this is a trauma manifesting in the 2nd generation?
I’ve never written this out before. Again, I’m sorry for the length.
This is an old post but it is still visited often and commented on.
Please don’t apologise for sharing your long story. This is a very common experience for many women – when your child is pregnant it naturally makes you revisit your own experiences. It is great that you are reflecting on this (many don’t). Until very recently birth was highly medicalised and routinely disrupted the hormones responsible for instinctive/physiological mother-baby bonding. Luckily we now understand how hormones work during labour for the promotion of the mother-baby connection and the sense of empowerment that can result from the birth experience. And trauma is in the eye of the beholder… if you felt trauma it was. If not, it wasn’t.
If your daughter really has obstetric cholestasis… then she is experiencing pathology (rather than physiology). If she is induced, her labour and birth will not be physiological. It may be very medical process (pathology is where medicine can work well). And, if this is her first baby she is quite likely to end up with a c-section. This may bring up your past for you too.
Often in these situations – when pregnancy/birth become abnormal – women opt to take a passive role. They ‘hand over’ to the ‘experts’ believing that they will do what is right (and they usually do).
Perhaps this is an opportunity for you to open up to your daughter and talk about your experiences from an emotional perspective? And about your concerns for her. I think the stories we are told about our birth are powerful and often the pattern will repeat. I am always interested in the birth stories of the women I care for ie. what they know of their own births. There is often a repeating pattern. And there can also be huge healing when the issues are acknowledged.
Thanks for the compassionate reply and validation. Daughter definitely has IHP, but mild, Bile Acid level at 24. Reading studies cited on your cite and others, I’m not completely convinced that 37 wk induction is necessarily the gold standard; it’s somewhat controversial, but the physician has presented it as the only viable option by using the feared stillbirth explanation (which I think the rate is actually 1.5% for levels over 40m, and virtually the same as healthy cases if the levels stay below 40; which seems low to me and which was not disclosed to her during informed assessment of the risk). Still, I don’t plan to interfere with daughter’s trust in her team by challenging the medical authoritarian system at this last hour (scheduled for Jan. 16).
It is so easy to lose sight of the fact that virtually ALL of the natural childbirth, empowerment of women, reforming-the-system-type of websites actually address only the normal, uncomplicated, physiological cases. I guess the women’s advocates don’t yet know how to incorporate the unusual, for I find only a dearth of resources of practical help in preparing for the pathologized situation, perhaps reflecting liability concerns? Since daughter is now walking through the cascading interventions of inducement + preterm, I’d only hoped that if she were more actively engaged, there could be “some” chance maybe of avoiding the dreaded C. But it that’s not possible, the best I can do is compliantly walk the path laid out with her by medicine and not make it worse. I won’t be telling her stories anytime soon, either– she knows them too well already!
I love the intelligence and compassion in your blog.
The problem with IHP is that very little is really known about it. And most care providers (myself included) have seen poor outcomes even with low levels. We only have research on women who opt for management – not for women who don’t get induced (there aren’t enough). The problem with IHP is that there are usually no warning signs before fetal death eg. abnormal heart rates etc.
The reason that many ‘natural childbirth’ type sites don’t cover pathology is that usually they are written by non-obstetricians. For example, I am a midwife. My scope/role/speciality is promotion and support of physiology; detection of pathology (then referral to medical practitioners) and management of emergencies (ie. sudden unexpected problems). Obstetricians are the experts in pathology and complicated birth… that is why we need to work together 🙂
Midwives do care for women in pathologized situations – but they are not usually the primary care provider at this point. The role becomes one of ensuring the women has enough information to make her decisions and assisting her to have the best experience possible within the confines of her situation.
I wish you and your daughter all the best. All you can do is be there for her and support her. 🙂
I should also add that in my experience women with IHP often respond very quickly to induction and labour well. Almost like their body knows the baby needs to be born. This also happens with pre-eclampsia 🙂