Trauma and Birth

A Handbook for Maternity Staff

Sheila Broderick, Ruth Cochrane

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000285345
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Our book aims to provide those working in the maternity services, including those in general practices, with an understanding of what it means to be on the receiving end of care. Together with a description of various types of traumatic birth, we explain some of the reasons why women vary in terms of how traumatised they are by their birth experience. We provide information, encouragement and support for maternity staff to help them lessen the incidence of birth trauma, and to develop the confidence to help women when birth trauma does occur.

The authors are a senior counsellor and an obstetrician, each with a long experience of helping women who have had difficult births. The approach of each to the subject is different but complementary. The book covers the psychological and emotional aspects of traumatic birth as well as the medical issues and includes a section on the effect of traumatic birth on the staff themselves.

The market for this book is practising midwives and obstetricians, who by understanding the prevalence of traumatic birth and some of its causes can contribute to its reduction. Those in their training years will find it helpful at the outset of their practice. It will also be of interest to general practitioners, health visitors and counsellors.

1 The experience of traumatic birth

Experiencing a traumatic birth can have a devastating effect on a mother and a marked effect on her nearest and dearest. One of the consequences of this can be that the woman feels isolated and misunderstood. Additionally, she may feel especially estranged from her baby. This estrangement only compounds the horrible way she feels. It is highly likely that she will not have been expecting to have to cope with either or both of the physical and emotional assaults on her being that a traumatic birth can bring.

Many women post-delivery are desperately unhappy because of their birth experience. This misery is regardless of whether the trauma was due to a medical intervention, an emergency or an apparently (as deemed by the obstetricians) uncomplicated labour.

The Birth Trauma Association states

Birth trauma is a shorthand phrase for post-traumatic stress disorder (PTSD) after childbirth. We also use it for women who have some symptoms of PTSD, but not enough for a full diagnosis.

PTSD was first identified amongst soldiers returning from the Vietnam War, and most people still think of it as a condition experienced by soldiers. In fact, PTSD can follow any traumatic event – such as being in a car accident, being sexually abused or having a very difficult birth. It can also happen to people who have witnessed a traumatic event, so people who have seen someone else violently killed, for example, often experience PTSD. This is why some partners, and even midwives, experience PTSD after seeing a traumatic birth.

In most cases, what makes birth traumatic is the fear that you or your baby are going to die. We very often see birth trauma in women who have lost a lot of blood, for example, or who had to have an emergency caesarean because their baby’s heartrate suddenly dipped.

Symptoms of birth trauma (postnatal PTSD)

There are four main symptoms:

• Re-experiencing the traumatic event through flashbacks, nightmares or intrusive memories. These make you feel distressed and panicky.
• Avoiding anything that reminds you of the trauma. This can mean refusing to walk past the hospital where you gave birth, or avoiding meeting other women with new babies.
• Feeling hypervigilant: this means that you are constantly alert, irritable and jumpy. You worry that something terrible is going to happen to your baby.
• Feeling low and unhappy (‘negative cognition’ in the medical jargon). You may feel guilty and blame yourself for your traumatic birth. You may have difficulty remembering parts of your birth experience.

Not everyone who has had a traumatic experience suffers from PTSD, but many do. It’s a completely normal response, and not a sign of weakness. It is also involuntary: brain scans show a difference between the brains of people with PTSD and those without. PTSD is not something that can be cured by ‘pulling yourself together’ or ‘focusing on the positive’, despite what other people tell you.

Who gets birth trauma?

Some women experience events during childbirth (as well as in pregnancy or immediately after birth) that would traumatise any normal person. For other women, it is not always the sensational or dramatic events that trigger childbirth trauma but other factors such as loss of control, loss of dignity, the hostile attitudes of the people around them, feelings of not being heard or the absence of informed consent to medical procedures. Some of the reasons for trauma given by the Birth Trauma Association are listed below:

• Lengthy labour or short and very painful labour
• Induction
• Poor pain relief
• Feelings of loss of control
• High levels of medical intervention
• Forceps births
• Emergency caesarean section
• Impersonal treatment or problems with staff attitudes
• Not being listened to
• Lack of information or explanation
• Lack of privacy and dignity
• Fear for baby’s safety
• Stillbirth
• Birth of a baby with a disability resulting from a traumatic birth
• Baby’s stay in the special care baby unit or neonatal intensive care unit
• Poor postnatal care
• Previous trauma (for example, in childhood, with a previous birth or domestic violence)

Finally, people who witness their partner’s traumatic childbirth experience may also feel traumatised as a result.

(Birth Trauma Association)

Experiences of a traumatic birth

One woman I met was a first-time mother who had a CS following a protracted labour. Whilst in the recovery ward it became clear to staff that she was losing blood. She then needed to go back to theatre for an emergency procedure to stem the blood. The procedure was successful and she was no longer in danger. She was taken to the Intensive Care Unit to recover. She spent several days there.

Her experience of what happened was extremely overwhelming and when I met her after six months, she was struggling to make sense of why she felt so bad. She was unable to believe that she was a good mother, which was understandably very hard for her.

Together we began to unravel her experience of giving birth and it became clear that she did not understand exactly what had happened and why they did in the way that they did. She needed a debrief with an experienced clinician who could explain what happened from an obstetric point of view and who could also understand her version of events. The latter is crucially important in the case of a debrief. It is not enough to explain to the patient what happened and why without being prepared to include and acknowledge the perspective of the mother and often her partner. The senior practitioner needs to be prepared to alter their version (which will often be a written one) after listening to the experience of the mother and her birth partner. This can be a painstaking consultation but really, really worth doing, as it can sometimes lift the veil of confusion that has blighted the woman’s experience of birth. Without this level of empathy, you will be in danger of causing additional injury and leave her more isolated.

The reaction to a traumatic birth and its aftermath is individual and this needs to be respected by all those who encounter someone in the midst of the trauma. It is essential that her thoughts, feelings and reactions are not dismissed with a quick retort or comment. You are dealing with someone whose self-image is likely to have been shaken beyond her wildest imagination.

Going back to the woman mentioned above, the debrief was extremely useful, as she and her partner were able to ask the questions they had been pondering over for six months. She was able to ask if her life was ever in danger. A significant moment for her was when she went to theatre for the emergency operation to stem the blood loss, one of the medical staff told her that her family had been called, as was normal in these circumstances. Whatever the staff member meant by that comment, what she heard was that she was in danger of losing her life and she underwent the anaesthetic thinking that she had just given birth to her son and that she might never see him or her husband again. This is an example of what we refer to in our introduction: that the words said at any time, let alone at moments of crisis, have a huge impact.

She did not die but woke up in the Intensive Care Unit. This experience of Intensive Care is covered in another chapter; sufficient to say here that it is not easy to find yourself waking up in a place which is associated with being extremely ill or with a life-threatening condition. One of her thoughts was ‘how did I end up here when I came in to give birth to my son?’

The separation from her son had a profound effect on her and she missed the first days of his life. This was justifiably difficult for her – especially when she will have heard all about skin-to-skin contact being essential in establishing mother and baby bonding. She went home as soon as she could as she wanted to get away from the hospital environment. What had not been explained to her was that, given what she had been through, she was likely to feel poorly for quite some time. Without this knowledge she was left with her own coping mechanisms to manage the trauma she had experienced. It is important to understand that without appropriate explanation, someone who goes from walking into hospital as a healthy person and who ends up in Intensive Care will not really have any comprehension as why they feel so physically, emotionally and sometimes psychologically depleted and feeling ill for such a long time.

As a means of understanding their experience, different people have diverse ways of managing. Some will devour television programmes covering medical emergencies, trying to see if other people cope in the way they did. Others will avoid any mention of hospitals and switch off the television at the mere mention of medical emergencies, as they do not want any reminder of their trauma. Once home, the mother expected to feel well and she did not understand why she was so tired and weak. She did manage to establish breastfeeding and fed her baby whenever he needed. She also had him close by her. She had a supportive husband and he looked after her well, but it was also very challenging for him to understand the changes in his wife.

Six months later she felt she had physically improved but she was still feeling extremely bad because she felt she had let her son down and that she had been a ‘bad’ mother. Part of our work together was helping her to separate her feelings of failure from the fact that she had been a good mother. Her feelings of failure were due to the fact that she had not experienced the warmth of connection between herself and her son that she expected to have. This lack of feeling of a connection was profound for her and not something she could ever regain. She did begin to feel close to her son but she had to grieve for the loss of closeness during the first few months. She also needed help to see that her son would not necessarily feel the same kind of loss as her: he had the closeness he needed.

One of the consequences of her trauma was that she did not want to interact with people as she had previously. This was sometimes a cause of tension between her and her partner. Her resources were severely diminished and she needed help to gradually rebuild these. The way that she did this was to only do things that were within her scope of capability at any one particular time. Prior to the trauma she had been highly efficient, and losing the ability to live like this was very challenging for her. It is not an understatement to say she did not recognise herself and she did not understand how this loss had happened. Some of the healing work we did was for her to give herself permission to consciously take control and to only do what was right for her. Learning ‘to walk (again) before she could run’ was frustrating for her and her family; they too had expectations of her being as she had been. Gradually as she took her time to believe in her reality, albeit a reality she would have much preferred not to have, she began to recognise herself again. The impact of her trauma continued despite her recovery. Two years after the birth of her son she was not at all sure if she wanted to have another baby. Her fear of something similar happening was so great that she could not contemplate another pregnancy.

The emotional aftermath of being in Intensive Care and how long it may take to begin to recover physically, let alone emotionally, needs to be understood by the patient, her family and all those who are looking after her: labour ward staff, community staff and GPs to mention a few. The experience of the woman described above would probably always have been challenging and traumatic but several interventions at an earlier stage could have helped her and her family enormously. Had she and her husband been appropriately informed prior to leaving the hospital, then they would have had some idea of what to expect. It is the equivalent of being ‘forewarned is forearmed’. Had she been helped to understand the length of time it would take her to recover physically, let alone emotionally, she would have had an explanation for her exhaustion. She would not have had to wait until she saw her obstetric consultant six months later who confirmed that her postnatal experience was to be expected and normal, given what she had been through. She would not have needed to have struggled without help from a counsellor to begin to make sense of the impact of her trauma. It is terrible to think that oversights like this happen daily.

The failure to notice the needs of women and their partners condemns them to isolation and further trauma. Empathy, understanding and the ability to relate is not high-tech. It does not require investment in expensive instruments, but the effects are as dramatic as any technical procedure.

We cannot stress enough the importance of developing a trusting relationship with pregnant and labouring women. There were 657,076 live births in England and Wales in 2018. If one-third of the mothers experienced trauma, some of which were due to a lack of a relationship with their caregivers (one of the major causes for traumatic birth), it means that a large number of these nearly 220,000 women could have avoided suffering at the crucial time of birth and the postnatal period.

Providing good care

An example of anticipating a traumatic reaction was described by one woman I talked to as a result of research for this book. The birth of her child was long and protracted, and she ended up with an emergency Caesarean section. Her partner witnessed the harrowing events that led up to the arrival of their baby. The mother did not initially feel that she had experienced any trauma and was to some extent perplexed by the reaction of staff who told her that she had. Before she and her partner left the hospital, she was given the name and telephone number of whom to contact should she begin to experience any symptoms of trauma. Within a number of weeks, she realised she did need to understand more about the circumstances of her experience and that her partner also needed to be included as she, too, had been through an ordeal. Their request for an appointment was acknowledged in an appropriate time frame. They met with an experienced midwife, in a room away from the maternity service. From the outset of the meeting they were made to feel that they and their experience were at the heart of the consultation. The debrief lasted 4 hours, which might seem excessive to some but it was worth every moment. As a result, both parents understood exactly what had happened from an obstetric viewpoint, and why certain decisions were made. Additionally, they were able to describe their individual reactions and responses to what had happened. The investment made by that particular hospital in their care probably saved the NHS at lot of money, as any longer lasting effects of trauma did not need to be treated by medication and visits to a GP. The hospital she attended was geared up for helping women who have a traumatic birth and had invested the necessary time and appropriate training for staff to offer continued care beyond the labour ward.

It should be a requirement that medical personnel appreciate that patients’ reactions to their experience varies greatly. We have known women who, from an obstetric point of view, have had horrendous births and who then find themselves to be the focus of much staff attention. The patient is surprised by the number of staff who come to them and tell them what a hard time they have had and keep asking how they are. It is certainly our experience that some patients do not perceive themselves as traumatised. This does not mean that they should not be offered a debrief and given appropriate information as to what to expect of themselves during their recovery. This information should include what to do should they begin to struggle to make sense of their experience at some point in the future. Conversely, there are many women who are regarded as having a routine or not particularly stressful labour, but who from their own point of view have had a traumatic birth.

We worked with a patient who had retained placenta and a postpartum haemorrhage. The correct obstetric procedures wer...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Acknowledgements
• Introduction
• 1 The experience of traumatic birth
• 2 Person-centred care
• 3 Birth plans
• 4 Prolonged labour and shoulder dystocia
• 5 Instrumental delivery
• 6 Perineal, anal sphincter and bladder injury
• 7 Surgical considerations including haemorrhage and transfusion
• 8 ICU and anaesthesia
• 9 Mental health issues
• 10 Debriefing and Serious Incident reporting
• 11 Managing the next pregnancy and delivery
• 12 Trauma for staff
• Index