Post-Traumatic Stress Disorder
Following a Traumatic Birth Experience

When Laura brought home her newborn son Sean, she expected to feel a little nervous but happy because she had waited such a long time for his arrival. Undergoing several rounds of fertility treatment, she eventually got pregnant and her pregnancy had been pretty normal. However, she wasn’t progressing normally during labor and ended up needing an emergency caesarean. The doctor told her that he needed to get the baby out quickly and she was whisked away to the operating room without being able to ask what was happening. Following Sean’s delivery, he was taken from her to the NICU and she wasn’t able to see him for a few hours. Due to her long labor, she was exhausted and kept falling in and out of sleep, fearing that her baby was dead and that was why no one would give him to her. Sean was healthy, but when she came home with him, she began obsessing that he would become ill and die. She had constant thoughts regarding his safety and didn’t want to be left alone with him. Her mind kept having flashbacks to the labor, the doctor’s worried face, and the fears she had. She began to have dreams in which Sean died in many different ways and frequently called her pediatrician’s office with concerns about Sean’s health. Whenever she talked to other moms, they seemed to be managing fine. She soon stopped wanting to be around them, as she felt such a failure. When she went back to the obstetrician’s office for her 6-week check-up, she experienced a full panic attack.

Laura’s obstetrician told her she had postpartum depression and prescribed her anti-depressants, but the flashbacks and the panic attacks would not go away. What she was experiencing was Post Traumatic Stress Disorder (PTSD), which can occur after experiencing or witnessing an event that threatens one’s own life or the safety of another significant person. It has been recognized as occurring after military combat, natural disasters, violent assault and serious accidents. More recently, research looking at the psychological factors influencing women’s subjective experience of childbirth indicates that labor and events around it can meet the definition of a traumatic stressor when a woman believes that either she or her baby will be harmed. PTSD has begun to be recognized within the context of traumatic birth experiences. This is referred to in the literature as either “birth trauma” or “PTSD following childbirth”.

A recent study entitled “New Mothers Speak Out,” commissioned by not-for-profit maternity care group Childbirth Connection and published in the Wall Street Journal, suggests that nearly one in ten U.S. women who have given birth recently meet the formal criteria for post-traumatic stress disorder resulting from childbirth.
The Birth Trauma Association clearly describes the types of symptoms that clinicians look for when diagnosing PTSD. These include re-experiencing symptoms, avoidant symptoms and symptoms of increased arousal.

Characteristic Features of PTSD Include: An experience involving the threat of death or serious injury to an individual or another person close to them (e.g. their baby). A response of intense fear, helplessness or horror to that experience. The persistent re-experiencing of the event by way of recurrent intrusive memories, flashbacks and nightmares. The individual will usually feel distressed, anxious or panicky when exposed to things that remind them of the event. Avoidance of anything that reminds them of the trauma. This can include talking about it, although sometimes women may go through a stage of talking of their traumatic experience a lot so that it obsesses them at times. Bad memories and the need to avoid any reminders of the trauma will often result in difficulties with sleeping and concentrating. Sufferers may also feel angry, irritable and be hyper vigilant (feel jumpy or on their guard all the time).

Re-experiencing symptoms in the context of birth trauma typically involves the mother being persistently reminded about events from her labor, or shortly thereafter, through intrusive thoughts, dreams and/or flashbacks about medical procedures, pain, and expectations of harm or death happening to either herself or the baby. It isn’t only the physical events that are remembered but also the re-experiencing of the emotions present during delivery such as fear, humiliation and most importantly, feeling that things are out of her control.

Support and care by both professionals and partners can mediate the effects of the events that happen during labor. If the staff explains procedures and answers questions, a woman can feel more in control of events because she can understand what is happening. When professionals fail to do so, either because of time constraints due to the emergency nature of a procedure, or because of staff shortage, women talk about experiencing isolation, pain, fear and feelings of helplessness.

Risk Factors for Experiencing Childbirth Related PTSD From: www.angelfire.com

Managed labor Induction Poor pain relief Feelings of loss of control Unnecessary trauma Traumatic delivery Impersonal treatment, overly professional, stand-offish or judgmental attitude of staff Shift changes Lack of explanations Feelings of loss of control Not being believed or listened to Lack of attention to dignity, e.g. no coverings True obstetric emergencies Invasive procedures without explanations or consent

Forceps, suturing without adequate analgesia Prolonged latent phase - resulting in demoralization Conflicting advice Having baby(ies) admitted to SCBU (Special Care Baby or Unit) or NICU (Neonatal Intensive Care Unit) Severe postnatal anemia Post Partum Hemorrhage Poor postnatal care Old trauma Unmet need to debrief, review, or to understand what happened Emergency Caesarean Section Poor Postnatal Care Postnatal problems

Karen describes feeling very concerned that the reading on the heartbeat monitor meant that the baby was in danger. “I saw that the heartbeat went up and called the nurse but when she came in she was very dismissive and said they were very busy and not to call her again. I thought there was something wrong and no one was listening to me but didn’t want her to get angry with me. I am usually a pretty assertive person but this was my first baby and I didn’t know what to expect. Also, the pain, the contractions and the exhaustion meant I just wasn’t able to stand up for myself and my husband didn’t know how to help either.”

Jane wasn’t given enough medication in her epidural but by the time the doctor realized it was too late to increase it as the baby had to be delivered. “She (the surgeon) was cutting though the skin and I could feel it and it really hurt… so once I felt the pain, my stomach tensed up so she had a lot of trouble to get him out.

Sarah Allen’s research on the cause and impact of traumatic birth was one of the first studies to find that it is the woman’s own subjective perception of the events that is meaningful to her. This is one of the most important things for healthcare professionals to remember because doctors are often unaware that women may be thinking that their life or the baby’s life is threatened and therefore may belittle their reaction to it.

Women who had such experiences often find it difficult to access help, as other people can find it difficult to understand how such a “natural” event can be traumatizing and expect her to “get over it and focus on the baby”. However, the reality is that some women’s experience, for a complex variety of reasons, can be very distressing. The lack of awareness of this disorder, on the part of family, friends and medical professionals, can lead to extreme isolation and detachment, as women feel increasingly guilty and a failure. This can have an extremely negative effect on relationships, attachment with the baby and other children in the family, as well as affecting her day-to-day quality of life. Experiences such as the anxiety symptoms detailed in the boxes above can also lead to feelings of depression and hopelessness, as there seems to be no where to turn.

PTSD is different from the more widely recognized Postpartum Depression. Anti-depressant medications are rarely enough. Therapy that addresses the labor experience and its meaning to the woman, as well as the resultant depression and anxiety symptoms, can help women put the experience behind them and move on to having better relationships, a better sense of themselves, and be open to experiencing future pregnancies.

Article provided by Sarah Allen, Psy. D., is a specialist in Perinatal Mood Disorders in Northbrook, IL and Chair of the IL PPD Alliance.