Originally posted May 2011:
Update: I'm reading When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Womenand it's fantastic - I think every childbirth professional (educator, doula, etc) should read this!! It's very, very well done.
When a woman has experienced trauma in her past it's important for all of her care team (OB, midwife, doula, partner) to be aware of and sensitive to this issue. Trauma can include a history with domestic or sexual abuse, assaults, prior traumatic births, a miscarriage or loss of an infant, etc. These are issues that ideally a woman will be comfortable telling her care team about but she may NOT be comfortable sharing (and probably not something she'll want to share with the variety of medical staff members that may come into her room and/or want to examine her.) Those aware of her previous traumas (doula, partner) will need to respect her privacy while also advocating for her - if she is not comfortable with vaginal exams from anyone besides her primary care provider, this needs to be shared with the L&D nurses or on call doctors, for example. If she's not able to express that need, her partner and/or doula need to make sure her wishes are respected. (If there are extenuating/emergency circumstances that necessitate things like immediate exams then the partner/doula need to turn their attention to helping her cope with the unexpected.)
The numbers are excruciatingly high for how many women will have experienced some type of sexual abuse, and they may or may not realize how birth can trigger memories and reveal old wounds. If a woman has experienced a trauma from a previous birth experience itself then it obviously can impact her subsequent births, and a mother may not realize traumatic births can cause PTSD. A doula is NOT a therapist but can provide referrals to therapists, during pregnancy if at all possible, but also postpartum if the issues are not revealed until during the birth itself. During the birth the doula and birth partner can help the woman cope with anticipated or unexpected issues surrounding her previous trauma.
Here are some thoughts from my experience working with survivors of domestic abuse & sexual assault (as a crisis team member and shelter worker) and some notes from The Doula Book. Please, please help mothers connect with professional resources experienced with PTSD, PPD, sexual assault, or whatever the issue may be. I'm working on that resource list now and waiting for some recommendations from local therapists. While a doula can be an enormous help during pregnancy, birth & postpartum we are NOT therapists and the issue of trauma and recovery is something that needs professional assistance.
- Be aware of the concept of disassociation and flashbacks for trauma survivors, and be prepared to offer support with eye contact, positive touch if desired, verbal affirmations, minimizing people in the room, etc.
- Provide the woman as much control as possible in the situation, recognizing that in emergencies there may be very little sense of control! Ask all staff to verbally explain anything that is happening and to ASK PERMISSION before touching the mother or performing any procedures. This includes asking staff to clarify or define unknown phrases, describing exactly what is going on, etc. If the mother cannot see something that is happening (for example with a surgery or if her baby is across the room) then ask her if she would like a detailed description (she may not want to hear surgical details or hear about baby being treated with oxygen!) Hopefully you'll know the mother well enough to know if you should edit a bit or share all.
- Create an environment in which she feels respected and in control as much as possible. Does she want the door shut, curtains drawn, extra sheet to keep her covered during vaginal exams, minimal personnel in the room, etc? If there are people unknown to her (nurses, etc) then encourage them to build rapport, listen to mother, gain her trust. (You can do this by asking them questions about themselves, encouraging her to ask questions, etc.) Important reminder - if mother is laying on her back in bed and everyone is standing over her this can make her feel in a position of submission. You can address this by offering a chair next to the head of the mother's bed for staff members to sit in while they speak to her. They may prefer to stand but a simple and quiet explanation may help them understand her need to see (literally and figuratively!) eye to eye with them.
As a mother, I know it made a world of difference to me that when things were about to get really ugly really fast, my doctor sat at the foot of my bed and asked very calmly and quietly what I wanted to do. When I said go for the c-section then he jumped up and everyone moved fast but those few quiet moments of him sitting by me and asking my opinion were crucial in how I processed our traumatic birth that followed.
- Be aware of possible concerns with physical touch. Always ask permission first before touching her, and begin with a gentle and visible touch such as placing a hand on her arm before giving her a back massage. If your hands are not visible (and specifically for care providers doing exams) then verbalize what is happening. I imagine many woman (survivors of trauma or not!) appreciate that, and I really appreciated my care providers being very explicit about what they are about to do and where they are about to touch me. I think that's respectful in general! If mother exhibits any concerning behavior then STOP and acknowledge it: shaking, withdrawal, eyes seeming to lose focus, tense muscles, repeating words/phrases or questions. Apologize, ask how she is feeling, try to get eye contact back, encourage her to do deep breathing, wait for her to give permission again.
This is something I witnessed while attending women during their Code R exams (sexual assault medical exam to gather evidence.) The very attentive midwife performing the exam was incredibly in tune with the women's body language and if they tensed or began to tremble even slightly the midwife would immediately stop, lift her hands up so they were visible to the woman, and wait for her permission to begin again. Sometimes it would be something as subtle as me seeing a tear form in the corner of the woman's eye and we would all pause and wait for her to be okay with us continuing. It was a humbling experience to share these moments with a woman and to see how respectful and gentle the care team was in these cases. A woman in labor deserves to be treated that gently, too.
- Ask, "How can I help you feel safer, more in charge, more comfortable right now?"
- Do not leave her alone. If you must leave the room then ensure she is left with someone she trusts.
- Be sensitive to her needs for privacy. Would she like a bathrobe, an extra hospital gown to wear as a robe, another sheet to cover her legs during an exam, etc?
- Be sensitive to any concerns about her body & bodily functions, explain to her that it's normal for there to be some mess with birth and it's quickly cleaned up and very common. Reiterate that her body is beautiful and perfect and normal!
- If she begins to disassociate, discuss this with her and her birth partner. Sometimes women will disassociate to a "safe place" as a way of coping with trauma and the intensity of birth can trigger that same coping technique for women. If you notice her seeming to disassociate (which can happen in ALL women in labor, not just survivors of trauma) then gently ask her what she is thinking/feeling or where she feels she is going. If she's disassociating to a scary memory then re-engage her! Eye contact, physical touch, words of affirmation, changing position or location, favorite scents, turn on music. Bring her back to the present. If she is going to a "safe place" in her mind then The Doula Book suggests you ask her if she wants to continue like that or become more present. (This would require a very self aware woman in labor and depending on how intense things are you may not get any response! So you'll have to go with your intuition and her birth partner's feedback for that one.)
- If she expresses hostility then stay close and listen and validate. Ask her what you can do to help her feel safer & more in control and more comfortable. (Don't take it personally, of course, and encourage her partner to not be upset by any hostility expressed.) Ask if there is anyone she would like to stay or leave the room.
- Be careful with your language. Specific phrases can trigger flashbacks and memories and you may have no way of knowing which can be traumatic for her, but watch her response to your words. Choose empowering phrases that reiterate how strong she is, how strong her body is, what a wonderful thing she is doing, how close she is to meeting her baby, etc. When a child is abused they are often coached with phrases such as, "Just relax!" These words may seem innocent and appropriate when supporting a woman in labor but can be trigger phrases for a woman that's survived abuse and heard them before. Be attentive to her body language and response when speaking with her.
Mothers may not consider their history to be relevant to the birth and may chose to not share it, but all care providers should be aware of the possibility. In my intake form I mention that prior traumas may impact their birth, letting moms know it's something I will bring up during our visits so we can discuss any concerns. Many of these tips are beneficial for every laboring woman but are crucial for a woman that has experienced a trauma in her past. While some of these are specific to survivors of sexual abuse, other issues such as the loss of an infant, a miscarriage, or a prior birth experience may trigger similar responses.
Update II: As a midwife assistant now this is something that has become even more crucial for me to be in tune with, as my role is different from that of a doula. Talking with another doula recently she said she explains to clients that their midwife/OB provides hands on care below the waist, but a doula stays above the waist - we may offer back rubs, we help with breastfeeding, we talk about the "head and heart" issues of birth with emotional and mental prep. But doulas do not provide the hands on care as far as vaginal exams, checking baby's heart tones, etc. As a midwife assistant I do provide a more intimate physical care, listening to heart tones, helping hold mom's legs, assisting with the placenta delivery, walking moms to the bathroom and helping them clean up after birth. Knowing that so many women are survivors of trauma it's become even more crucial that I cue into their body language and treat each of them with gentleness & respect their physical autonomy: ask before touching them, be in tune with their body tensing and verbal or non-verbal cues that they are uncomfortable, explaining what I will be helping with when providing hands on care. I'm grateful to work with midwives who do keep me informed of special situations and provide such respectful care to their clients. In some cases this means letting moms labor quietly in the dark with minimal physical checks, or it may mean catching a baby from a mom choosing to birth in a tight spot in the corner of a room so that she can feel safe and protected (as the midwife literally lays on the floor to catch a baby!) But it's about meeting the mom in the space where SHE feels comfortable and safe, and supporting them with no judgement and with lots of love.