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Traumatic childbirth: what we know and what we can do

11 June, 2008

Traumatic childbirth: what we know and what we can do

This paper provides an overview of childbirth-related post-traumatic stress disorder - its diagnosis and treatment. The authors seek to address the issue of psychological therapy in the postnatal period.


This paper provides an overview of childbirth-related post-traumatic stress disorder - its diagnosis and treatment. The authors seek to address the issue of psychological therapy in the postnatal period. 


Midwives magazine: June 2004


  In recent years there has been a growing awareness that some women's experiences of childbirth are characterised by feelings of horror and helplessness, which can lead to severe and chronic post-traumatic stress reactions. At some stage midwives, health visitors and obstetricians are likely to encounter women who are experiencing posttraumatic stress.


The aim in writing this brief overview of the traumatic childbirth literat ure is to provide a guide for health professionals as to wh at to look for in women who might be experiencing post-traumatic stress reactions. First of all, it is important that we are equipped to detect women at risk, and second that we are aware of the possibilities for preventative work in the antenatal period, as well as the role of support and psychological therapy in the postnatal period.


Post-traumatic stress disorder

Psychiatrists refer to post-traumatic stress disorder (PTSD) (American Psychiatrie Association, 1994) to describe the psychologically distressed state that can arise following exposure to traumatic events. Initially when we began to work in the area of childbirth-related PTSD, our colleagues were surprised. PTSD is usually discussed in relation to road traffic accidents, war-related experiences, and large-scale disasters. Childbirth seemed too ordinary and usual an event to precipitate PTSD.


However, the research, as well as the letters and telephone calls we have received from numerous women, testify that childbirth can be a traumatic experience, and that some women go on to develop post-traumatic stress reactions. We are not the first to draw attention to this issue. Over the last few years a series of articles have been published on the topic of PTSD and childbirth in a variety of journals related to birth (e.g. Ayers and Pickering, 2001), medical practice (Crompton, 1996) and midwifery (Golbeck-Wood, 1996). It is now no Ion ger contentious that childbirth can lead to PTSD (see Bailham and Joseph (2003) for a comprehensive review).


In this overview we will describe the state of knowledge about childbirth-related PTSD and its treatment, as weil as offer so me comment on criticisms that we are serving to pathologise women's experiences.


Diagnosis of PTSD

For a diagnosis of PTSD to be made, women must have experienced an event that involved actual or threatened death or serious injury, and this must be accompanied by a response involving fear, helplessness, or horror. Diagnostic criteria for the symptoms of PTSD fall into three clusters. First, re-experiencing in the form of intrusive memo ries; second, avoidance behaviours; and third, symptoms of anxiety and arousal (see Box 1). A number of case studies have been published describing childbirthrelated PTSD. Fones (1996) for example, describes the case of a 40-year-old woman who still had intrusive memories, panic and anxiety symptoms nine years following her traumatic labour.


Avoidance behaviours are central to the diagnosis of PTSD. Fones (1996) describes how the woman avoided a sexual relationship with her partner, because she feared conceiving a second child. Sexual avoidance has been found in other case study material. Secondary tokophobia is an unreasonable dread of childbirth, and is not uncommon in women following traumatic childbirth. Many studies indicate that women who request elective caesarean sections with sub sequent pregnancies often do because of traumatic experiences with earlier pregnancies (Ryding,1993).


As well as sexual avoidance, there is evidence from case studies that women with PTSD can experience difficulties forming attachments with their babies and this has implications for later parenting difficulties and infant mental health. Ballard, Stanley and Brockington (1995) illustrate case studies of four women presenting with clinical PTSD following childbirth, two of these women have marked mother/infant attachment problems. There is also evidence indicating that women with PTSD following childbirth can experience difficulty with breastfeeding (Reynolds,1997).


The diagnostic category of PTSD is helpful, because it allows us to draw together a range of previously disparate phenomena under one conceptual umbrella, and to understand how specific problems often noted by health professionals might actually be indicative of PTSD. In particular, we would draw attention to how sexual avoidance and parenting problems may be signs of post-traumatic avoidance and emotional numbing, as might requests for elective caesarean sections (CS) withsubsequent pregnancies. Although there are clear diagnostic criteria for PTSD, we must also be alert to the possibility that the experience of trauma can manifest in a variety of different ways. Alcohol and drug use, eating and psychosomatic problems, and relationship issues are a few of the problems that have been seen to increase following trauma (Joseph, Williams and Yule, 1997).


What is important to emphasise is that the diagnosis of PTSD is not made lightly, but only when the distressing memories and avoidance behaviours become overwhelming- Iy disruptive to the person's ability to lead their life. Many women may perceive their experience of childbirth as 'traumatic' and experience some subsequent post-traumaticlike symptoms, but in most women these symptoms will remit with time, possibly over aperiod of a month.


It is not uncommon for women to state that they frequently re-experience images of their labour in the first few weeks of the postnata~ period, but in the majority of women, intrusive images become less frequent over the following months. However, what is of concern are those women who experience chronic and severe psychological problems. Research is sparse at present, but estimates suggest that around 2% to 3% of all women might develop PTSD in the first year or two. Out of those who experience a traumatic delivery, it is possible that around one-third go on to develop clinically significant levels of PTSD (Bailham and ]oseph, 2003).


Historical perspective on PTSD

Although there is now no doubt that some women go on to develop PTSD following childbirth, historically this has been a controversial issue. Although women who have experienced a traumatic childbirth have always experienced the symptoms of intrusive thoughts, avoidance and hyperarousal, they would not always have been eligible for a formal diagnosis of PTSD.


Prior to the 1994 edition of the American Psychiatry Association's Diagnostic and statistical manual, a traumatic event was defined as 'something outside the range of usual human experience' and therefore was usually associated with events such as major catastrophes.


However, in 1994 the American Psychiatry Association changed their description of what constitutes a necessary traumatic event for the diagnosis of PTSD to 'an event in which the person witnessed or confronted serious physical threat or injury to themselves or others and in which the person responded with feelings of fear, helplessness or horror'.


In contrast to earlier definitions that emphasised the unusualness of the event, this latter definition emphasised the individual's subjective appraisal as important. The implication of the changing terminology now meant that the diagnosis of PTSD could be made with people who had experienced events not outside the range of usual human experience such as childbirth (]oseph, Williams and Yule, 1997).


Postnatal depression is not the same as PTSD

Not all health professionals are knowledgeable of how these criteria have changed and in our experience, women experiencing all the symptoms of PTSD have sometimes been told that they are suffering from postnatal depression (PND). Certainly, it is possible that in some cases women with PTSD also have PND, but we would emphasise that these are distinct conditions and that a woman suffering with PTSD will not necessarily also be suffering from PND.


Czarnocka and Slade (2000) identified eight women with PTSD, only six of which also had elevated scores of depression according to the Edinburgh Postnatal Depression Scale (EPDS). These results have implications for screening procedures. At present PND is routinely screened for, but PTSD is not.


Czarnocka and SIade (2000) express concern that if only PND is routinely screened for in the postnatal period, then it is possible that 25% of women who are fully symptomatic with PTSD could remain undetected.


Previously we have made recommendations for investigation into the usefulness of routine screening for PTSD (Bailham and ]oseph, 2003). This is important as there are distinct treatments for PND and PTSD. Often drug treatments are found to be effective in helping with PND, but psychological therapies are thought to be more appropriate with PTSD.


Vulnerability factors for PTSD

We have previously reviewed the evidence for vulnerability and protective factors in women who have experienced childbirth-related trauma (Bailham and ]oseph, 2003) and we are able to point tentatively to those factors that we think are likely to be important in understanding why some women are more likely than others to develop post-traumatic stress reactions.


First, it is possible that women who have experienced past psychological difficulties, or who may already be experiencing PTSD prior to delivery because of experiences that may have happened earlier in their lives, might be at greater risk of developing PTSD.


Second, the more traumatic the delivery experience is itself, the more likely we might expect it to be that PTSD will develop subsequently.


Third, factors subsequent to the experience itself are likely to be important, for example how the woman subsequently appraises her experience, what ways of coping she uses, and the extent of social support available from family and friends are alllikely to playa role in determining how she adjusts psychologically.


In understanding post-traumatic stress reactions following childbirth, we are guided bya psychosocial perspective that assurnes reactions to trauma are multiply determined (Joseph, Williams and Yule, 1997). The experience of the traumatic event is necessary, but given that not everyone who experiences a traumatic event goes on to develop PTSD, the event is not sufficient. For this reason, we have to consider those personality and social context factors that might be important.


Are 'wepathologising women's experiences?

Critics of our work have suggested that in talking about PTSD, we are serving to pathologise women's experiences. This is a concern to us and we would emphasise that our aim is to increase awareness that difficulties of post-traumatic stress do occur in some women. In this we have been encouraged by the letters and telephone calls we have received. Many women have told us of experiences that have been truly horrific and who remain deeply affected many years later. Some have told us of how they have feit unheard by partners and by doctors, and have thanked us for bringing this issue to greater public awareness. On the one hand we feel that our work has been valuable, but on the other we have concerns about how our use of language serves to pathologise women's experiences and there are· two points we feel it is important to make.


First of all, we have used the term PTSD. However, we would emphasise that although we are using the term PTSD, we do not think there is anything 'disordered' in the reactions of women to horrific delivery experiences. Theirs is, we would argue, anormal reaction to an extremely upsetting and horrific event. We use the term PTSD because that is the language of medicine and psychiatry.


We would prefer to talk of'post-traumatic stress reactions; but if women are to have their experiences taken seriously then it is irnportant that the medical and psychiatrie community understands their experiences and for this reason we have on occasion used the term PTSD. We want women's experiences to be taken seriously within the medical and psychiatrie community. If a person experiences distressing nightmares, upsetting memories, and so on the current term in medical and psychiatrie cirdes is PTSD.


We are aware that the use of diagnostic categories in psychiatry is controversial, but that is a different issue. What we are concerned with is that help is made available to those who need it.


Second, we have talked about childbirthrelated trauma, but often wh at is traumatic für women is connected to the medical procedures, surgery, attitudes of staff, staff negligence and a sense of violation. For example, one woman described how her experience was like being raped with a pair of scissors. The term childbirth-related PTSD is a broad term encompassing a variety of experiences and there is no intention to imply that giving birth is in itself a traumatic experience. We are talking about experiences that are extreme.


What can we do?


How should a woman who may be vulnerable be supported during labour? Evidence suggests that continuous caregiver support during labour from a female caregiver can produce beneficial effects for both mother and child (Hodnett, 2000). According to the Cochrane database of systematic reviews, 14 studies of continuous caregiver support were reviewed and found that it reduced the likelihood of medication for pain, operative vaginal delivery, CS and was associated with better baby Apgar scores. We have developed aversion of the perceptions of labour and delivery questionnaire for use in assessing women's appraisals of delivery along three dimensions: sense of support and control during delivery, fear for self and for baby, and level of pain experienced (Bailham, Joseph and Slade, at press).


Some women may have post-traumatic stress responses that predate the labour. This is not uncommon in women who have had a history of sexual abuse or rape. The labour itself could awaken feelings and triggers associated with the original trauma, possibly because the woman will feel vulnerable, out of control and experience pain. In addition the intimate procedures that occur during childbirth may result in a woman re-experiencing memo ries of earlier abuse, assault, or rape.


How would we know that this was occurring? If a woman becomes unusually distressed even though she has been given adequate analgesia, this may be more evident when she is feeling particular vulnerable, for instance during internal examinations or when she has her legs in 'stirrups'. If a woman appears to dissociate, that is, if she appears to be distant and preoccupied, or if she screams out of control despite reassurance, support and adequate analgesia. These are all clinical signs that a woman maybe re-experiencing feelings, thoughts or memo ries from an earlier traumatic experience. What a woman needs most at this moment in time is understanding, sensitivity and reassurance, and to know she has support available to her.


After care

 There is an increasing interest in 'after-care trauma services' for women who have experienced a traumatic birth. This often involves a woman voluntarily seeking a consultation with a midwife to clarify why certain procedures and events occurred during the labour. Some reports indicate that around one-third of hospital Trusts in the UK have postnatal 'debriefing' services (Small et al, 2000). However, there is a need for evaluative research to determine the effectiveness of these services, because outcomes of postnatal debriefing services have produced conflicting results (Lavender and Walkinshaw, 1998; Small et al, 2000). Although these interventions have been targeted at PND or anxiety and not necessarily PTSD following difficult childbirth, in general there is limited evidence that debriefing is effective for preventing the development of PTSD.


However we would caution that the debriefing research only teils us about particular forms of intervention. It would be inappropriate, as some of the media have done to generalise too far from these studies about the role of psychological therapies more generally following trauma.


We know that in general psychological therapies are effective in helping people in distress and we would argue that psychological help should be available to those women who request it. Most research into therapy for PTSD has been with cognitive-behavioural techniques. However, given that women sometimes report feeling as if they have been abused and violated during delivery, it is important that we as psychological therapists do not work in such a way as to evoke these feelings in women.


Our preference as health professionals is to work gently and in a more non-directive way than might be the case with other dient groups. Our view is that the use of a more client-centred approach promises to be a fruitful avenue for further research.


One important recent development is postnatal support groups, although there is little evaluative research to determine their effectiveness. The aim of the support groups is to provide an environment for first-time mothers to meet and talk about their experiences of childbirth and motherhood facilitated by a health professional. This type of environment could provide a therapeuticenvironment for women experiencing PND or post-traumatic stress reactions if facilitated by an appropriately qualified health professional.


At this moment in time, we are not aware of any studies evaluating the effectiveness of support groups, but this does look like a promising avenue for future research.


In conclusion, there is now no doubt that some women develop post-traumatic stress reactions in response to childbirth-related trauma. This is anormal reaction to an extremely horrific event and consists of upsetting and intrusive memories, thoughts and dreams accompanied by attempts at emotional and behavioural avoidance from reminders. Research is needed to understand more about therapeutic interventions, as weil as how best to prevent post-traumatic stress responses. Preventative social support interventions along with after care psychological therapies are likely to be helpful.



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