Birth Trauma
Was birthing your baby a bit… more… than you bargained for?
Most new parents feel exhausted, overwhelmed and stressed as they adjust to the demands of caring for their newborn. Many will experience low mood or increased anxiety during the early weeks and months. Whilst these feelings are quite normal, severe anxiety, depression, or trauma is not. What if you have felt traumatised by the experience of pregnancy, childbirth or postpartum?
Understanding Trauma
A traumatic experience can be defined as ‘any event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening, and that has adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.’
Traumatic stressors can vary in severity, complexity, frequency, duration, predictability, and controllability. It makes sense to view traumatic experiences on a stress intensity continuum and blur any absolute distinction between “regular” or catastrophic stress.
Personal reactions to traumatic events are diverse and influenced greatly by our pre-existing vulnerabilities and past experiences. The experience of trauma is highly subjective, and hinges on our experience of a threatened sense of safety.
Following a traumatic experience, many people will have an acute stress reaction that mirrors the symptoms of PTSD. However, these reactions generally fade as a sense of security returns. When reactions persist for more than one month, it may be a sign of something more problematic, like Post Traumatic Stress Disorder (PTSD).
Understanding Birth-Related Trauma and PTSD
Current research indicates that one third of birthing people describe their birth experience as traumatic, (although many of these might have had a birth that would be viewed as medically uncomplicated). One in 4 will experience some symptoms of PTSD and up to 6% of (or 1 in 16) birthing people will meet full diagnostic criteria for PTSD during postpartum.
Birth-related psychological trauma may be experienced by the birthing person, non-birthing partners, witnesses to the birth, and even attending healthcare providers. Unfortunately, while the incidence of birth-related trauma is high, many people who develop PTSD will remain undetected, undiagnosed and untreated.
PTSD in the postpartum period is poorly recognised and is unfortunately not routinely assessed during postnatal checks. When birth-related PTSD symptoms are observed, they are frequently misdiagnosed as postnatal depression (PND). Postnatal anxiety (PNA) can occur following a traumatic experience but must also be differentiated from PTSD.
PTSD, PND and PNA can occur simultaneously, and there can be overlap in the causes as well as how they clinically present. However, it is important to distinguish between these conditions to ensure timely access to effective and appropriate intervention, as different psychological treatments are indicated.
The Criteria for PTSD
To meet the criteria for PTSD, an individual must display at least one symptom from each of the following four symptom clusters, with symptoms evident for at least four weeks.
The first cluster, “Re-experiencing the Event”, includes symptoms such as:
Intrusive and distressing memories of labour, birth and immediate post birth
Flashbacks to the birth
“Reliving” the birth
Nightmares
Feeling distressed, panicked, or anxious from reminders of the birth
The “Avoidance” cluster includes symptoms of:
Trying to avoid thinking/talking about the birth
Using strategies (watching TV, playing video games, keeping busy, using drugs or alcohol) to distract or numb self to avoid thoughts about the birth
Avoiding places, people or activities that trigger reminders of the birth
Feeling unconnected to baby
The “Negative Mood/Emotion” cluster includes:
Negative thoughts about self, others and the world (as a direct result of the birth)
A sense of overwhelming guilt or shame
Difficulty remembering important parts of the birth
Feeling detached from others and difficulty maintaining relationships
Lack of interest in activities that were previously enjoyed
Lack of positive emotion
The final cluster, “Hyperarousal” includes symptoms such as:
Being easily startled (fearful or jumpy)
Feeling alert or on guard
Impulsive and reckless behaviour without concern for the consequences
Difficulty with sleep and concentration (not attributable to disruption from baby)
Increased irritability, angry outbursts
The Result of Untreated Trauma
Following a traumatic event, our brains naturally try to make sense of what has happened by repeatedly bringing the event back into mind. This can be during the day in the form of re-living (like a scary internal looping video), or at night in the form of nightmares. These experiences can be extremely unpleasant as they trigger the same feelings experienced at the time of the event.
If we try to distract and suppress these memories and feelings, it can disrupt the necessary psychological processing. It’s quite natural to try to shut down the processing and distract ourselves, given the unpleasantness of this experience. However, avoidance can intensify the feelings to the point we may begin to avoid anything that risks triggering these uncomfortable feelings. New parents may even avoid other people who might ask about the birth, such as family or other people with babies. Similarly, traumatised couples may avoid talking to each other about their experience, to avoid upsetting themselves, and their partner.
These unpleasant reactions to a traumatic birth don’t necessarily lead to negative feelings towards the baby, but new parents may still feel guilty for not seeing the birth in a more positive light. Mothers are particularly at risk of being critical of themselves for these responses, feeling like they are going ‘mad,’ or judging themselves as a parent.
Unfortunately, sometimes when a traumatised parent does attempt to talk about their experience, well-meaning family members and friends will close down these conversations, saying “put it behind you” or “it’s over now,” rather than giving time to talk about what happened.
Importantly, if trauma is not properly explored and processed, it can become chronic and develop into PTSD, with broad reaching effects, including an impact on the ability to bond with the baby, and relationships with a partner, friends and family.
Mothers with PTSD often delay or avoid further pregnancies. When they do become pregnant again, they may suffer from tokophobia (fear of childbirth). Women with tokophobia are more likely to request elective caesarean as a strategy to manage their fear, as this can feel like a way to increase control over the next birth experience.
Untreated, PTSD alters how we perceive the world, resulting in a heightened expectation of danger. When we have PTSD, we become hypervigilant and primed for threat, long after the original danger has passed.
What can I do if I think I know someone with birth-related PTSD?
It is useful to promote the understanding that intrusive thoughts and images are a normal part of memory processing after trauma, with the purpose of helping make sense of distressing events. Traumatised patients need to know that when memories have been processed, they just become a part of our life story and no longer have an effect day to day. But, when something has been highly traumatic, this processing can take some time.
Emphasise the importance of talking to others to help process the experience rather than using avoidance, even if it feels difficult or uncomfortable.
Gently challenge any self-blame or self- criticism that they are having these responses. Having a trauma reaction has no implications on whether you are “a good parent”.
Encourage activities which increase bonding, as normal post birth experiences such as early skin to skin contact may have been interrupted or unavailable if the birth was traumatic. Recent research suggests that new mums want more education and support with strategies to bond with their baby, and many received no advice about techniques for bonding during their antenatal care.
Even when a birth experience has been smooth, it is important to normalise that not all new parents instantly bond with their babies. For a parent who has been traumatised by their pregnancy or birth experience, it is even more critical to recognise that it may take a while for the bond to develop.
Seeking Help
There is now consensus by perinatal mental health experts that screening for birth-related PTSD should be a routine part of postnatal care, but that doesn’t mean it always happens. Additionally, as trauma isn’t only experienced during the birth itself, it is important that we also explore how we are feeling about fertility, pregnancy and postpartum experiences.
Some people take a while to realise that they are not feeling okay about their birth-related experiences. PTSD symptoms onset can be delayed by as long as six months, and it might take a while to feel ready to speak about a traumatic experience varies. One size does not fit all, so even if it’s been some time since your baby was born before you realise you aren’t feeling okay, it’s okay for you to still reach out and ask for help.
It is essential that identification of birth-related trauma results in specialist perinatal mental health referral. If daytime re-living, nightmares, or recurrent, intrusive traumatic thoughts or images about the birth do not resolve (or markedly reduce) within about four weeks, it is time to arrange a prompt referral for specialist intervention. You can do this by contacting your GP, child health nurse or private obstetrician.
Finally, birth-related trauma is not only psychological. If you don’t feel physically “normal” after birth, it is critical that you receive assessment of physical trauma, pain, or functional changes to ensure you get the treatment you need.