Healing the Trauma: Entering Motherhood with Posttraumatic Stress Disorder (PTSD)
by Jennifer Jamison Griebenow
© 2006 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 80, Winter 2006.]
Making the leap to parenthood is a challenging transition even at the best of times. For some mothers that transition is made even more difficult by additional challenges in the postpartum period. Most people know about the baby blues, and the media has given a good deal of attention to postpartum depression (PPD) and postpartum psychosis. They have given less attention to the unique problems suffered by mothers who experience symptoms that seem like postpartum depression, but don't completely fit that profile. PTSD may be the culprit.
How is such a situation possible? Can childbirth—something so common—create a physiological reaction in a mother, complete with insomnia, nightmares or flashbacks? For some, it does.
Denise was one of those women. At nine centimeters dilation, her doctor told her that her baby girl was too big and she needed a cesarean. The physician told her about a large baby getting stuck and being decapitated, with the mother undergoing a cesarean to remove the rest of the infant's body. Denise says, "[The doctor] was obviously angry with me…because then he flung his glove (which was covered with blood) all over me…. He even wrote in my chart that I told him I felt forced to have a c-section and that I called him mean."
Too many times women must give birth unsupported, while being poked and prodded in a depersonalizing and sometimes literally violent process, as Denise did. Is it any wonder that we react to the things that happen to us during our children's births? Being treated in a patronizing manner, receiving interventions without knowing why they are needed and being refused food and drink all are common in current birth settings. Women are also pressured to get the baby out within a certain amount of time. A vacuum extraction, an episiotomy, and of course, the ultimate intervention, a cesarean, are all common today, at least for the hospital staff who perform them.
The problem is, these experiences are not common for the mother who is living them.(1) Labor alone is an incredibly powerful and overwhelming experience. When you add in an unexpected situation—the baby being in danger or an emergency surgery—the drama of birth can become overwhelming.
What Does PTSD Look Like?
When seeking help, you may be told that you are experiencing the baby blues or PPD, either of which may be present with PTSD. However, along with the typical weepiness, anxiety and depression of PPD, key symptoms of PTSD include insomnia, irritability and angry outbursts, panic attacks, nightmares about the birth, a desire to avoid the baby or anything relating to the birth, feelings of detachment from loved ones, and a sense that some other disaster is imminent.(2) This sense that something bad may happen can also manifest as suicidal thoughts.
Many women experience physiological and psychological reactions to reminders of the birth, including seeing the birthplace and anniversaries of the event. Susan was unable to celebrate her son's first birthday on the actual date of his birth, as she wept all day. She also avoided the hospital where her son was born due to the physical and emotional reactions she experienced on seeing it. She went so far as to refuse to go to the emergency room of that hospital when she later became ill, although her family doctor strongly recommended that she go.
In some cases, the birth trauma is so severe that it includes the flashbacks with which PTSD is commonly associated. Linda [name changed for privacy] experienced this after her child's birth, in every part of her life, including lovemaking: "I couldn't have sex at first because I saw the [hospital staff's] faces whenever I had my legs apart."
Psychologist Lynn Madsen works extensively with women who are experiencing PTSD due to their births. Her book Rebounding from Childbirth, published in 1994, is an excellent resource for working through birth trauma and currently the only book specifically devoted to the subject. (Editor's Note: Motherbaby Press, an imprint of Midwifery Today, has published a book entitled Survivor Moms: Women's Stories of Birthing, Mothering and Healing after Sexual Abuse.) The attention she has brought to PTSD has opened doors for further study, as interest in the subject has increased since 1995.
Going beyond the simple acknowledgment that trauma can occur with childbirth, researchers and professionals are beginning to evaluate what can be done to assist women with PTSD. Therapists are using short-term, cognitive group therapy "to reduce or resolve ongoing psychological disruption and/or trauma" to assist women who have had traumatizing interactions with their care providers during childbirth.(3)
Nonetheless, media and public understanding of PTSD's relation to birth experiences lags behind, and Madsen's book remains a unique and essential guide for professionals and laypeople alike. Throughout the book, Madsen addresses the factors that can lead to a traumatic stress reaction, among them the trauma experienced during the birth itself, a previous traumatic situation, childhood abuse and a loss experienced around the time of the birth or in tandem with the birth.
Other risk factors have been identified in medical studies, as well. Women who have had a prior stillbirth are at increased risk for PTSD (4), as are those who have had psychological counseling prior to a first birth.(5) Another predisposing factor is anxiety as a personality trait.(6) Understandably, women who are extremely fearful about childbirth have a greater risk of psychological difficulties post-birth, especially if the birth does not go as hoped or expected.(7)
A medical study of 500 women that evaluated the effects of obstetric intervention concluded that in a first childbirth experience such interventions have psychological risks "rendering those who experience these procedures vulnerable to a grief reaction or to posttraumatic distress and depression."(8) While the PTSD rate varied from study to study, in this case up to 5.6% of women were found to have PTSD.(9)
Several other studies found that when mothers felt that they had no control over the birth experience and their partners and staff were not supportive, the risk of PTSD increased.(10) These studies mesh with the statements of the women I interviewed in that they identified unwanted procedures and interventions as one of the primary causes of their PTSD reactions.
Madsen advocates respecting the mother's interpretation of events and her reactions to the birth. The first step to healing is acknowledgement, which sometimes does not come easily. As Madsen notes, our culture denies pain and trauma. "The most common and blatant denial of the pain of a traumatic birth is the phrase, 'What is important is that your baby is…healthy…. Put the past behind you.'"(11) Madsen turns this on its head with the truth that a mother must determine for herself whether a birth was traumatic: "One essential guideline is that if she feels traumatized, she was."(12)
Whether a birth will cause PTSD is specific to each individual.(13) Linda had planned a homebirth but as her pregnancy reached 42 weeks her midwife began to question her readiness for labor. The midwife issued an ultimatum that if Linda did not start labor within two days she would no longer provide care. Linda spent the final hours of her pregnancy agonizing over what she might be doing "wrong."
"They told me that I had to 'get mad and decide that I am going to have this baby,' but I couldn't figure out how to do it. I think they expected me to do it with mind control—just by willing labor to start."
When Linda went into labor, the doula told her she was not surrendering to it. Without the necessary emotional support, she felt she had failed and eventually was transported to the hospital. Linda says, "Turning birth into a medical delivery (without…true complications to justify medical involvement) is against all of my beliefs and there was no health reason to justify being there. I simply failed to stand up for myself…and [gave in to the pressure to use] drugs out of self-destructiveness and total demoralization." The mental stress involved in having to abandon one's deepest beliefs can be quite violating.
To add insult to injury, the midwife and doula told Linda that "…this was the best hospital birth we have ever seen!" Linda felt that such a response invalidated her perceptions and feelings. Her child was more than a year old at the time she discussed her experience with me, yet she was unable to call his arrival a birth; it was, she said, "a removal."
Many women experience this kind of trauma as a rape. Birth can include the threat of violence against them (for example, "if you don't dilate soon we'll have to use Pitocin") and the threat of harm to the baby. Women are vulnerable at this time as never before, and childbirth, obviously, is a profoundly intimate and sexual act. The loss of control can be very frightening in an emergency situation or when being coerced into unwanted procedures. Labor alone can create a feeling of losing control that is difficult to assimilate. Thinking and compassionate people are now taking rape seriously, and the incredibly challenging experience of a traumatic birth should be taken seriously too.
What Can Women Do?
First, be aware that you are not alone and that the symptoms you are experiencing, however disturbing, are not unusual for someone who has gone through a traumatic or life-threatening situation. Do not judge yourself. You are deserving of support and respect for having survived this experience and for being a feeling human who is upset by what happened.
Second, surround yourself with supportive, loving people who are able to care for and nurture you. Tell people who need to know that you are having a hard time and ask for support. Get extra help with the baby, if possible. Caring for an infant who indirectly was responsible for the ordeal you have been through can be difficult. You may have no feelings or have very negative feelings about your baby. Do not blame yourself. Know that gradually your feelings about your baby will change and become more positive. Give yourself time to recover. Becoming a mother is a wonderful but unsettling transformation at the best of times; you've come through what, for you, was one of the worst of times. You need nurturing and care too.
Some women feel that they are to blame for the interventions or trauma that occurred. They think, "If only I had eaten better…" "If I had just tried for one more hour…." This internal bargaining is a normal part of working through what has happened. Most likely you could not have done anything "better" given the information you had at the time you went into your labor and birth. As both Madsen and Nancy Wainer, author of Silent Knife, point out, you have acted with love, allowing yourself to be injured, doing all you could to give your baby life. You are to be admired. All of these feelings, the guilt and the difficulties connecting with your baby are understandable given what you have experienced. Let yourself feel what you feel and know that you have done what you could.
Lynn Madsen states that healing means eventually coming to the place where you can accept the reality of what has happened to you.(14) "Trauma is trauma, and its identification is one more way of acknowledging the power and importance of the birth experience."(15)
In some situations, a woman also knows or suspects that the problems within the birth were iatrogenic and feels betrayed and angry. Forty-eight hours after the surgery, nearly 10% of women in one survey believed that they had been treated badly by the hospital staff when undergoing a cesarean.(16)
Madsen comments that one of the benefits of a diagnosis of PTSD is that it lets a woman know she is not crazy.(17) The symptoms are unpleasant but they are a normal part of trauma recovery. While this emotional work is undoubtedly very difficult, as Madsen points out, it doesn't die if repressed; it will simply come forth later demanding to be dealt with. "Feelings and memories seem to have lives of their own; they emerge when a person is ready to experience them. The job is to meet them halfway."(18)
What Can You Do to Feel Okay Again?
When working through PTSD after a birth, any activity or process that brings healing to you can be helpful. Many women draw, paint or sculpt, bringing out the images that are bothering them. When physically possible, exercise can help relieve the pain. Journaling is always a good choice. Writing letters to the people who were involved in your birth can be very therapeutic, whether you choose to send them or not. I wrote letters expressing my anger to the hospital staff: most I didn't send, the last few I did, letting them know how I felt about my care and what they could have done differently.
Therapies that promote whole body wellness are likely to help recovery from trauma. Massage, hot soaks and aromatherapy are comforting, supportive and healing to the mind, body and spirit. Cranial sacral therapy to release the physical trauma has proven quite helpful to many women.
Walking yourself and your baby through the birth experience again and creating a more positive outcome in your mind may be helpful; for example, I wrote out my birth story in detail as I wished it had happened.
An option suggested by Nancy Wainer is to wrap yourself and your child (you can do this with older children too) in your robe or a warm blanket and walk/talk yourself and your child through your birth experience. When it's time for your baby to be "born," open the robe and say to your child just what you would like to have said to him or her at the birth. I have found as the years go by, when cuddling with my cesarean-born son, that we sometimes lapse into baby talk and "mother talk" almost unintentionally. I hold him close and comment on how beautiful and sweet he is. It sounds a bit funny when explained, but each incident, I find, draws us closer, perhaps bringing us another step toward what should have been from the beginning.
Learning all the details of what happened, what interventions were used and why, although painful, can be cathartic and provide a sense of closure. You may need to obtain your medical records and review them with a knowledgeable third party to gain a complete understanding of what happened.
Many women find that experiencing a subsequent birth in a different setting is quite healing; however, recovery is always possible, whether or not one has another child. For me, what helped the most was finding other women who were supportive and talking, talking, talking. Most of these contacts were made online, where finding a sympathetic listening ear can be easier than among personal acquaintances.
Find a counselor who is knowledgeable about PTSD, supportive about women's issues, or both. If no such person is in your area, look for someone who has a reputation for being open-minded. A rape recovery counselor may be helpful. Be wary when interviewing counselors; someone who urges you to just be thankful for the baby and put the past behind you will not be helpful. If a supportive counselor is not available, several Internet-based support groups may be of help.
A relatively new, but somewhat controversial, therapy that is used in healing trauma is eye movement desensitization and reprocessing (EMDR). In sessions with a trained professional, individuals work through specific traumatic memories, while using an external stimulus, such as eye movement or tapping, to facilitate processing the traumatic memories. Studies appear to show that this is a very effective way to move through healing.(19)
Other recommended therapies for processing trauma are relaxation training (20) and prolonged exposure therapy.(21) A competent counselor will be able to help you to use these, or refer you to someone who can.
Another option is the judicious use of medication. Madsen comments, "Medication for emotional pain can give a woman a break from the intensity of her situation and free her to look at her situation more clearly. [However], for some, medication prolongs denial and suppression of images and emotions that need to emerge."(22) Each woman's needs are different, and her decisions about medication use should be honored.
Your Family's Reactions
Those closest to someone experiencing PTSD, whether husband, partner, parent or close friend, can be a part of the healing process as well. Partners may react with anger, frustration, sadness, withdrawal or sympathy when you are struggling with PTSD. These reactions are understandable. However, those who care need to know that mothers need support most of all. A traumatic birth is an event from which recovery is possible, but time-consuming; thus patience on a day-to-day basis is essential. A partner may not understand fully why you feel as strongly as you do or why you are acting in the ways you are. You can explain that although he or she may not understand you, you need full acceptance of your feelings in order to move forward.
Feeling angry that your partner did not do more to protect you from unwanted interventions or abusive care providers is also not unusual. Talk such feelings through at length with another person before bringing them up with your partner.
Partners also can experience some PTSD symptoms as well, depending on their individual reactions to the traumatic birth. They too deserve a supportive response and help from extended family and friends. Their close connection to the experience also highlights why you will likely benefit from finding other people with whom to share your feelings and thoughts; sometimes a partner may not be able initially to fully understand your feelings and process what you've gone through, as well as what he's gone through. My husband and I got through this by scheduling selected specific times during which I could talk all I wanted about what had happened, so that he didn't feel completely overwhelmed with my need to process the birth.
What about the Baby?
Babies are affected by their birth experiences and the way they come into the world. A variety of research addresses their experiences, and some care providers—most of them in alternative therapies—are gradually acknowledging the reality of infant trauma.
Mothers can balance their concerns that the experience traumatized the baby with the knowledge that their love, the passage of time and their care can bring healing. Holding the baby closely, looking into her eyes and expressing your sorrow over the birth situation can help both of you. One primary recommendation for babies who've experienced a traumatic birth is to take them to see a children's cranial sacral therapist. This non-invasive, holistic therapy can work wonders for many subtle problems that traditional medical care providers can't solve, including physical and emotional birth trauma.
Obviously, the best solution is to avoid PTSD if at all possible. Birth can come with surprises, and interventions including surgery may be necessary. You cannot plan what to do in all scenarios. If the unexpected happens, get the help you need as you recover from the birth, or have your partner get you the help you need.
You can avoid many unpleasant outcomes by carefully choosing a care provider for the birth. Interview providers thoroughly, picking a birth setting that fits your views on how birth should be supported. Avoid a setting in which most births are handled differently than you prefer; avoiding the procedures that are applied to everyone else will be difficult, even if the provider says that you will be able to waive the standard procedures or interventions. Homebirth is a good option for this reason. You will have much more control over the setting, the people present and the tone of the birth, and a homebirth midwife is more likely to be respectful of your autonomy than a hospital-based care provider.
Regardless of the best-laid plans, you will need to anticipate and talk through some of the possible outcomes with your partner, doula and other helpers. Be sure they fully understand what you would like and how they can support and advocate for you. During labor, if something doesn't seem right to you or is being forced on you, ask for alternatives and help from your partner and doula, if at all possible. Selecting a care provider carefully in the beginning will help you to avoid situations in which you don't have the power to make free choices or in which your partner or doula do not have enough information or influence to help you. You also want a care provider who will do all she can to assist you emotionally, as well as physically, in the event of an unexpected or emergency situation.
Pregnant Again: How to Minimize a Recurrence
When planning for another birth, start researching childbirth attendants before you even conceive. Finding someone you believe is both qualified and compassionate may take time and will be easier when you are not dealing with the fatigue and other challenges of pregnancy. Of course, if you are halfway through your pregnancy and are still looking for the best care provider for you, all is not lost. Your effort will be worthwhile when you find someone whose philosophy of birth is a good match. That type of person is much more likely to handle your birth experience gently and with respect. Prevention of PTSD is more likely if the care provided during labor "enhances perceptions of control and support."(23)
Questions to ask a provider might include the following:
- How do you help support a laboring woman?
- What type of situation is of concern to you but is not an emergency?
- What constitutes an emergency situation, in your opinion?
- How would you handle such a situation?
- What kind of choices are parents likely to have in this type of situation?
- Can you be with me throughout a transport and/or in case of an emergency?
You also will want to request references from each potential provider and question those mothers about how they were treated. Get two references for each provider in whom you are interested, including at least one woman who had either an emergency or a complication in her labor, and be sure to ask that woman how the care provider handled the situation and treated her.
If you will be delivering in a hospital or birth center you may want to visit and talk with the nursing staff and the anesthesiologist. If you are planning a homebirth, visit the hospital you would be transported to in an emergency. Having a face and a name that you already know if transport becomes necessary can be reassuring. Obviously you will need to make the decisions that are right for you.
Many women with previous trauma find the strength to face an upcoming birth through religious or spiritual beliefs. Life brings rough roads to everyone; trust in a higher power can help to make some sense of past experiences and to provide comfort as you journey forward into new life territory.
Making the Difference
Compassionate professionals are out there. They can be hard to find but the effort is worthwhile, whether you are seeking postpartum counseling or a birth care provider for a subsequent pregnancy. People are available to help you as you move along the path toward healing. You can also find valuable information in much greater depth than what is presented here in books and on the Internet.
Care providers are more aware of the possibility of birth trauma than ever before. They may implement a number of strategies to assist you, among them "careful prenatal screening of past trauma history, social support and expectations about the birth; improved communication and pain management during the birth; and opportunities to discuss the birth postpartum."(24)
Also, the severity of posttraumatic stress due to an emergency c-section can be decreased by early postpartum counseling.(25) One study notes that "…women reported that an opportunity to talk with someone about the birth was helpful in facilitating recovery."(26) A long-term approach to talking things through is more beneficial than just one counseling session in the hospital.
After her horrible hospital experience, Susan made very different plans for her second son's birth. "I made the decision to have a natural birth and then…to have a homebirth with a midwife. While initially the decision was based on fear of the hospital, the more I learned the more I decided that homebirth with a midwife is smarter and safer."
Susan felt an immense difference. "I was treated respectfully and with true care for me as a person. The first time I was treated rudely and abusively and my role as Mother was not acknowledged. Even if the outcome of the birth had been another cesarean, it would have been a much more positive experience."
As in Susan's case, my homebirth after cesarean was a good choice. The outcome of this birth was different from my first—a vaginal birth instead of a cesarean. The way I was treated was different. My midwife acknowledged my concerns and supported and respected me. I gave birth, not the midwife, a surgeon or anyone else. The difference for me during the postpartum period was stunning. I did experience anxiety for several weeks that I would have a PTSD reaction again. That didn't happen, and the rest of postpartum was uneventful.
Although my first birth was horribly traumatic, I have had the opportunity to grow and change. As Madsen comments, "I do not wish this opportunity to learn from trauma or pain for anyone, yet here is the paradox: if such things do happen, then I hope there are gifts from having learned the hard way. These gifts are powerful, and they will continue to keep on giving throughout one's life."(27) Suffering is painful, but help is available; healing, recovery and new growth are absolutely possible.
Jennifer Jamison Griebenow, MA, Phi Beta Kappa, is a psychology minor and mother of three—one born by cesarean, two at home. A former chapter leader and board member of ICAN, she is currently homeschooling her children.
- Beck, C.T. 2004. Birth trauma: in the eye of the beholder. Nurs Res 53(1): 28–35.
- PTSD symptoms from DSM-IV as experienced by postpartum women. Diagnostic Criteria for PTSD. Online Psychological Services. www.psychologynet.org/ptsd.html. Accessed 1 Oct 2002.
- Sorenson, D.S. 2003. Healing traumatizing provider interactions among women through short-term group therapy. Arch Psychiatr Nurs 17(6): 259–69.
- Ryding, E.L., et al. 2003. An evaluation of midwives' counseling of pregnant women in fear of childbirth. Acta Obstet Gynecol Scand 82(1):10–17.
- Turton, P., et al. 2001. Incidence, correlates and predictors of post-traumatic stress disorder in the pregnancy after stillbirth. Br J Psychiatry 178: 556–60.
- Wijma, K., J. Soderquist and B. Wijma. 1997. Posttraumatic stress disorder after childbirth: a cross sectional study. J Anxiety Disord 11(6): 587–97.
- Hofberg, K., and I. Brockington. 2000. Tokophobia: an unreasoning dread of childbirth. A series of 26 cases. Br J Psychiatry 176: 83–85.
- Fisher, J., J. Astbury and A. Smith. 1997. Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study. Aust N Z J Psychiatry 31(5): 728–38.
- Creedy, D.K., I.M. Shochet and J. Horsfall. 2000. Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 27(2): 104–11.
- See note 9 above; Czarnocka, J., and P. Slade. 2000. Prevalence and predictors of post-traumatic stress symptoms following childbirth. Br J Clin Psychol 39(Pt 1): 35–51.
- Madsen, Lynn. 1994. Rebounding from Childbirth. Westport, Connecticut: Bergin and Garvey.
- Ibid. 19.
- Soderquist, J., K. Wijma and B. Wijma. 2002. Traumatic stress after childbirth: the role of obstetric variables. J Psychosom Obstet Gynaecol 3(1): 31–39.
- See note 11 above.
- Ryding, E.L., K. Wijma and B. Wijma. 1998. Experiences of emergency cesarean section: A phenomenological study of 53 women. Birth 25(4): 246–51.
- See note 11 above.
- Carlson, J., et al. 1998. Eye movement desensitization and reprocessing (EMDR): Treatment for combat-related post-traumatic stress disorder. Journal of Traumatic Stress 1: 3–24; Ironson, G.I., et al. 2002. Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. J Clin Psychol 58(1): 113–28.
- Stapleton, J.A., S. Taylor and G.J. Asmundson. 2006. Effects of three PTSD treatments on anger and guilt: exposure therapy, eye movement desensitization and reprocessing, and relaxation training. J Trauma Stress 19(1): 19–28.
- Rothbaum, B.O., M.C. Astin and F. Marstellar. 2005. Prolonged Exposure versus Eye Movement Desensitization and Reprocessing (EMDR) for PTSD rape victims. J Trauma Stress 18(6): 607–16.
- See note 11 above.
- Czarnocka and Slade.
- Soet, J.E., G.A. Brack and C. DiIorio. 2003. Prevalence and predictors of women's experience of psychological trauma during childbirth. Birth 30(1): 36–46.
- Ryding, E.L., K. Wijma and B. Wijma. 1998. Postpartum counselling after an emergency cesarean. Clin Psychol & Psychother 5(4): 231–37.
- Gamble, J.A., et al. 2002. A review of the literature on debriefing or non-directive counselling to prevent postpartum emotional distress. Midwifery 18(1): 72–79.
- See note 11 above.
- International Cesarean Awareness Network (ICAN) Web site—mailing list, support group available, information: www.ican-online.org
- Post Traumatic Stress Disorder After Childbirth: www.ptsdafterchildbirth.org
- Midwife Archives Maternal Birth Trauma Page: www.gentlebirth.org/archives/ppdepres.html
- Emotional Recovery from Cesarean: www.plus-size-pregnancy.org/CSANDVBAC/csemotionalrecov.htm
- Upledger Institute for information about cranial sacral therapy: www.iahe.com/html/therapies/cstfaq.jsp
- Eye Movement Desensitization and Reprocessing (EMDR): www.emdr.com
- Birth Psychology site, useful for mothers and babies: www.birthpsychology.com/birthscene/index.html
- Birth as an American Rite of Passage, an online chapter: www.birthpsychology.com/messages/contents.html
- Making peace with your Birth: www.lalecheleague.org/NB/NBMarApr02p44.html
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