The Dynamics of Trauma in Childbirth.

The fear of childbirth is powerful in American culture. For many women--and many maternity caregivers--even the risks of surgical delivery seem less threatening than natural childbirth. Yet, ironically, when trauma does occur in the birthing room, it is rarely acknowledged as such.

Unless the outcome is blatantly catastrophic, birth is presumed to have been "successful," well worth any complications, difficulties, and disappointments. Such a limited perspective on trauma leads to a further denial of the potential aftereffects for the mother and baby, and also for the family, friends, and professional caregivers who bear witness.

Trauma is not an event. It is a set of responses that arises when a person perceives that she is facing (or witnessing) serious danger that she is powerless to avert. Thus trauma is a very subjective experience. One woman's "perfect birth" could be deeply traumatic for her sister or her labor assistant. A mother may be haunted for years by a birth that was just another routine delivery for her doctor.

Clearly, an understanding of trauma must be based upon a willingness to honor the perspective of the person who experiences it. "When the victim is ... [socially] devalued (a woman, a child), she may feel that the most traumatic events of her life take place outside the realm of socially validated reality. Her experience becomes unspeakable."(1) This is the dilemma of many women whose birth traumas are discounted as unimportant, unimpressive, or even untrue.

When addressing trauma, it must be understood from the outset that any effort to break down the topic into manageable categories will blur the big picture of trauma's all-encompassing nature. For discussion's sake, a distinction could be made between physical trauma (arising out of a perceived danger to the body) and emotional trauma (involving a perceived danger to the psyche); but reality defies such neat verbal categories. Although the symptoms may be fragmented, every trauma engages both the body and the emotions, as well as an individual's logical, moral, and social sensibilities. A person is always traumatized in totality.

Trauma originates in the nervous system, which automatically mobilizes the entire human organism to cope with danger. Whether the threat is to the body or the psyche, a physiological "gearing up" occurs: basic body functions (heart rate, respiration, mobility, sensory alertness) become acutely stimulated and sharply focused so that the individual is well-resourced for either fighting or fleeing.

When neither of those options is effective, however, the only remaining choice is to freeze. Although many animals "play possum" as a matter of course when threatened, such "frozenness" is usually a very distressing state for humans, arousing a perception of helplessness that "constitutes the essential insult of trauma."(2)

If all people perceived all circumstances in uniform ways, trauma would be a predictable experience. But of course, even when faced with identical situations, different people respond in different ways. Differences in such factors as sociability, religious beliefs, self-esteem, physical health, emotional security, and favored coping skills will play a role in determining not only whether an individual will perceive herself to be helpless in the face of extreme danger, but also how she processes the experience. "Predictably, those who are already disempowered or disconnected from others are most at risk"(3) of suffering traumatic aftereffects from a troublesome experience.

Infant Trauma

The most vulnerable participant in childbirth is unquestionably the baby; however, a baby's experience of birth trauma is beyond the scope of this article. The work of pediatric psychiatrists, rebirth practitioners, developmental psychologists, and therapeutic hypnotists leaves little doubt that trauma produces a lasting imprint on the newborn psyche. But unless their traumatic experiences are glaringly obvious, the distress of many babies is likely to be casually diagnosed as "colic." Such denial is in no way condoned by this article's exclusive focus on the adult participants in childbirth.

Maternal Trauma

It is possible for birthing women to experience either or both of two types of trauma: primary trauma, which is a response to a perception of danger in the present birth experience; and re-traumatization, which is a revival of responses that were originally triggered by a traumatic experience in the past.

Primary trauma

Childbirth is an experience of unrivaled vulnerability, encompassing all that is most personal and most precious: a woman's physical safety, her sexuality and body image, her beliefs and values, her deepest emotions and attachments, and her hopes for the future. In addition, most North American women experience this potent event among strangers in unfamiliar surroundings. When coupled with the intense, involuntary sensations of birth, these factors create a highly-charged setting that can easily give rise to perceptions of danger and helplessness.

For the birthing mother, the presence of perceived danger may take many forms, including some which have little or nothing to do with the physical details of the birth process. Although laboring women may actually be strong and capable of giving birth with minimal assistance, their sense of safety can be compromised by beliefs that infiltrate the birthing environment, whether such beliefs are their own or those of their caregivers and labor companions.

Attitudes that might influence a woman's perceptions of danger or helplessness include preconceived beliefs about the riskiness of birth; expectations about the nature of contractions and labor sensations; expectations about self-competence in labor; expectations about interpersonal relationships (especially with a spouse or partner) during the labor and birth; expectations about professional relationships with caregivers; and expectations about the baby.

When reality does not validate such expectations, or when the mother's beliefs clash with those of her caregivers or companions, emotional distress may override all other details of her experience. This source of trauma is often overlooked because there is rarely an obvious link between it and the birth's objective outcome. When only physical outcomes are considered relevant, there is no need to face the troubling fact that birth sometimes wounds a woman's spirit.

Physical complications are more obvious sources of potential trauma, especially in extreme situations. Cord prolapse, placental malfunction, hemorrhage, fetal hypoxia, emergency surgery, and infant loss are expected to be traumatic, for the elements of danger and helplessness are so blatant. Complications that necessitate the separation of the mother and baby (prematurity, for example) are also generally acknowledged as potentially traumatizing. For the laboring woman, however, even a briefly dangerous episode (such as fetal distress, which is quickly resolved by oxygen or a position change) or a minor problem that is misunderstood by the mother to be much more serious, may elicit a perception of trauma.

Surgery is a feature of more than 70 percent of all American births: 50 percent include an episiotomy, while at least 20 percent of babies are delivered by cesarean section. In a technology-worshipping society, surgery is generally perceived as a thoroughly positive experience. The fact that surgery always violates physical integrity is easily ignored because it occurs without the pain that would normally signal the brain that massive trauma is occurring. The mind is quite effectively tricked out of its normal response to such wounds. But

   Even though a person may recognize that an operation is necessary, and
   despite the fact that they [may be] unconscious as the surgeon cuts, ... it
   still registers in the body as a life-threatening event. On the "cellular
   level" the body perceives that it has sustained a wound serious enough to
   place it in mortal danger.... Where trauma is concerned, the perception of
   the instinctual nervous system carries more weight [than the
   intellect]--much more. This biological fact is a primary reason why surgery
   will often produce a post-traumatic reaction.(4)

Symptoms of trauma

Despite the popular belief that "all's well that ends well," a mother's trauma is not "over" as soon as the birth is complete and any danger is past. Trauma is not resolved so logically because the mind plays such a minor role in the physiological processes of the trauma response. When a person has experienced the "frozenness" of a thwarted "fight or flight" defense,

   Each component of the ordinary response to danger, having lost its utility,
   tends to persist in an altered and exaggerated state long after the actual
   danger is over. Traumatic events produce profound and lasting changes in
   physiological arousal, emotion, cognition, and memory. Moreover, traumatic
   events may sever these normally integrated functions from one another. The
   traumatized person may experience intense emotion but without clear memory
   of the event, or may remember everything in detail but without emotion. She
   may find herself in a constant state of vigilance and irritability without
   knowing why. Traumatic symptoms have a tendency to become disconnected from
   their source and to take on a life of their own.(5)

The experience of trauma is highly individualized, but such lingering symptoms are remarkably consistent. There are three components of trauma that predictably continue to affect people in the aftermath of their experience:

1. hyperarousal--increased heartbeat and breathing, agitation, anxiety, racing thoughts, etc.

2. intrusion--spontaneous replaying of the traumatic experience, in the form of flashbacks, nightmares, emotional outbursts, compulsive participation in similar situations, etc.

3. constriction--restricted physical, perceptual, and emotional functioning, which first serves to sharpen one's focus on the urgent need for self-defense but then continues as a numbing of trauma's ongoing impact.

When these symptoms occur within one month of the triggering event, they are classified as Acute Stress Disorder. If they persist or suddenly surface after the first month, they are diagnosed as Post-Traumatic Stress Disorder (PTSD). The PTSD label is readily assigned to combat veterans and rape survivors whose lives are disrupted by trauma, but new mothers are more often diagnosed with a postpartum disorder, the causes chalked up to hormone fluctuations. Childbirth trauma, if not consciously denied, may be glossed over as only one of many "contributing factors" to postpartum depression.

Re-traumatization

A significant number of women bring histories of trauma to their pregnancies. Pregnancy, labor, and postpartum are also common times for women to release traumatic memories to consciousness for the first time; but whether or not a conscious connection is made between the trauma and the maternal experience, PTSD symptoms can be triggered or exacerbated. The resulting hodgepodge of sensation, emotion, and mental confusion is extremely difficult to integrate, especially if the memories are fragmented into pure sensation or pure emotion with no context. A woman may doubt her own sanity when she unexplainably responds to the normal experiences of pregnancy and birth with rage, terror or total numbness.

A trauma survivor's fear of birth may not be so obvious, even to herself. It may surface as an intense distrust of her doctor or midwife, as a refusal to tolerate any of birth's sensations ("I want an epidural as soon as labor begins"), or as a dark skepticism about the birth's outcome. Some women are unduly apathetic, passively allowing their caregivers to make all of the relevant decisions.

Even the best of births include some potential reminders of past trauma. Especially (but not exclusively) if her past trauma involved her sexual identity (painful gynecological dysfunction, childhood sexual abuse, rape or other sexual trauma, past childbirth losses or complications), the pregnant woman is faced with a minefield of possible triggers for intrusive memories.

Overwhelming sensations in the pelvic area may arouse memories of pain, shame, or terror. A woman may panic because she again feels helpless to control what is happening to her body. Sharing the most private areas of her body with impersonal caregivers may feel like a re-violation of her personal boundaries. Birth, by its very nature, then re-traumatizes her. If physical or emotional complications arise during the present labor, she is even more vulnerable to a recurrence of traumatic response patterns.

The survival skills that a woman learned in response to past trauma will come into play if she feels threatened by her birth experience. A common PTSD symptom is dissociation, or the ability to separate one's mental or emotional experience from the present physical reality. Everyone experiences dissociation to some extent--daydreaming while driving on "automatic pilot," for instance--but trauma survivors may unconsciously employ it on a regular basis to distance themselves from emotional or physical pain.

For childbearing women, this may include the use of medically sanctioned dissociation: "distraction" techniques in labor, epidurals, or elective cesarean deliveries. If such coping mechanisms are withheld or are not effective for some reason (such as an epidural that only provides "spotty" relief), the woman is left feeling once again betrayed by her own best efforts to protect herself.

Re-traumatization is no less "real" than primary trauma. Although it can be very perplexing to caregivers when a woman compares a fairly straightforward birth to rape, war, or other traumatic events, her nervous system makes no distinction. Even an obscure similarity to a dire threat from the past (such as a caregiver's gender) can trigger a full-blown neurological "flashback" of the then-appropriate trauma response.

If the woman has no conscious memory of her trauma, or if she has made no connection between it and her labor experiences, she may be the most baffled by--or even ashamed of--her "overreaction." If her feelings are not validated--if she meets with indifference, disbelief, or denial among those around her--both the past trauma and the present re-traumatization will remain embedded in her functional patterns.

It must be pointed out that a history of trauma does not guarantee re-traumatization during childbirth. When a woman is able to create a sense of safety and empowerment in her choices and plans for birth, she may actually experience her birth as a great triumph over her past victimization. She then has a new frame of reference for her experience of her body and her sexuality, and she understands her own power to impact that experience.

Witness Trauma

Although mothers and babies deserve prime consideration in a discussion of childbirth trauma, other people form the social context for their experience. Not only will the presence of certain people affect the labor process,(6) but the mother's and baby's experiences will affect those who witness them. Birth cannot be studied solely as a maternal-child experience when other relationships are such an integral feature.

"Witnesses as well as victims are subject to the dialectic of trauma."(7) Although witnesses may not share the threat of personal danger, their fear and helplessness are acute. Many men have expressed the anguish of being unable to take away their wives' / partners' pain during labor. Men are not socialized to share pain; they are conditioned to believe that they must do something about it. For some, the stress of helplessly observing the birth is more than they can bear, and they either leave the room or lose consciousness (whether by "tuning out," falling asleep, or even fainting). Their distress is likely compounded by a sense of guilt: "She's going through all this because of me--I impregnated her."(8)

Perhaps because of such guilt; perhaps because of the lack of personal danger; perhaps because of an individual need to avoid deep feelings or fears, witnesses are sometimes the first to brush aside a woman's trauma experience in childbirth. Personal labor companions, whether family or friends, must maintain an ongoing relationship with the mother and baby. Painful memories, guilt, and outrage over a trauma that is "over" may seem an unnecessary and threatening burden on that relationship. It is difficult to live with such an awareness of human vulnerability as it applies to one's dearest loved ones. "Forgetting" or downplaying trauma restores a daily comfort level.

Witnesses--including professional caregivers--also bring their own traumatic histories into the birthing room. Whether or not a woman perceives her birth experience as traumatic, it may trigger intrusive memories or dissociation among her companions and/or observers. Re-traumatization is a potent form of witness trauma, extracting a sense of personal danger from another person's experience.

Re-traumatization of maternity caregivers may be a more powerful element in childbirth dynamics than is readily apparent. It is a commonly recognized phenomenon that people tend to gravitate toward professions that address their own most challenging personal issues, such as recovering alcoholics who become addiction counselors and sexual abuse survivors who pursue careers in therapeutic bodywork. Similarly, those who work in obstetrics may have a personal stake in issues of sexuality, birth, and maternity in general.

The ramifications for maternity care are staggering. A nurse, for instance, may feel outrage or panic if a patient chooses to forego pain medication, because her own experience of sexual abuse has rendered her incapable of being present with unmitigated pelvic sensation. By encouraging pain medication, she validates her own need for relief; when such medication is refused, she feels personally threatened. At the same birth, a labor assistant may become angry when medication is encouraged because physical numbness is associated in her mind with victimization and a lack of control over her own body. The needs of the laboring woman then become hopelessly tangled with the efforts of her caregivers to resolve their own past trauma issues.

Past childbirth traumas also tend to intrude upon the interactions among laboring women, their companions, and caregivers. Any mother who attends a birth will access memories of her own birth experiences. (This may be most poignantly true of the baby's grandmother, for whom the birth is a direct link to her own childbearing history.) A woman is wise to ask about her doctor's or midwife's childbirth experiences in order to better understand any potential triggers for traumatic response patterns.

Professional birth attendants have a unique perspective on primary birth trauma. Their training, skills, and protocols serve as a buffer against the sense of helplessness that is trauma's central feature. They may perceive birth complications as "routine" opportunities to utilize their skills. Even in the face of serious danger to the mother or baby, they may actually relish the task of "coming to the rescue" and resolving the situation with their medical expertise. As Korte and Scaer point out in A Good Birth, A Safe Birth, doctors are trained to focus on ultimate outcomes, not the "details" of a birth.(9) Far from being traumatized, they may walk away from difficult births with a triumphant sense of satisfaction. This perspective on trauma creates an implicit tension between caregivers and the women they serve.

Of course, health care providers are not immune to primary witness trauma; but they are certainly discouraged from admitting to it. The definition of professionalism within health care includes an element of emotional distance from patients. To be distressed by a patient's trauma is to be unbearably vulnerable in a job that involves frequent exposure to such trauma. Doctors may also feel that if they share their patients' pain, they may be claiming responsibility for it, or for their inability to alleviate it. In many ways, it is safer for medical professionals to deny trauma's impact on both themselves and their patients.

Trauma Prevention

As with many of life's challenges, the best cure for trauma is prevention. Obviously it's impossible to prevent all birth trauma from occurring, but the potential for trauma is greatly reduced when steps are taken to create a supportive, empowering environment for pregnancy, labor, and birth:

* Knowledge of the birth process helps a woman realize that birth is something she can do rather than something that is done to her. Prenatal classes, videos, books, and conversations with other women assist her to set well-informed priorities and to plan realistically for the birth she wants.

* Counseling may be especially helpful during pregnancy to help a survivor of past trauma come to grips with the vulnerability of birth. It is important to find a counselor who is not overly fearful of birth herself.

* Somatic therapies, such as Trauma Touch Therapy[TM], can also help a woman learn to cope with any physical panic responses or numbness that lingers from past trauma. Such therapeutic bodywork is always done with the utmost respect for a woman's boundaries and sensitivities.

* A respectful doctor or midwife, who is willing to listen carefully and to plan cooperatively for the birth, can help reduce a woman's fear that she will be powerless in the birth drama. Trauma survivors may need to interview several caregivers before finding one who is sensitive to their special challenges in childbirth; but the benefits of rapport and trust are well worth the search.

* Good labor support is essential for creating an emotionally safe atmosphere for birth. Studies have shown that although women value the presence of their husbands/partners, they greatly benefit from the additional support of another woman. The best labor assistants are those whose outlook on birth is positive and who can actively support the laboring mother's need for privacy, flexibility, and sensitive care.

Trauma Resolution

Trauma has a permanent impact on a victim's life, but it need not be permanently debilitating. Just as a body heals from surgery, the entire self can heal from the wounds of trauma. "The fundamental stages of recovery are establishing safety, reconstructing the trauma story, and restoring the connection between survivors and their community."(10)

A certain degree of safety is restored when the birth process is complete. Unlike a rape survivor, a new mother need not fear that her trauma could suddenly happen again with no warning. Birth takes place within very limited parameters.

The implicit connection between childbirth and a woman's overall sexual functioning is not so easily confined, however. "Any reminder of the reproductive cycle may activate unpleasant memories and associations [with a traumatic birth].... Having sex again ]represents] the whole cycle that could begin again: creativity, conception, pregnancy, birth."(11) A sense of safety at this point requires patience and understanding from a woman's partner if she isn't ready to resume sexual relations. As she works at integrating her birth experience into her identity, she must feel that she can control her own fertility without jeopardizing her marriage/primary relationship.

A study of rape survivors showed that "the length of time required for recovery was related to the quality of the person's intimate relationships."(12) Personal support not only provides an emotional haven within which to heal, it gives a woman a sympathetic audience for her story. Every mother needs opportunities to talk about her birth experience; traumatized mothers desperately need to be both heard and believed. "The survivor needs the help of others who are willing to recognize that a traumatic event has occurred, to suspend their preconceived judgments, and simply to bear witness to her tale."(13)

When personal support is lacking, a birth trauma survivor may find the audience she needs in more structured contexts. Support groups such as ICAN (International Cesarean Awareness Network) serve the dual healing roles of listening respectfully to traumatic birth stories and providing it transitional step into the society of other mothers. Their acceptance and empathy help restore the survivor's faith in other people.

Personal counseling is another source of support and reconnection for a survivor of birth trauma. Whether she seeks out her childbirth educator, a pastor, a social worker, a psychologist, or a psychiatrist, what matters most is that her trauma is acknowledged as real. She is more likely to respond to any among the array of available treatments if she feels validated and empowered by her relationship with her counselor. The means to healing is not nearly so important as the environment in which it takes place.

One of the saving graces of a traumatic birth for a woman with a history of past trauma is the opportunity to heal part and parcel. In the course of her counseling, she is likely to deal with old wounds as well as fresh ones, and the new coping skills she acquires will enable her to live in the present as never before.

Somatic therapies are also a possible tool in the quest for post-trauma recovery. Various holistic practitioners and bodyworkers are trained to address the aftereffects of trauma through body awareness. Trauma Touch Therapy[TM], Hakomi Integrative Somatics[TM], Hellerwork, and Somatic Experiencing[R] are among the modalities that utilize touch/massage, breathwork, and/or movement to facilitate trauma resolution.

Living with the Scars

"Part of healing is to reclaim the entire cycle, from having sex again after birth, having a complete menstrual cycle, to another conception and birth. For a woman who is done with childbearing, her job is to love her body again, love its power to create, whether it's a baby or the ability to get through the day."(14)

Living in peace with her femininity, her maternity, and her humanity is the birth trauma survivor's goal. As with all such lofty goals, it is a journey, involving winding routes, detours, and maybe even backtracking. She will be challenged by her memories, her future pregnancies, her associations with other childbearing women, her experiences with medical caregivers, and her encounters with other traumatic events. But if she integrates her birth trauma into a positive self-image of herself as a woman, she will also meet her challenges with strengths and depths of perception that she may never have otherwise achieved.

In the words of maternity psychologist Lynn Madsen, "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."(15)

Endnotes

(1.) Judith Lewis Herman, MD, Trauma and Recovery (New York: Basic Books, 1992), p. 8.

(2.) Herman, p. 41.

(3.) Herman, p. 60.

(4.) Peter Levine, Waking the Tiger (Berkeley, CA: North Atlantic Books, 1997), p. 54.

(5.) Herman, p. 34.

(6.) Marshall H. Klaus, MD, John H. Kennell, MD, and Phyllis H. Klaus, M. Ed., Mothering the Mother (New 'York: Addison-Wesley, 1993), pp. 31-51.

(7.) Herman, p. 2.

(8.) Bruce Kluger, "The Day My Baby Was Born," Glamour, October 1995, pp. 230-231, 269-270.

(9.) Diana Korte and Roberta Scaer, A Good Birth, A Safe Birth (Boston: Harvard Common Press, 1992), p. 97.

(10.) Herman, p. 3.

(11.) Lynn Madsen, Rebounding From Childbirth (Westport, CT: Bergin & Garvey, 1994), p. 101.

(12.) Herman, p. 63.

(13.) Herman, p. 68.

(14.) Madsen, p. 101.

(15.) Madsen, p. 89.

Other Resources

Gloria A. Bachmann, MD, Tamerra P. Moeller, PhD, and Jodi Benett, BA, "Childhood Sexual Abuse and the Consequences in Adult Women," Obstetrics and Gynecology, Vol 17, No 4, April 1988, pp. 631-642.

Victoria L. Banyard, "The Impact of Childhood Sexual Abuse and Family Functioning on Four Dimensions of Women's Later Parenting," Child Abuse & Neglect, Vol. 21, No. 11, 1997, pp. 1095-1107.

Diane K. Bohn and Karen A. Holz, "Sequelae of Abuse: Health Effects of Childhood Sexual Abuse, Domestic Battering, and Rape," Journal of Nurse-Midwifery, Vol. 41, No. 6, November/December 1996, pp. 442-456.

Anna Cassin, "Sexual Abuse and Motherhood," Nursing Times, Vol. 92, No. 15; April 10, 1996, pp. 38-39.

"Effects of Childhood Sexual Abuse on Childbirth," Birth: Issues in Perinatal Care, Vol 19, No 4, December 1992, pp. 214-225.

"The Experience of Childbirth for Survivors of Incest," Midwifery, 1994, No. 10, pp. 26-39.

Ruth Gallop, Patricia McKeever, Brenda Toner, William Lancee, and Maria Lueck, "The Impact of Childhood Sexual Abuse on the Psychological Well-Being and Practice of Nurses," Archives of Psychiatric Nursing, Vol. 9, No. 3, June 1995, pp. 137-145.

Debra A. Neumann, Beth M Houskamp, Vicki E. Pollock, and John Briere, "The Long-Term Sequelae of Childhood Sexual Abuse in Women: A Meta-Analytic Review," Child Maltreatment, Vol. 1, No. 1, February 1996, pp. 6-16.

Paulina Perez, RN, "When a Birth Causes Trauma," Childbirth Forum, Summer 1996, pp. 1-5.

"Pregnancy Tips for Sexual Abuse Survivors," Special Delivery, Vol. 18, No. 2, Spring 1995, p. 8.

Naomi Rhodes and Sally Hutchinson, "Labor Experiences of Childhood Sexual Abuse Survivors," Birth, Vol. 21, No. 4, December 1994, pp. 213-220.

"Sexual Abuse and its Impact on the Childbearing Years," International Journal of Childbirth Education, 1992, No. 7, pp. 33-34.

H. Tidy, "Clinical Midwife: Care for Survivors of Childhood Sexual Abuse," Modern Midwife, Vol. 6, No. 7, July 1996, pp. 17-19.

C. Westcott, "Sexual Abuse and Childbirth Education," International Journal of Childbirth Education, 1991, No. 6, pp. 32-33.

--Sue Radosti is a Certified Childbirth Educator, Licensed Massage Therapist, and Labor Assistant residing in Sioux City, Iowa. This article is a rewrite of an ALACE recertification project.

Sue Radosti, Certified Childbirth Educator and Labor Assistant, Certified Trauma Touch[TM] Therapist3