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Birth trauma: posttraumatic stress disorder after childbirth.

Posttraumatic stress disorder (PTSD) was first recognized by the American Psychiatric Association (APA) as a mental disorder in 1980 when it was introduced to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (Friedman, 2007). Since then, millions of people faced with traumatic events have been diagnosed with this disorder. Only recently have specialists who work in the field of maternal health begun to research and recognize childbirth as a triggering event for the development of PTSD (Wijma, Soderquist, & Wijma, 1997). These specialists, including midwives, childbirth educators, doulas, labor and delivery and postpartum nurses, and physicians must be made aware of this disorder in order to effectively help postpartum women recover from such mental anguish. Women's health specialists are in a unique position to observe the signs and symptoms of birth trauma and assisting the mother to receive help. The proper diagnosis and treatment of PTSD is vital not only for the mother, but also for the relationship she has with her family, partner, and infant (Ayers, Eagle, & Waring, 2006). This article examines PTSD as it relates to a mental disorder after childbirth, its prevalence among women, causes and risk factors, symptoms, diagnosis, and treatments.

Childbirth and PTSD

Prevalence

Numerous researchers have indicated that the prevalence of birth trauma after childbirth ranges between i.7% and 6% from four to six weeks postpartum respectively, with 10.5% to 30% of women labeling their birthing experience as traumatic without meeting full diagnostic criteria for PTSD (Soet, Brack, & Dilorio, 2003; White, Matthey, Boyd, & Barnett, 2006; Wijma, Soderquist, & Wijma, 1997; Zaers, Waschke, & Elhert, 2008). Ayers and Pickering (2001) found that the occurrence of PTSD from six weeks to six months postpartum improves from 2.8% to 1.5%, indicating that for some women, the symptoms lessen with time or proper treatment. The prevalence of PTSD at six months postpartum was found by White et al. (2006) to be 2.4% and again 2.4% at 12 months, revealing no evidence of improvement in symptoms over time. In order for the PTSD diagnosis to be made, the diagnostic signs, symptoms, and behaviors exhibited by the patient must be expressly related to their birth experience. This makes determining the prevalence of this condition problematic because many other psychiatric disorders have similar, if not identical, signs and symptoms, which can lead to a misdiagnosis of the true disorder (Theroux, 2009).

Causes and Risk Factors

Any exposure to perceived trauma can lead to PTSD, and new mothers may be very susceptible to this disorder because of their hormonal fluctuations during birth and postpartum (Sichel & Driscoll, 1999). Sichel and Driscoll (1999) described the postpartum period as a very high-risk period where stressors can easily cause reproductive hormones to disrupt the brain's chemistry. The subjective experience of how the birth is perceived through the eyes of the mother is the most important factor (Alder, Stadlmayr, Tschudin, & Bitzer, 2006). Events which may be perceived as traumatic during the childbirth process can include unexpected medical interventions, pain beyond the coping ability of the woman, care from providers that was uncaring, unsafe and inhumane, and the possibility of injury or death for herself or infant which leads to lasting physical or emotional effects of the trauma after the birth (Beck, 2004; Sawyer & Ayers, 2009).

A number of risk factors have been determined by Gamble and Creedy (2005), which help to identify pregnant women who are already at risk of developing PTSD. If the risk factors are detected in women during pregnancy, it gives the provider time to educate the patient and promote healing before the birth occurs. It also sheds light onto which women are likely to need more support and care during their postpartum period regardless of whether they develop PTSD or not (Gamble & Creedy, 2005).

Two primary risk factors that increase a patient's vulnerability to developing PTSD that can be determined prenatally are previous traumatic experiences and pre-existing depression. (Gamble & Creedy, 2005; Soderquist, Wijma, Throbert, & Wijma, 2009). According to Simkin and Klaus (2004) for victims of sexual trauma, which can have lifelong psychological effects, childbearing can evoke anxiety and fear. Simkin and Klaus also report that one in five women is sexually abused during childhood, and while these experiences may have been pushed into the unconscious mind, childbirth can be very traumatic and cause these memories to resurface (2004). For some women who have been victims of sexual abuse, vaginal exams, nakedness in the presence of others, a perceived or actual lack of control in the situation, and pelvic pain are all potentially traumatic events (Simkin & Klaus, 2004). These experiences can cause a woman to relive or have flashback of the sexual abuse she once endured.

In a study conducted by Soderquist et al. (2009), women who experienced clinical depression before and during pregnancy have a 16.3% risk of developing PTSD after childbirth. Depression causes an impaired ability to cope with stress and traumatic life events, and this decreased coping ability can put women at risk for developing a severe mental illness, such as PTSD. Depression can also change the perception a woman has of her childbirth, easily allowing her subjective experience to become traumatic, which can greatly affect her ability to bond with her infant. Soderquist et al. noted that women who have a preexisting fear or anxiety of childbirth (tokophobia) are also vulnerable to postnatal PTSD. Risk factors that are identified before the birth can be discussed with the appropriate provider, which can help begin the healing process before any new or additional trauma is experienced. Ultimately, the prevention of this condition, by recognition of risk factors, will allow women to have a more dignified and empowering birth experience (Soderquist et al, 2009).

Events that occur during delivery have also been identified as risk factors for the development of PTSD. A positive association between an operative delivery and birth trauma was found by Gamble and Creedy (2005). Emergency caesarean deliveries and the use of forceps or a vacuum device greatly increased birth trauma experienced by the mother. In Gamble and Creedy's study of 348 women, 73% of those who had an emergency caesarean section reported having a traumatic birth, and 79.3% of the women whom had forceps or a vacuum used during their birth experienced trauma. The reaction to unexpected medical procedures during birth can be highly traumatic and can result in lifelong physical and psychological damage (Gamble & Creedy, 2005).

Symptoms

Ayers et al. (2006) examined the effects that childbirth has on women and their relationships. Although symptom expression varies widely, Ayers et al. revealed a number of symptoms experienced by women who have PTSD. Physical symptoms may include long-term pain from the birth itself (Ayers et al., 2006). Episiotomies, caesarean sections, and the need for pelvic reconstructive surgery can cause severe physical pain. Women who had a traumatic vaginal birth also reported to Ayers et al. a lack of vaginal sensation and physical deformation to the vagina. Extreme exhaustion and lack of energy is another common symptom for women with PTSD (Ayers et al., 2006).

Psychological symptoms reported by women in Ayers et al.'s (2006) study included extreme depression, suicidal intentions, anger, and changed feelings about themselves. The anger can be directed at the father of the child, the child, or the woman herself. This emotion may stem from the loss of control felt after a traumatic birth. The feelings the woman has about herself commonly change from a positive self-image to one that is negative and of no self-worth (Ayers et al., 2006). Other participants revealed having suddenly higher standards for themselves with regard to how they must portray their lives in order to cover up the physical and emotional pain they were experiencing (Ayers et al., 2006). Nearly all women report being fearful of having another child after birth trauma, and this fear transposes into their sex life (Ayers et al., 2006). The fear of getting pregnant again, is one of the causes for women not having sex with their partners post birth. Physical pelvic and vaginal pains as well as negative memories of the trauma also both deter sexual intercourse (Ayers et al., 2006).

Ayers et al. (2006) determined the social effects of birth trauma to be profound. The two most important relationships affected by postnatal PTSD are the relationships between the mother and her partner and the mother and her child (Ayers et al., 2006). The strain on the relationship between partner and mother can be caused by a loss of sexual feelings, blaming the partner, or feeling a lack of support. Unfortunately, without proper therapy, it is common for separation or divorce to occur (Ayers et al., 2006). Strong (2012) described how the mother-child bond is greatly affected by PTSD. Women may find themselves being either avoidant to the child or overly protective, and neither of the symptoms results in a positive mother-child relationship (Strong, 2012). PTSD can produce feelings of anxiety when the infant needs the mother's attention. Some woman may blame their child for the emotions and pain they are experiencing and have thoughts to harm the infant. On the opposite end of the spectrum, women may feel an overwhelming need to protect their child. Long-term effects can be seen within the children who have mothers with PTSD (Strong, 2012).

Assessment and Diagnosis

PTSD assessment should begin prenatally to identify possible risk factors. Providers should establish positive rapport with their patients in order to be able to discuss previous traumatic experiences and personality characteristics, like depression (Leeds & Hargreaves, 2008). The discussion of these personal topics will yield data that is very important to improve the care of the patient. All women should be properly educated on situations that could occur during delivery and should be kept well informed during the entire delivery process so they do not feel a loss of control (Beck, 2004). Assessment questionnaires, such as the Beck's Depression Inventory, can assist the provider in obtaining information about depression, and other questionnaires can assess a woman's response to past traumatic events (Varcarolis & Halter, 2010). Leeds and Hargreaves (2008) reported that women's health providers must also be aware of the situations that occur during labor and delivery that may cause birth trauma. Careful documentation should be made about the woman's condition and emotional status during her labor process, and the provider's notes should be passed along to all people who are involved in the new mother's care (Leeds & Hargreaves, 2008). If a traumatic event did occur or the woman lost control during the process, then postnatal physicians, midwifes, and nurses should be aware of this information in order to address these issues (Alder et al., 2006). The Posttraumatic Diagnostic Scale (PDS) can be used to screen for PTSD before the patient leaves the hospital and throughout the postpartum period, as it corresponds directly with the diagnostic items on the DSM-IV (White, Matthey, Boyd, & Barnett, 2006).

The DSM-IV-TR has specific guidelines for the diagnosis of PTSD. The necessary criteria include a stressor, intrusive recollection of the event, avoidance or numbing characteristics, and hyper-arousal (APA, 2000). These criteria must be present for at least one month and cause disturbances in important areas of functioning before diagnosis can be made (APA, 2000). The condition can be classified as either acute or chronic: acute PTSD symptoms last for less than three months, while chronic PTSD lasts for more than three months (APA, 2000). Women may experience a delayed onset of symptoms, where they do not experience PTSD until six months after their childbirth experience (APA, 2000). Ayers and Pickering (2001) proposed that the memories of birth trauma may be put into the subconscious until the chaos of having a new baby subsides at which time the signs and symptoms of PTSD may develop. In this case, screening is important even after the typical six week postpartum visit with a provider.

Cognitive and Complementary Treatment

Cognitive and complementary treatment is necessary for all women healing from birth trauma because medications alone are not enough. Psychological and psychosocial treatments can help improve the quality of life for women suffering from PTSD. Cognitive behavioral therapy (CBT) involves discussing the events of the birth with a psychologist in order to make sense of the feelings and thoughts that arise (The Birth Trauma Association, 2011). Maladaptive perceptions and emotions are changed into adaptive and more manageable ones. CBT teaches women to develop coping skills that are healthy. Relaxation techniques can be used during the therapy session to create a safe and healing environment, which reduces anxiety when discussing the traumatic events (Bryant, Moulds, Guthrie, & Nixon, 2005). CBT helps reduce the rate of comorbid symptoms such as depression and insomnia in women with PTSD, and has over 50% effectiveness of reducing PTSD symptoms when used at least once per week for two to three months (Kar, 2011). Family therapy and marriage counseling is also available to provide treatment for partners and other family members that have been affected by the birth trauma (Ayers et al., 2006).

According to the Substance Abuse and Mental Health Services Administration (2013), Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy designed to reduce the symptoms of PTSD in daily life. During this form of therapy, a patient works one-on-one with a therapist to determine a positive memory that is associated with calm and relaxed emotions. This memory can be used when distressing emotions are evoked during the repetitive side-to-side eye movements (Substance Abuse and Mental Health Services Administration, 2013). A study conducted by van der Kolk et al. (2007) found that EMDR is over 29% effective in completely removing all symptoms of PTSD and 88% of patients no longer met the criteria for the PTSD diagnosis. The patients who were exposed to this treatment had positive results and long-term maintenance of the disorder after eight weeks of treatment (van der Kolk et al., 2007).

Hypnosis or hypnotherapy is a very effective treatment for women who have experienced birth trauma. According to Lynn and Kirsch (2006) symptoms of PTSD can be dramatically reduced after hypnosis sessions. The basis of the therapy is for the traumatic events to be relived in a controlled and safe environment, and events can then be restructured subconsciously (Lynn & Kirsch, 2006). Bryant et al. (2005) found people using CBT with hypnosis to be more effective than the people using CBT alone at a six month follow up. Fewer recurrent symptoms were found in the group who participated in hypnosis (Bryant et al., 2005). Hypnosis allows for patients to alter the traumatic memory by changing characteristics of themselves, changing their feelings at the event, making the traumatic memory become one that is pleasant, or pushing the memory out of their mind until the next session (Lynn & Kirsch, 2006).

Implications for Women's Health Providers

Women affected by birth trauma need providers to be knowledgeable about all aspects of the mental disorder that can follow. Around 1.7% to 6% of women suffers from birth trauma and do not receive proper treatment from their health care providers (Zaers, Waschke, & Elhert, 2008). Education on this topic as well as assessment for risk factors should begin prenatally whether taught by a childbirth educator, doula, midwife, or OB/GYN. The Mother Friendly Childbirth Initiative is being implemented throughout hospitals with the goals of making the childbirth process more natural while improving birth outcomes including the satisfaction of the mother and her family (Coalition for Improving Maternity Services, 2013). Risk factors, depression, and previous sexual abuse should be screened for by primary care givers, and referrals should be made to psychologists before delivery when warranted. Some cases of birth trauma may be prevented with education (Soderquist et al., 2009). Discussion of medical procedures that could occur during birth, such as forceps, episiotomies, and emergency C-sections, must be talked about in detail (Gamble & Creedy, 2005). Preparation for what is to be expected and other circumstances that can occur will help decrease anxieties among women. Better birth outcomes will occur if more education and preparation is done prenatally (Soet, Brack, & Dilorio, 2004).

Simkin and Klaus (2004) describe the unique care women who have experienced previous sexual abuse require. Providers should feel comfortable asking about and discussing sexual abuse with women. Open communication and trust are necessary for women's health providers to build with women in order for them to open up about their abuse (Simkin & Klaus, 2004). Encouraging women to tell their stories or seek counseling from therapist or support groups will help in their healing. A childhood sexual abuse survivor may have flashbacks and feelings of no control during delivery (Wilson, 2011). Nurses, midwives, and doctors should use patience and describe all procedures before they are done; this will help the woman gain a sense of control. An empowering birth for a woman who has experienced previous trauma may help her heal, while a traumatic birth can cause a downward spiral of symptoms (The Birth Trauma Association, 2011).

Postpartum doulas, midwifes, and OB/GYNs should screen all women after birth for trauma, especially if the birth involved any unexpected medical procedures. The woman's perception is usually different than that of the health care providers, who may assume the birth was not traumatic (Gamble & Creedy, 2005). Screening should begin before the woman leaves the hospital, and if there is any reason to believe she may have difficulty processing the delivery, she should be referred to outside resources for follow up. Holistic care is of the upmost importance for healthy physical and psychological development of the newly postpartum mother and her infant (Beck, 2004). Strong (2012) reported PTSD can have long lasting and devastating effects on the infant raised by a mother with this mental illness. Children have increased risks of depression, being overweight, and having insecurities when raised by mothers who are suffering from PTSD (Strong, 2012). The long-term effects of trauma on women can predispose them to autoimmune diseases and ineffective coping mechanisms, such as substance abuse (Wilson & Severson, 2012).

Conclusions

Birth trauma resulting in PTSD is a severe mental illness that affects the lives of as many as 6% of childbearing women (Zaers, Waschke, & Elhert, 2008). Support websites raise awareness and provide women, who may feel alone, with hope and education on the condition (The Birth Trauma Association, 2011). Health care providers need more training and education on how to minimize and prevent trauma during delivery and childbirth educators have a role in making these issues more recognized. We must be aware that medical interventions can have psychological consequences (Gamble & Creedy, 2005). The psychological wellbeing of mothers and their families requires holistic care by all women's health providers throughout the childbearing process and during the postpartum period (Beck, 2004). The prevention or recognition of PTSD early will greatly improve maternal and infant health outcomes.

References

Alder, J., Stadlmayr, W., Tschundin, S., & Bitzer, J. (2006). Post-traumatic symptoms after childbirth: What should we offer? Journal of Psychosomatic Obstetrics & Gynecology, 27(2), 107-112.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev). Washington, DC: Author.

Ayers, S., Eagle, A., & Waring, H. (2006). The effects of childbirth-related post-traumatic stress disorder on women and their relationships: A qualitative study. Psychology, Health, & Medicine, 11(4), 389-398.

Ayers, S., & Pickering, A. D. (2001). Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth, 28(2), 111-118.

Beck, C. T. (2004). Birth trauma: In the eye of the beholder. Nursing Research, 53(1), 28-35.

The Birth Trauma Association. (2011). Retrieved on February 1, 2013, from http://www.birthtraumaassociation.org.uk/default.asp

Bryant, R. A., Moulds, M. L., Guthrie, R. M., & Nixon, R. D. V. (2005). The additive benefit of hypnosis and cognitive-behavioral therapy in treating acute stress disorder. Journal of Consulting and Clinical Psychology, 73(2), 334-340.

Coalition for Improving Maternity Services. (2013). Mother-friendly childbirth initiative. Retrieved on May 6, 2013, from www.motherfriendly.org/ MFCI

Friedman, M. J. (2007). PTSD history and overview. Retrieved on February 1, 2013, from http://www.ptsd.va.gov/professional/pages/ptsd-overview.asp

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Leeds, L., & Hargreaves, I. (2008). The psychological consequences of childbirth. Journal of Reproductive and Infant Psychology, 26(2), 108-122.

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Gamble, J. & Creedy, D. (2005). Psychological trauma symptoms of operative birth. British Journal of Midwifery, 13(5), 218-224.

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Sawyer, A., & Ayers, S. (2009). Post-traumatic growth in women after childbirth. Psychology and Health, 24(4), 457-471.

Sichel, D., & Driscoll, J. W. (1999). Women's moods: What every woman must know about hormones, the brain, and emotional health. New York, NY: William Morrow and Company.

Simkin, P., & Klaus, P. (2004). When survivors give birth: Understanding and healing the effects of early sexual abuse on childbearing women. Seattle, WA: Classic Day Publishing.

Soderquist, J., Wijma, B., Thorbert, G., & Wijma, K. (2009). Risk factors in pregnancy for post-traumatic stress and depression after childbirth. BJOG An International Journal of Obstetrics and Gynaecology, 116, 672-680.

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Wijma, K., Soderquist, M.A., & Wijma, B. (1997). Posttraumatic stress disorder after childbirth: A cross-sectional study. Journal of Anxiety Disorders, 11, 587-597.

Wilson, D. (2011). Preparing adult survivors of childhood sexual abuse for pregnancy, labor, and delivery. International Journal of Childbirth Education, 26(2), 7-8.

Wilson, D., & Severson, M. (2012). Long-term health outcomes of childhood sexual abuse. American Nurse Today, 7(10). Retrieved on February i, 2012, from http://www.americannursetoday.com/article. aspx?id=9564&fid=9534

Zaers, S., Waschke, M., & Elhert, U. (2008). Depressive symptoms and symptoms of post-traumatic stress disorder in women after childbirth. Journal of Psychosomatic Obstetrics and Gynecology, 29(1), 61-71.

Grace Helen Zimmerman, RN BSN Birth Doula

Grace Zimmerman graduated with her Bachelor of Science in Nursing from Middle Tennessee State University in 2013. She is currently a women's health nurse resident at Vanderbilt Medical Center and has future aspirations of becoming a Certified Nurse Midwife. Grace volunteers as a Birth Doula for women of low income and women recovering from addictions in the Middle Tennessee area.

Table 1. Tips for Childbirth Educators

1. Incorporate education on birth trauma, such as risk
factors like previous sexual trauma and depression,
into classes.

2. Adequately describe medical procedures, include
details and pictures of how the procedures are done
as well as when and why they could be necessary.
This will help to reduce mother's anxieties during
her birth if she is prepared and educated.

3. Be educated on resources in your area, such as psychologists,
doulas, and hypnotherapists, to be able
to refer mothers who may benefit from these.

4. Educate mothers and their partners or family support
on signs and symptoms of PTSD after childbirth.
Let them know how common and undiagnosed
this condition is, and that help is available if
they feel like they are developing this condition.

5. Help women recognize their fears and anxieties
about their pregnancy, birth, and postpartum
beforehand in order to begin early treatments and
mental processing.
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Author:Zimmerman, Grace Helen
Publication:International Journal of Childbirth Education
Article Type:Disease/Disorder overview
Date:Jul 1, 2013
Words:4106
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