What is PTSD?
Post-traumatic stress disorder (PTSD) is a condition where the effects of a life-threatening or frightening event linger for weeks, months, or even years after the event has passed. A traumatic event impacts the brain and causes heightened emotional and physical responses. Experiencing or witnessing any life-threatening event may cause PTSD. Military combat, natural disaster, assault, accidents, or childbirth can be traumatic events.
What might a patient with PTSD feel?
Survivors may find thoughts of the trauma are with them for many years and just as painful as they were when the trauma occurred. Details of the trauma may be hard to recall. Their memories are waking nightmares, and their dreams are sleeping nightmares. They remain vigilant, on edge, waiting for a recurrence of the traumatic event. Sleep may be impaired. The survivor may isolate from others. Avoidance is common in PTSD; to minimize their memories, they often avoid any reminders of the experience. They may become reclusive.
Specific to childbirth, the intimate examinations, blood, pain, and loud noises common in childbirth may trigger memories of earlier traumas, even those not associated with childbirth. Patients may be panicky or numb, and may be unable to tolerate procedures or participate in the labor process.
In the case of birth-related PTSD, patients may avoid talking about their birth experience. They may find reminders of childbirth on television or in movies difficult to tolerate. They may not remember any details of the birth or they may have very vivid memories or flashbacks of the event. Often, they feel responsible for the negative events surrounding their birth, or blame others involved in the birth. During the postpartum, new parents may have difficulty bonding with the baby or feel uncomfortable with their infant. Others may be overly attentive to the baby, excessively anxious to prevent further trauma. Some will not allow the baby out of their sight and may keep watch over the sleeping baby. Parents often feel ashamed, guilty, or numb.
Patient Example 1: Robin had been planning her pregnancy and her delivery for as long as she could remember. She was working with a nurse midwife who shared Robin’s vision for a natural delivery at the local birth center. At 40 weeks, Robin’s water broke. After over 30 hours, Robin was only 5 cm dilated and tired. The midwife had Robin transferred to a sister hospital where the doctor determined she would need a cesarean section. Robin cried quietly at the news. The baby had Apgar scores of 2 and 5 and was brought to the NICU, but recovered quickly.
Patient Example 2: Tori is G2P1, currently 16 weeks EGA. Her last pregnancy was significant for postpartum hemorrhage, which presented while the obstetrician was stitching up her episiotomy. Tori feels that the obstetrician caused the hemorrhage by doing the episiotomy and now wants NO intervention with her pregnancy. She is refusing all blood draws and ultrasounds at this time.
What causes birth-related PTSD?
Each individual defines trauma differently. Common emergency procedures or even routine interventions during labor may be traumatic. Unplanned events such as an operative delivery, hemorrhage or obstetric tear, uncontrolled pain, or having a child need medical intervention or intensive care may be traumatic. We know that prior trauma, poor support, and depression during pregnancy may be risks for traumatic childbirth.
How is PTSD diagnosed?
The PC-PTSD is a commonly used screening tool for PTSD. The City Birth Trauma Scale is specific to birth related trauma. During the course of an interview, if you are concerned about trauma you may want to ask:
- Have you ever been the victim of trauma?
- Seen things you should not have to see?
- Experienced something that people ought not have to experience?
- Has someone done something to you that they ought not do?
Given that military combat and rape are what people generally consider to be traumatic events, patients may need encouragement to consider their birth experience a trauma.
Medications may be helpful in managing symptoms related to PTSD and associated depression and anxiety. PEACE for Moms can help you determine which, if any, medication may benefit your patient.
It is not unusual to try to numb the pain of the trauma by using drugs or alcohol or even certain legal medications. These substances inhibit recovery from trauma and the patient should be encouraged to avoid these.
The mainstay of trauma treatment is trauma-informed psychotherapy, designed to help process thoughts and feelings around painful events. Trauma informed care involves realizing the impact of trauma, recognizing the symptoms of trauma, responding to the patient’s needs and resisting re-traumatizing individuals.