Belly Tales

Chlamydia is the sexually transmitted infection du jour in our clinic. On a daily basis I probably encounter at least one, often 2, and sometimes 3-4 women per day who have it. For the majority of the women I see, learning that they have an STI is often like a wake-up call. They usually get treated, then their partner gets treated, and then, to their credit, they often remain STI free for the rest of their pregnancy. Many of them choose to break-up with the partner that infected them, or stop sleeping with him/her altogether, or else become religious in their condom use. However, sometimes it’s not that easy. In one woman whom I’ve been taking care of since I started my new job (i.e. over 5 months now) she’s had chlamydia 3 times. In other words, she’s been reinfected twice after being treated, probably because her partner has 1) never been treated or 2) keeps getting reinfected himself. In another case, a woman has been treated twice for chlamydia now because her husband has multiple wives, and obviously we still haven’t gotten all of them treated yet. I spend much of my day talking myself hoarse about safe sex, strict condom use and the importance of getting partners treated. And then the CDC releases studies which show that nearly half of all adolescent African American girls have had at least one STI, compared to only 20% of all white and Mexican-American teenagers (keep in mind that the predominant populations in our clinic are African American and Hispanic). It makes me want to cry. We get fifteen minutes alloted to us on our templates to take care of an OB or gynecology revisit. That’s fifteen minutes to conduct an entire interval history, address any questions or concerns, follow-up on lab results and order upcoming tests, do the physical exam (listen to the fetal heart tones, Leopold’s, measure the fundal height etc.), and then write a note on it. Fifteen minutes is barely enough time to tell a woman she has chlamydia, what the treatment is, how important it is that she get treated and then not reinfect herself, how crucial it is that her partner is also treated, and how essential condom use with future partners is. It’s like the tip of the ice berg when really these women need so much more than just counselling on safer sex and strict condom use. They need to learn how to assert their power—how to put their foot down with a partner that may potentially be cheating on them, how to say emphatically “no condom, no koochie” and not buckle in to seduction or pressuring, how to choose and insist on respectful partners. It’s like staring at a huge, roaring wildfire, and your only weapon against it is a tiny fire extinguisher. So what do we do? Keep trying to extinguish the chlamydia, one case at a time, and keep talking ourselves hoarse about safe sex.

Without getting into a huge amount of detail here…I had a new OB patient recently who came in for her initial visit and eventually told me that she wasn’t sure who the father of the baby was….becasue she had been raped by four men. She had gone to a different hospital immediately afterwards and had had a rape kit collected, and had already been through one round of testing for STIs and HIV, all of which had come back negative. The semen analysis is still pending. She’s been seeing a therapist weekly since the rape, and has the full support of her very large family. Because of her religious beliefs she will be continuing with this pregnancy and plans on giving birth in early September at our hospital. I was stunned, and didn’t even know where to begin with her. I talked a little bit about how rape and trauma can come up again during pregnancy, and especially during birth, but she’s only 10 weeks pregnant at the moment, so I didn’t see any point in getting into that deeply just then. I suggested that we could talk a lot more about it as the birth approached, and she agreed that that sounded like a good idea. We talked a little bit about postpartum depression, and depression in general, and I made a very thorough assessment of her support system and resources, and they all seem ample. In addition to the therapist she’s currently seeing at the other hospital, she was also visited by our social worker, so that additional resources at our hospital can be offered to her as well. I asked a few very broad questions about what she was thinking or feeling about the pregnancy, but she didn’t want to talk about it very much, so we moved on to other topics. And then we did the actual physical exam. She had as much control over the process as possible. We made a deal that whenever she felt uncomfortable or scared or uncertain, all she had to do was say “stop” and I’d stop. So that’s what we did. My assistant held one of her hands (her other hand was between her legs and on top of my hands as I guided in the speculum) and we gently talked her through it. She would tense up, say stop, then we’d stop, let her collect herself and calm down, and then when she was ready, we’d guide in the speculum another half inch. We went inch by inch. It took about 10 minutes total to get the entire speculum in, then I collected the samples and removed the speculum as soon as possible. She actually seemed to handle it amazingly well (I was close to tears).

I can only imagine how birth, which can be so traumatic in its own right, can bring up so many terrifying memories and associations with trauma and rape. Birth is another situation where she can potentially feel vulnerable and exposed, in a situation that she can’t really control, experiencing pain, perhaps feeling helpless and angry and powerless (and keep in mind that this will be a hospital birth and not a woman-on-her-own-turf-at-home-birth). So here’s my question to all you midwives and doctors and nurses who’ve been doing this a lot longer than I have, and who have probably been present at births with women who have a history of trauma or rape (or women who have survived rape or trauma and gone on to birth yourself). Do you have any suggestions? When it comes closer to the time of the birth, what should we focus on? I have many thoughts about where to start: avoiding vaginal exams during the birth, offering early pain relief if desired (maybe a prophylactic epidural before the strong contractions even begin), letting her dictate when and how to push, making her environment as calm and serene as possible…what else am I missing? Any good books on this topic? Any posts that you’ve written which I should read? Anything at all would be helpful, because I still have another 8 months of prenatal care with this woman prior to her birth, and I want to try to make it as healing and empowering as possible (or, at the very least, not compound the trauma with more trauma).