Birth after trauma

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).

This entry was posted in Labor and Birth, Pregnancy, Violence Against Women. Bookmark the permalink. Trackbacks are closed, but you can post a comment.

16 Comments

  1. Posted March 5, 2008 at 2:45 pm | Permalink

    You had me moving right along with you about the proactive comfort measures…up until the epidural. Hmmm…is there something about how she’s dealing with you that says that she will not want to feel her birth or her body during birth? I’ve dealt with a lot of trauma survivors. Most of the wimmin I’ve known were either raped or molested or both. Their relationships with their bodies run the gamut. I’m not sure how regulations work in this area, but have you considered a consult with her therapist and her? Are you allowed to do that? Does she talk about her therapy appointments as related to her beliefs or concerns about the upcoming birth. Really, I’m not sure how it will be possible to go about getting ready for her birth unless you’ve made absolutely sure to keep on with the approach you’ve used so far which seems to be about making sure she has as much space to define her birthing experience as possible.

  2. Posted March 5, 2008 at 3:16 pm | Permalink

    I am not a birth professional, all I can say is oh my. I can not even imagine the horror. More power to her for being able to have the baby. Although the trauma of termination might make things worse.

  3. The Midwife
    Posted March 5, 2008 at 4:28 pm | Permalink

    DD: My only thought on the pain relief is that I imagine that rape, by its very nature, is very brutal and therefore very painful, and that another huge dose of uncontrollable pain might be traumatic for her all over again. But then, I may be wrong on that point, and will talk to her more as the day approaches. The option will certainly be there for her, if that’s what she wants, although I do see how there could be a sense of re-birthing or re-claiming her body through the pain of birth, so we can talk about that too. Again, since she didn’t seek out midwifery care, but was rather assigned midwifery care because that’s how our hospital works, she might have envisioned an epidural for her birth all along anyway, who knows.

    Very good suggestion about meeting with her *and* her therapist. I’ll investigate and see if that’s possible. Thanks!

  4. lynnettecpm
    Posted March 5, 2008 at 9:36 pm | Permalink

    http://www.amazon.com/When-Survivors-Give-Birth-Understanding/dp/1594040222

    I haven’t read it, but sure seems to fit the bill. I am not sure that I agree with the prophy epidural. It might make her feel more out of control. How about letting her decide for herself after preparing the best that she can. An experienced doula can help her, too.

  5. Posted March 6, 2008 at 11:15 am | Permalink

    I *highly* recommend “When Survivors Give Birth” – it’s on my shelf and is fabulous. Also there are training seminars that are highly praised for this very topic through a group called “A Safe Passage” here: http://www.asafepassage.info/ They also have distance learning options.

    I will say though, that what you are doing sounds amazing. :)

    On the pain meds front, as a doula when I work with women with abuse or suspected abuse pasts, I try and thoroughly explain both sides even more than I normally would (in this case, how pain meds might effect her birth both medically and emotionally), then let her make the call without any judgment or trying to sway her in either direction. The thing about sexual abuse is that it takes all the power away from the woman. If you can really involve her in making her own birth decisions while providing great support she can perhaps take some of that power back. Finally I second the suggestion for a good, experienced doula – preferably one that has read the afore-mentioned book. Looking forward to hearing how it all turns out. She’s honored to have you.

  6. HSP
    Posted March 6, 2008 at 2:59 pm | Permalink

    Midwifery Today has just published a book called Survivor Moms: http://www.midwiferytoday.com/books/survivormoms.asp

    They’ve posted an info article in their Livejournal as well:
    http://midwiferytoday.livejournal.com/12148.html

  7. second_banana
    Posted March 7, 2008 at 10:55 am | Permalink

    I second When Survivors Give Birth. It is an excellent read.

    I am a student midwife and a rape survivor. The only thing I can think to say is that it is even more important with trauma survivors to remember that every woman’s experience is different. This woman’s rape may not have been physically painful (I know several women who had that experience) or it might have been the worst pain she has ever felt. That being said offering her a prophylactic epidural as a top tier option *may* come across as “you can’t handle the (normal) pain because you’re damaged” or as “I don’t want to deal with your issues around pain so we just won’t have you feel any.” Or she might be all over that like white on rice. If it were me I’d probably make sure to mention that some women find the disconnect from their bodies to remind them very strongly of the disassociation that can be felt during sexual trauma.

    My heart goes out to this woman! And to you for stepping outside a known comfort zone with this. It sounds like you’re doing awesome and are asking good questions.

  8. Posted March 11, 2008 at 3:59 pm | Permalink

    I have a question – if she was not in labour, why were you perfoming a vaginal examination?

    We do not perform VE’s here in the UK unless they are clinically indicated. Was this woman draining liquor?

    Personally, I would not have done a VE on this woman unless she begged me to. It doesn’t sound like she needed one.

    In labour, I would be watching for external signs of her dilation. I would probably know when she was coming up to fully. In fact, if you’ve got a very good sense of smell, you can smell when a woman is fully. I would do what I normally do, watch, listen, watch, listen…

    …if you are interested in hands-off labour, here is some suggested reading:

    Walsh D (2007) Evidence-based Care for Normal Labour and Birth : A guide for midwives Abingdon : Routledge – general mention of loosing the alternative skills

    Burville S (2002) Midwifery diagnosis of labour onset British Journal of Midwifery 10 (10) 600:605 – behaviours of labouring women

    Lemay G (2005) To push or not? Midwifery Today 74 p 7 – body language

    Sutton J (2003) Birth without active pushing and a physiological second stage of labour IN Wickham S ed Midwifery Best Practice Edinburgh: Books for Midwives – rhombus of michaelus

    Kitzinger S (2000) Rediscovering Birth Little, Brown and Company : London – jamaican midwives talking of the ‘back opening’ – ie ROM

    Bryne D L & Edmonds D K (1990) Clinical method for evaluating progress in the first stage of labour The Lancet 335 (8681) 122 – purple line

    Wickham S, Roberts K, Howard J & Waters S (2004) body wisdom ~ smelling birth The Practising Midwife 7 (1) 30 : 31 – smell in room changing

  9. The Midwife
    Posted March 11, 2008 at 6:18 pm | Permalink

    Thanks for all these resources! I’ll certainly have to check many of them out. That’s very interesting about the smell of fully dilated. I’ve never noticed it before, so I will certainly have to pay more attention in the future. I have noticed the smell of amniotic fluid, but that’s certainly different.

    Just to clarify a few things because I don’t think you understood the context of this visit: we also don’t do vaginal exams here unless they’re clinically indicated. However, a vaginal exam at the initial prenatal visit is absolutely clinically indicated for many reasons. We do a speculum exam to check for vaginitis (yeast, BV, trich etc.), test for gonorrhea and chlamydia (because if they have those infections, you’ll certainly want to treat them during the pregnancy), do a pap smear (again, if there’s anything unusual w/ the pap, it’s a good idea to find out sooner rather than later, especially when many of these women don’t get regular paps on an annual basis since many of them don’t have health insurance). We then do a digital VE to assess their cervix (is there cervical motion tenderness–a sign of pelvic inflammatory disease–is their cervix shortened or opening–might they need a sonogram to get a baseline cervical length? Do they have a history of preterm labor or cervical cerclage?). If they’re still in early pregnancy, we also do a bimanual exam to assess for anomalies in the uterus (fibroids, cysts, adnexal masses or tenderness), and then we do clinical pelvimetry to get a sense of their pelvis (gynecoid, android, anthropoid etc., how big was their biggest baby to date, any anomalies in the pelvis from a motor vehicle accident or rickets etc. etc.) And then we’re done.

    I have a feeling women in the UK probably receive a similar assessment at their very first prenatal visit too, as part of the standard of care.

    In the above case, however, all I did was the test for gonorrhea and chlamydia and then the pap, and that was it. I didn’t do a digital cervical exam or bimanual exam. I felt the STI tests were particularly important given the fact that she had been raped, and perhaps it had been too soon to detect STIs at her exam immediately after the rape.

  10. Yehudit
    Posted March 12, 2008 at 12:43 pm | Permalink

    Agatha is quite right, in the UK it is quite usual to go through a pregnancy without a vaginal examination, and we certainly don’t have the kind of assessment you describe at the first antenatal appointment. The first VE I had in my second pregnancy was when I had a membrane sweep at T+7. I think I had one to assess cervical length with my first pregnancy at about 24 weeks (uterus didelphys).

    Routine smear for cervical cell change are done through the national health service screening programme, at the local GP, so no VE would be done for that purpose by a midwife here. In any case, treatment of precancerous cells is not done in pregnancy (will be scheduled for a date after the end of pregnancy) and although the national screening programme advises smears in pregnancy, personally I wonder whether it’s ethical to diagnose what you don’t propose to treat.

    Testing for STDs is part of the routine blood tests, so no VE required for that. If the woman complained of vaginal irritation, discharge consistent with a minor infection for which we don’t do a blood test (e.g. thrush) some investigation might be in order (to confirm cause, and prescribe) but otherwise not necessary.

    No evidence that doing serial cervical length measurements are protective against preterm labour (especially not in early pregnancy) so no VE would be done for that. If there was a history of preterm labour, that would come up in the initial oral history not on VE, and prompt referral to a doctor for consideration of any preventative measures (unlikely in the UK, unless confirmed cause was cervical incompetence).

    If nothing points to PID, no reason to prod her to see if it hurts. And to be honest, I don’t see how you can get an accurate assessment of the PID-associated cervical pain from an examination of someone so traumatised that the entire procedure already hurts.

    Fibroids, cysts etc..will show up on the dating ultrasound, so no bimanual exam for those.

    The fetal head is the best pelvimeter, so definitely no VE for that purpose – and definitely not bothered here about what type of pelvis she has. Either she’ll have a baby or she won’t, but a VE on the first antenatal visit isn’t going to decide the issue. History of pelvic fracture would come up as part of the oral history taking. If concerns about possible CPD then refer to a doctor and possibly do an MRI if things look ambiguous, but early pregnancy is the wrong time for this – because we don’t know the size of the baby yet.

    I think on the other side of the pond, we are perplexed by the number of vaginal examinations done stateside, and the reasons for doing them.

  11. The Midwife
    Posted March 12, 2008 at 1:15 pm | Permalink

    Wow, very interesting to realize how different the standard of care in both countries is. We routinely do pap smears in this population because they very rarely get health care, so sometimes this is the only pap they’ll have for years. And we actually do treat LSIL and HSIL findings with colposcopies during pregnancy, so we do offer treatment to them if something is looking unusual. Again, I think it’s mostly just because you have no idea when she’ll show up for a pap again in her life, so you’re trying to take advantage of her having health insurance for the duration of her pregnancy.

    How do you test for gonorrhea and chlamydia? There is no bloodwork that can be done for those two STIs, at least not over here, and we do them all the time because they run rampant in our clinic.

    And just to restate what I did (and did not) do on this woman: I did a culture for gonorrhea and chlamydia and I did a pap smear. I did NOT do a vaginal exam to assess cervix, a bimanual exam to assess uterus (or poke and prod on a poor traumatized woman), or an exam for pelvimetry.

  12. Yehudit
    Posted March 12, 2008 at 2:03 pm | Permalink

    If an abnormal smear in pregnancy (not done by the midwife, but through the normal screening programme), then the woman would be given an appointment for colposcopy for further investigation, and treatment scheduled for after the end of pregnancy.

    The number of STIs tested for routinely are more limited here: HIV, syphilis and HepB are tested (serology), with follow up culture to confirm syphilis. Other tests aren’t offered routinely, though could be done if there was a particular indication/demand for them (arguably the fact of being pregnant is an indication for them). I guess the situation is very different because of the availability of testing for STIs both through free GP (family doctor) service as well as a free confidential (though underfunded) Genitourinary Medicine service.

  13. Yehudit
    Posted March 13, 2008 at 4:14 am | Permalink

    Just to add…here’s another view on routine VEs in pregnancy from a UK GP (family doctor) (his views on midwives suck, but I think he gives a good sense of what is regarded as normal here).

    http://nhsblogdoc.blogspot.com/2006/03/vaginal-examinations-in-pregnancy.html

  14. Posted March 23, 2008 at 12:35 pm | Permalink

    I think your empathy level is going to help this woman have the best birth experience possible. Your level of concern is wonderful and she is extremely fortunate to have you as a care provider.

    The only other thing I can suggest in addition to limiting pelvic exams to the bare minimum is to encourage or even insist on an upright birth position. Not only is this a physically and psychologically superior position for any laboring woman, but in her case it will probably help her avoid some very painful memories that can scar her birth memories and potentially stall the labor.

  15. Posted June 4, 2008 at 6:11 pm | Permalink

    I am a survivor of childhood sexual abuse and assault as a young adult. I’ve given birth twice, both in a hospital.

    I’d been through counseling years before my husband and I got pregnant and I thought that my issues with the abuse were resolved. However, when I was about 36 weeks pregnant with my older son, I ended up in the hospital in early labor. Unfortunately, I had a nurse who was rude and who did a vaginal exam without even introducing herself. I had a normally progressing pattern of contractions, but when the nurse did this I felt very powerless and my body went in to “fight or flight” mode. I don’t understand all of the biochemistry, but my contractions stopped completely for about a week. During that time, I shared the concern with my OB that memories and feelings of the abuse and been triggered by the nurse. Her only suggestion was to get an epidural.

    When I went into labor a week later, I was hoping to have a natural childbirth. But as things became more painful I felt like everyone I was supposed to trust doubted my ability to give birth naturally. I had an epidural and my son was born quickly. A good outcome, except I felt out of control of the situation.

    When I was pregnant again 2 years later, I wanted to give birth in a birth center with a midwife. When I went into preterm labor at 23 weeks, however, I had to transition back to hospital care. Thankfully my son stayed put until 35 weeks. When I went into labor on a Tuesday, I went into the hospital, but again I found myself to be very triggered by everything. My body had the same sort of fear reaction, although to a lesser extent, and we went home.

    The next day, I went to the bookstore and read everything I could about natural labor, again. I was doing everything I could to convince myself that I could do it. That I was in control of many things and that I had made great choices: midwives I trusted, a hospital supportive of natural birth, my husband who would be with me, etc. On Thursday, my contractions started again. When we finally checked into the hospital late Thursday night, things slowed down again for a while as I dealt with fear and anxiety. But this time, my midwife was patient, she helped to create a safe environment and respected what I wanted, and no one offered me an epidural. Instead, they offered me lots of other ways to get through labor and I had a great time. I came away from my second labor feeling incredible.

    So I don’t know that I would be quick to offer an epidural. For me, the feeling of being forced to lay down and be out of control of so many things was very difficult. I am thankful that the second time around the midwives were awesome about letting me control what I could – wearing my own clothes, listening to my own music, turning off lights, limiting procedures before and after birth, encouraging me to walk around, get in the tub, and try different positions, limiting visitors, limiting monitoring, letting me eat and drink freely, etc.

  16. VoiceUpNorth
    Posted July 19, 2008 at 8:13 am | Permalink

    I can tell you my own experience.
    I didn’t tell my OB/GYN with my first birth that I had been sexually assaulted as a teenager. However, I was lucky enough to have a respectful dr and nurses. I wanted a natural birth and they offered a big tub to labour in with my husband by my side. My husband helped me to stay calm and “listen” to the contractions. They started to seem more like waves than pain. I love swimming in the sea and used to swim in the cold English channel with my parents as a kid. We kept my focus on the waves and drifting over them. I lost much of my focus during transition and panicked. But managed to find control again when I was pushing. I felt more in control without pain meds. I couldn’t control the labour outcome, contractions or intensity. But I could control how I experienced them and how I responded. It felt like I was back out at sea and I could thrash around and panic or float on my back and ride the waves.

    It was much easier the second time around as I found myself much more quickly. My first labour was 29 hours long and I think much of that was because I held myself up whenever I lost focus. My second labour was 8 or 9 hours and I felt much more focused and relaxed. I found framing the experience on my own terms made the difference.

    I can’t tell you want will work for her come this September. Pain killers may help her frame the experience. But for me they only would have induced panic as I was on drugs during my ordeal. The last thing I wanted during labour was drugs to dull my senses.

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