A few years ago, a patient was referred to me from one of the OB offices.  I was told that she had severe PTSD from previous sexual assault and was very “difficult.”  Her previous pregnancy, which was approximately 5 months prior, ended tragically at 19 weeks with the loss of her 3rd child.  This experience was incredibly traumatic for her, as one could imagine, because of the loss of her child. In addition, she was traumatized during the experience as a result of the negative treatment she received from the medical community.  For her upcoming delivery it was recommended that she have a repeat cesarean section because of her previous cesarean deliveries.  ​

        At this point in my career, I did not have the knowledge and understanding that I do now regarding the care of these individuals, but the obstetricians knew that I already had a way of caring for patients that was gentle and respectful, so they asked for my assistance.  I had no idea that this particular patient would be the one to start me on the path that I am on now, which is to bring trauma-informed care practices to all obstetric providers. Little did I know that she would enlighten me on how I was doing things “all wrong” and inspire me to be a catalyst for change.  ​

        Initially I thought that I would be the one to create a care plan that would direct her through labor and delivery.  I was quite mistaken. Ultimately, I became the student and she the teacher and guide through what she anticipated would be a very triggering and terrifying time for her.  Learning to share control- not always easy for physicians- was crucial for us to ultimately achieve a positive birth experience for her. She taught and I listened. Anne’s entire experience was built on a foundation of listening and building trust- now called “shared decision making.” 
 
       I met Anne and her husband Mike in a neutral location one evening to begin some discussions about her upcoming delivery.  She was due in April. It was currently October. She was too terrified to even enter a hospital, so I agreed to meet her one evening (outside of the hospital) after a class I was teaching. This first meeting revealed some fundamental characteristics about Anne that I was going to have to accept and understand.
   
​       First, she had some very strong opinions about her current pregnancy and requests for her upcoming delivery.  Second, she had a very strong relationship with her significant other and wanted him included in every step of the planning. Third, she understood her PTSD much better than I did, and fourth, she was a compassionate, competent, involved mother of two boys and deserved respectful care. 

Our framework for navigating her childbirth experience included the following:
 
Preliminary Work

• Establishing trust and learning how to give her control
• Prioritizing time to talk through all her specific concerns
• Finding neutral places to have meetings
• Ensuring psychological safety

 
Next Few Months

• Phone calls to check in
• Confirm plans, shared decision making with consents
• Written concepts- triggers with solutions/plan

 
 Within One Month of Delivery

• Multidisciplinary conference
• Confirm teams- have Anne meet everyone
• Extend trust to other providers

       Anne taught me so much about what it is like for someone to live with PTSD and how triggering labor and delivery is for women who have survived sexual trauma.  I also learned how vulnerable she was to re-victimization- which is exactly what happened to her with 2 of her 3 prior birth experiences. Her terror was palpable, and she commented more than once that she would rather die than be strapped down.  She even communicated that much of what happens during birth was very reminiscent of sexual trauma. I had never made these associations before. She provided valuable resources for me (books, articles) and suggested that I contact the local rape center for more information.  

​By the time we met to discuss particular details about possible triggers, she had already completed worksheets that she had received from the rape crisis center. She very honestly and coherently shared these intimate requests with me.  This was one of the most courageous and desperate actions I’ve experienced with a patient up to this point. Here is a sampling of some of these things:

“Filling out papers-signing my name to them”
     -Causes me to feel loss of control over my own body...like I lost the right to my body.  I hate PAPERS.

“Stirrups”- Flashback

“Anything put inside me” - Huge FLASHback

“Laying down flat while people stand over me”-Flashback

“Medical table” - Flashback

“Anything forced against my will, even words.  Telling me I have to do something...I will fight back.  I just can’t when forced it hurts my brain.” - Huge Flashback

“Naked - my clothes protect me.  I HATE having to take off my underwear”
-Flashback.

“All medical things and places...once I walk into the building”
-Flashback

“Any loss of control over my body."

​“I am terrified to be restrained- I can’t fight a bad guy off.  I have to be able to protect myself. It hurts My BRAIN very bad.  It will cause more trauma to me."

  “Light-any exam light.  He used a big industrial light, the kind you use for drying paint.  I HATE big lights, but any light. I will never forget the heat I could feel coming off the light when he was hurting me.
FLASHBACK.

“I am terrified to be put to sleep EVER.  Someone could hurt me and I wouldn’t be able to stop them or protect myself.  I will always refuse to be put to sleep in a medical place/hospital. If someone does it I am NOT giving permission, it is against my will.  Don’t EVER put drugs in me to make me sleep-even a light sleep. I can’t protect myself."

I NEED trust built with you and the practice.  Trust is very important for me to be able to get care.  I have a hard time trusting because my trust was violated with rape.  Trust is very difficult for me but important to get care.”

       As providers, we only get a small glimpse into the lives of these women.  This glimpse is usually during times of immense stress, and many providers (I have been guilty of this myself in the past) often misinterpret traumatic stress behaviors for manipulation, acute psychiatric issues (not related to trauma), drug use or withdrawal or non-compliance. Unfortunately, a biased view is often formulated without fully understanding where these women come from.  Everyone comes into childbirth from a different place and they all need something different. A common phrase that I often use on our labor and delivery floor is, “One size fits no one” to reflect this specific idea.
 
       We scheduled Anne’s cesarean section on a day that I was not scheduled so that I could be available to care for her exclusively and not have to manage the busy labor and delivery floor simultaneously.  It took over four hours from the time she was admitted, to complete her surgery. This included extra time for her to mentally prepare to walk down the hall into the operating room, have the surgery, and return to a private room for recovery. (She felt empowered by walking herself to the operating room. She felt that it allowed her some control and choice in this process.)  Ativan - a anti-anxiety/relaxing medication was prescribed for her to take on the evening before and the morning of surgery to help prevent panic and increase the likelihood that she would present for her surgery. Anne expressed to me how helpful this medication was to keep the ruminations, flashbacks, and triggers at a minimum and to allow her some much needed rest on the eve of her surgery.
​

Specifics of Anne's Care Plan

---

• Her significant other was with her the entire time including in the operating room for the placement of her anesthetic.
• Small additional doses of a relaxing agent (midazolam) were given as needed to keep her relatively calm and oriented to the present.
• She received a combined spinal/epidural procedure for her anesthetic which allowed me to add extra medication at any time, if necessary, to increase the degree of pain relief. 
  • One of her biggest fears was general anesthesia, and by having this epidural catheter in place, I could also extend the duration of the anesthetic if necessary through the epidural.  (She could not bring herself to physically sign a consent for general anesthesia, but with calm, non-triggering discussions, she verbally consented to general anesthesia as a life-saving measure if we promised that she would not wake up with any restraints on her arms.)
• A surgical drape with a clear opening was used to offer her the quickest view of her son after delivery.
• Her bladder catheter (a standard of care for our cesarean section patients as it helps to decrease any injury to the bladder) was placed by her obstetrician per her request as she had developed a trust with him, and it was only placed when she was emotionally ready for him to do it.  She looked at photographs with her husband during this time to help keep her from panicking and to keep her distracted.
• There were no arm boards/extenders on the bed at all, and she was permitted to rest both of her arms/hands on her chest.  Her blood pressure cuff was placed on her leg to accommodate this. We (my CRNA, her significant other, and I) kept Anne engrossed in conversation throughout the case.  She did not experience any dissociation or panic - although she came close a few times. “Verbal anesthesia therapy” and small doses of midazolam (0.5mg x3) was sufficient to keep her oriented and relatively calm.
• She was able to participate in skin-to skin bonding with her baby boy shortly after delivery (within 10 minutes) which was monumental for her.
• Postpartum care proceeded according to her plan, and she even stayed in the hospital for the entire recommended duration of three days.  During prior deliveries, she left the hospital early due to negative birth experiences.  

       The plan that she helped us to create was carried out with very little deviation.  I must admit, her case was as challenging as any high risk physical case would be and immensely more emotionally impactful.  She ultimately had an experience that was “less traumatic” than the others. She stated that she felt she was “robbed” of the chance to have her baby on her chest immediately after delivery even though she understood that in the context of a cesarean section this is not usually possible.  She also wished she would have had more say in choosing her type of delivery. Her postpartum period had its “good and bad days”, and even though breastfeeding proved to be unsuccessful, she was able to bond with her newborn.
​
       This amazing woman keeps in touch with me through email to the current day.  It was a privilege and a blessing that I could take care of her. I am immensely grateful that she was willing to revisit all of these memories when I asked for her feedback and consent for her story.  It was incredibly challenging for her, but she risked emotional lability in the hopes that her story will inspire change.   
​

Postlude

When asked what she would like to see happen in the future/communicate to providers, this is what she mentioned:

• Mandatory education for all obstetric providers in the management of women with a history of sexual trauma
• More direct lines of communication to physicians- she felt frustrated having to go through so many layers of “Gatekeepers” who have little understanding of the needs of trauma survivors.  (She hated having to repeat her issues over and over again.)
• Trauma survivors do not need an “audience” during exams or during the birthing process. ( She was referring to students and trainees)
• Providers need to think differently when taking care of trauma survivors and understand their unique needs.  (She felt that too many providers just “follow the rules” and don’t allow for any creative care.)
• Consider anti-anxiety medicine for the postpartum period as well as the antepartum time. 
• She was saddened when others got to hold her baby before she did in the operating room.  Why not have resuscitation closer to mom? 

 
We as providers can have an enormous impact on families by establishing a culture of patient centered care during childbirth.  Kindness and empathy and some shared decision making made all the difference in this woman’s( and family’s) experience.

Resources

1. Simpkin P, Klaus P. When survivors give birth.Seattle, Washington: Classic Day Publishing, 2004 
2. Sobel L, O’Rourke-Suchoff D, Holland E, et al. Pregnancy and childbirth after sexual trauma. Patient perspectives and care preferences. Obstet Gynecol.2018;132(6):1461-8
3. Worksheets for trigger management can be found in Simpkin’s book, or by contacting  Dr. Vogel at theempowermentequation.com.

 
All names and places have been changed to protect privacy.  Written consent was obtained prior to posting this story.

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