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        The word “congratulations” usually invokes positive thoughts and feelings in most of us that hear it. It is a word that is often offered to those who are pregnant or have just delivered a baby. In most cases, I would like to believe, it is a happy occasion and the new parents receive the word “congratulations” with joy and gratitude. The following story shows us what can happen when we say this word without truly appreciating how a person is receiving it.  
        I strongly encourage reading Faith’s story in its entirety (click here) before reading through the following excepts with commentary.  This story, written entirely by the patient, is incredibly moving and teaches us all about a new mother’s desperation, resiliency, and hope.
        The following two passages reveal the need for better understanding of traumatic histories and the need for a well-informed screening process.

“Congratulations! You’re pregnant!”
“You have severe bleeding, you probably lost the baby we’ll call you in a couple days!”
“Congratulations!  You’re still pregnant!.."
“It looks like your baby will be due in July.  
​I left not sure I’d make it to that appointment.  I cried in the front of my boyfriend’s Honda Civic...  As hormones clouded my brain, I was sure I was never worthy of the name Mom. No one asked, they kept saying congratulations.

        Within the first few lines of her story, Faith describes the sadness and the sense of detachment that she feels as she experiences the potential loss of her baby.  She also states that she was never worthy of the name “Mom.” Many new moms may feel overwhelmed or unprepared for motherhood, but not all feel this sense of “unworthiness.”  Any significant disclosure of low self esteem or marked anxiety about the pregnancy should prompt providers to delve a bit deeper as to “why” she feels that way. A low sense of self worth or self esteem is common in adult survivors of childhood trauma or any unresolved trauma in the past. (Vander der Kolk, Bessel MD The Body Keeps the Score. Copyright 2014. Penguin Book Publishing.)  By identifying survivors of prior trauma, specialized care plans can be developed to help them navigate the childbirth experience and maximize the chance for a positive outcome.  (Simpkin Penny, Klaus Phyllis. When Survivors give Birth. Copyright May 2015.  Classic Day Publishing- this book provides worksheets for adult survivors to prepare for their upcoming deliveries.)
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        Although there is no consensus for the best way to assess for previous trauma, asking about ACE (adverse childhood experiences) scores (“Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults,” American Journal of Preventive Medicine  1998, Volume 14, pages 245–258.), history of anxiety or depression or other mental health pathology, and/or particular fears of the upcoming delivery may help to identify those individuals that need a different care plan for their labor and delivery.   

… We got there.  We looked at the envelope.  We stared at the envelope. Then we opened it! Congratulations! It’s a GIRL. …A girl? Ugh.  “Congratulations!” They all enamored. We called Monday to make the appointment for our repeat ultrasound.

        According to Penny Simpkin's book “When Survivors Give Birth,” some women with a history of prior sexual trauma feel apprehensive about raising girls because of their own history.  Some women feel that they may not be able to “protect” them. I think that at any time a patient has such strong feelings about the sex of their child (boy or girl) it warrants at least asking the “why” question.
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​        The following passages illustrate potential breakdowns in communication within the hospital and care management systems:

Ok, Faith, you need to schedule your breastfeeding classes, because you will breastfeed. ..We walked past the operating room, “don’t worry you won’t need this ladies, you will get through your labor naturally” the teacher said. ...  “Just follow the breathing techniques,” the lady said, “you will get through this, Congratulations!” No one asked, they just said congratulations.

        Here, Faith talks a lot about the expectations that were set for her and those she sets for herself.  I think as providers we need to take a critical look at how we express our own agendas and goals for our patients.  Even though we may all feel that breastfeeding is a wonderful goal, we need to understand barriers that may prevent patients from pursuing this. (In a recent viral post on Instagram a breast cancer survivor discussed how she felt compelled to create a sign to hang above her bed so providers would understand preemptively that she couldn’t physically breastfeed and to not “formula shame” her.  I think we need to provide the right education to patients, so they can be empowered to make their own decisions.  If we set them up with only one expectation (i.e. “you will breastfeed,” “a breastfeeding baby cannot have a bottle,” “you won’t need the operating room,”) then we also set them up for a higher likelihood of disappointment, and for some women this translates as failure because of the unpredictable nature of the labor and delivery process.

…6 AM hit and so did active labor… I screamed and begged can I please get up.  “No, you can’t get up.” I couldn’t breathe anymore. I gave in. I got the epidural.  “Don’t worry everyone gives up, you’re fine.”

        Here again we feel Faith’s feelings of failure because she chose an epidural.  It is not clear to me if it was her self-inflicted expectation to not receive an epidural, or it came from her providers, but education and empowerment about this choice may have mitigated these feelings.

“Faith, the baby’s heart beat is dropping. We have to take you into surgery!”  No, I exclaimed. “We have to,” and they prepped me for surgery. … I mourned that opportunity to birth my sweet baby.  No one asked they kept saying congratulations!     ​

        As providers, we need to understand how traumatic it can be for some women to receive an emergency procedure during childbirth.  Her description of her surroundings and her sensations of the surgery itself are especially insightful and illuminating for me as an anesthesiologist.  It serves to reinforce how important it is to maintain some discretion with the blood collection canisters, for example, and to remember that everything in our environment is foreign—and potentially terrifying—to most patients.  Her comment, “I was sure I was going to die as they ripped my body open,” suggests a significant disconnect between provider testing and patient’s feedback of efficacy of this anesthetic. Women who experience significant pain during surgery may perceive their experience as traumatizing, increasing their risk for psychological peripartum complications. (Lopez, U).  Faith’s comment about the “vag-anus”, although humorous to providers, was not perceived that way by the patient. She states that she was actually mourning the loss of her chance to “do the birthing” herself. Our failure as providers to recognize this could potentiate a negative view of the experience.

The next night came.  Can you please take my baby to the nursery?  I’m exhausted. “Get used to it, you’ll be exhausted for the rest of your life.  Our policy says you have to keep your baby here.” 4 AM came. “Here’s your percocet, here’s the baby feed her, we’ll check back in a couple minutes.” A couple minutes came and went.  My eyes shut. I fell asleep. My baby, my sweet Sydney, she rolled right onto the hospital floor. I screamed...

        As a community of providers, we know that this is a devastating event for all involved.  Faith goes on to describe the tremendous guilt she feels and ultimate depression that takes over. I think we also need to examine how the system failed her here.  The movement now to have babies with moms from the time of birth is an admirable one, but there has to be flexibility in any system to use the “common sense” rule to manage those situations that don’t fit the standard algorithm.  Every patient is different, and although it is a worthy goal to achieve the standard, every practitioner should be empowered to advocate for those patients that need something different, such as keeping a baby in a nursery so the mother can rest.  

They kept making funny stories, “Faith, my kid fell on the floor a million times.”  “This is a part of motherhood.” “Congratulations! She’s beautiful.” No one screened me for postpartum depression.  I considered death in those moments as I watched my baby be transferred to the NICU.

        We need to recognize this event as a traumatic birth experience and respond appropriately. Based on her testimonial and from discussions with Faith, it doesn’t sound like anyone provided her with the essential counseling resources before she left the hospital.
        The rest of her story reflects how her postpartum depression impacted her life and her ability to be the mother she thought she was supposed to be.  I can’t emphasize enough the impact that postpartum depression can have on the physical and psychological well-being of both the mother and the baby, and how important it is for us to actively screen for it in a meaningful way and to offer the necessary interventions.

    ​  I have used Faith’s story as a teaching tool during one of my symposiums.  When I spoke with her the first time, she shared with me that she came from a history of childhood trauma and had been sexually assaulted as a young adult.  She is a survivor. When I re-read her story with this context in mind, her words and emotions align with what we understand of adult survivors of trauma. Had she felt comfortable to disclose her history early in pregnancy and her providers were familiar with a trauma-informed care approach, her situation may have turned out differently.  Faith continues to participate in regular counseling and is in a loving, stable relationship with her husband at this time.

        I am so grateful and honored that she agreed to share her story with me and ultimately agreed to share it with the world in the hopes of initiating positive changes within the healthcare system.    

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