Mental health specialists define a traumatic event like this: it is any event that exposes an individual to actual or threatened: death, serious injury or sexual violence. (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, DSM V).
Further, the DSM V states that the trauma doesn’t have to occur by direct exposure, but can happen from witnessing the event or learning that a traumatic event has happened to a relative or close friend, or indirectly as medical professionals often experience.
When we think of obstetric trauma, we often, and appropriately, think about how it affects the patient. However, we may not fully consider what happens to the family members as a result of these terrifying events. These individuals are perhaps tending to the other children at home, maintaining employment so that insurance coverage does not lapse, and supporting the woman in her challenging postpartum period--one that may now be complicated by post traumatic stress symptoms. Currently, there are no widely-used screening tools for gauging depression, anxiety, or trauma, or protocol pathways that assist the loved ones after a traumatic peripartum event. Resources barely exist for the woman herself, let alone the family. This is a largely unexplored area of study in medicine, yet one that is undeniably needed to provide understanding and recommendations for identification, referral and treatment for emotional and mental health intervention. Importantly, this should happen in conjunction with the recognition of any mental health challenges the patient is left facing. Otherwise, the mother does not get the support that she needs, the mother-baby bond is weakened, relationship issues are more likely to arise, and the family itself can be destabilized.
Further, the DSM V states that the trauma doesn’t have to occur by direct exposure, but can happen from witnessing the event or learning that a traumatic event has happened to a relative or close friend, or indirectly as medical professionals often experience.
When we think of obstetric trauma, we often, and appropriately, think about how it affects the patient. However, we may not fully consider what happens to the family members as a result of these terrifying events. These individuals are perhaps tending to the other children at home, maintaining employment so that insurance coverage does not lapse, and supporting the woman in her challenging postpartum period--one that may now be complicated by post traumatic stress symptoms. Currently, there are no widely-used screening tools for gauging depression, anxiety, or trauma, or protocol pathways that assist the loved ones after a traumatic peripartum event. Resources barely exist for the woman herself, let alone the family. This is a largely unexplored area of study in medicine, yet one that is undeniably needed to provide understanding and recommendations for identification, referral and treatment for emotional and mental health intervention. Importantly, this should happen in conjunction with the recognition of any mental health challenges the patient is left facing. Otherwise, the mother does not get the support that she needs, the mother-baby bond is weakened, relationship issues are more likely to arise, and the family itself can be destabilized.
The following testimonial presents a family member’s struggle during a traumatic event in the labor room, highlighting the importance of supporting loved ones as well as patients during these moments.
Margaret’s daughter was full term. Despite a history of rheumatoid arthritis, her pregnancy was uncomplicated and she was in optimal physical and emotional health going into labor. Margaret described her daughter as a very resilient, stoic individual that hardly ever complained of pain, even when facing the often painful manifestations of arthritis. Her labor started earlier in the evening while dining out at a favorite restaurant and she arrived at the hospital around 2 am. As per the hospital’s protocol, the providers added Pitocin to her IV to augment her labor. At 5 am her water broke on its own and subsequently she requested an epidural which was placed by the anesthesiologist without any noticeable difficulty. Margaret supported her daughter over the next few hours, proudly describing her courage and strength through it all. At 11:30 am, the obstetrician visited again and after performing a cervical exam, explained that the baby’s head was turned in an odd position and that the likelihood of safely delivering vaginally was low. Margaret’s daughter who just minutes before had been laughing, now sat focused, contemplating her doctor’s remarks. Her relationship with her doctor was one of trust and respect, and she realized what she needed to do. She gathered her family around her and discussed with her obstetrician the positives and negatives of having a cesarean delivery, including the possible physical complications, the postpartum recovery, whether or not she could do skin-to-skin bonding or even breastfeeding in the operating room, and what would be the likely course of events if she chose not to have surgery. As her delivery was not urgent at this moment, and definitely not an emergency, everyone had time to talk, ask questions, and contribute to this new conversation.
Close to noon, a mutual decision was made to proceed with a cesarean delivery, and the anesthesia team was notified. Within a few minutes, the anesthesiologist arrived. As he began to disconnect the epidural from the continuous infusion pump, Margaret had a moment to ask him a few questions. Margaret’s employment in healthcare and her previous work as an EMT gave her a deeper understanding of medical procedures. Consequently, she wanted more information about her daughter’s anesthesia; for example, she wondered whether she would be “completely out” or if she would receive “conscious sedation.” The doctor briefly explained that she would not be completely out, and in fact she may not be sedated at all. At 12:41 he dosed the epidural with 20 ml of the additional anesthetic medication.
Margaret was at the head of the bed, watching her daughter’s response, along with the nurse and the obstetrician. At 12:42 she recalls, “My daughter’s eyes got heavy and she murmured ‘mommy, mommy I can’t breathe.’” A moment later, the nurse declared “she’s unresponsive,” and immediately the team responded. There was little discussion, just action. “This is my baby girl,'' Margaret thought as she steadied herself on the bed rail. She briefly considered the scenario; how many hundreds of times have I stood at the head of a bed during a crisis? But now, this is my daughter.
Without even realizing what she was doing, Margaret instinctively helped disconnect her daughter’s monitors for rapid transport to the operating room. As they started rolling the bed toward the door she caught a glimpse of her son-in-law in the corner of the room- she had forgotten in the moment that he was even present. His eyes were “as big as saucers and I just assumed he was in shock,” Margaret recalls. One of the nurses tossed him the paper scrubs to put over his clothes, anticipating that he might get a chance to go into the operating room with his family, while Margaret, not wanting to disrupt the team, mouthed the words “go, go” to instruct him to follow his wife and the team toward the operating room doors. At 12:43, as her daughter’s bed was pushed into the hallway she heard the “Code Blue” alert on the overhead speaker and realized in horror that this was her daughter’s Code Blue. In that instant Margaret knew that her daughter’s life was in jeopardy. She felt her knees buckle as she watched the staff running with the crash cart (emergency cart) toward her daughter.
Meanwhile, her son-in-law, struggling to keep up with the moving team, was not allowed past the operating room doors. Instead, he was alone with only the frantic worry about his wife and baby’s condition. It would be hard to overstate the feelings of fear and helplessness family members experience in moments such as these. Knowing only that his wife’s life was in jeopardy, he texted his parents in the cafeteria saying “pray now.”
Margaret, too, was alone. After making her way to the couch in the corner of the room and pausing for a moment to catch her breath, she called her ex-husband and told him what was happening. She remembers only fragments of the conversation but was able to convey to him that their daughter “appeared to have had a reaction to the epidural medications” and was in the operating room. At 1 pm she was still on the phone when the charge nurse came in with news. “They are both alive, everyone is ok.” The nurse went on to tell her that her “granddaughter was born at 12:46, only 3 minutes from the time the code blue had been called. They delivered the baby while they were intubating her daughter. Your granddaughter is heading to the NICU (neonatal intensive care unit) and your daughter will be in the recovery room shortly.” Her son-in-law’s parents returned from the cafeteria, asking Margaret for all the updates. She doesn’t remember much of the conversations that occurred in those moments, but she does recall that it felt “odd” that she had been given the role of spokesperson or public information officer for everyone else despite having herself just experienced one of the most terrifying moments in her life.
Around 1:30 pm, several hospital administrators came in to offer explanations and check-in with the family. Margaret knew what this meeting was about. In fact, in her role as a healthcare worker, she had often initiated these conversations with families. Although the intent is to offer additional reassurance and support, if not handled deftly, these talks can leave a family feeling unsatisfied or even dismissed. In Margaret’s view, the meeting conveyed little more than “we’re sorry for your experience,” as if they were apologizing for poor service at a restaurant or a back-ordered item that didn’t arrive. In fact, even their attire- suits and dress shoes- struck Margaret as very “out-of-place” in the moment; she longed to see someone in scrubs or operating room clogs, like the charge nurse or anesthesiologist, who could offer more concrete information.
No one came to talk with her daughter (or other family members) about possible mental health consequences that could result after such a traumatic event. No mental health referrals were given and no one else from the administrative staff came to speak with them after that initial visit. What this family desperately needed was more than scripted apologies and a conjectured explanation of the events. They needed validation for their experience and the acknowledgement that this was an event that would be addressed and reviewed.
After the event, Margaret wrote a grievance letter to the hospital on her daughter’s behalf. She knew she couldn’t change what happened to her daughter, but perhaps she could prevent this from happening to any other woman. She carefully described the timeline, explaining that her daughter still has nightmares and routinely wakes up feeling like she can’t breathe. She experiences frequent episodes of panic, and now has to manage anxiety in addition to adapting to life as a new mother. Her daughter required an extended stay in the hospital for 6 days and her granddaughter required not only a NICU stay, but also treatment for a tibial-fibular fracture that was sustained during the emergency delivery. Margaret also requested a RCA (root cause analysis) of the event to investigate possible system-based errors that could have contributed to the adverse outcome. She also requested that the self-pay balance be waived.
The hospital responded with a form letter. It stated that there would be no adjustment to her balance and no need for any further review. And, as if to confirm that the event was over, at least from their perspective, they added: “We determined your medical treatment was appropriate.” In Margaret’s words, “It was awful!!” This form of dismissal only adds to the anger and frustration of an already traumatized family.
At the time of this initial interview, there had been no other communication. Meanwhile, her daughter was still paying off the $6,000.00 balance, a year and a half later.
Margaret had never assumed that anything other than an adverse reaction to the epidural medicines had caused her daughter to experience near complete cardiovascular collapse. She thought that it must have been an allergy to the medication or perhaps it was the wrong medication. When I pointed out that there were other potential causes of this situation such as a complete spinal block, she was surprised. I continued to explain that a complete spinal occurs when the medication given with the intent of being delivered to the epidural space actually gets delivered to the spinal fluid. In other words, the large volume of local anesthetic her daughter received could have been a spinal overdose. Margaret’s description of her daughter’s fragmented memories of the event are more consistent with this situation rather than an allergy or “wrong medication” error.
Margaret’s daughter shared with her after the event that she could still hear voices around her even though she could not move or speak. She distinctly remembered hearing the words “she's unresponsive.” Having grown up with a mom who was an EMT, she knew that the oxygen mask was keeping her alive, so when they removed it to place the endotracheal tube she recalled terror and panic. She was frustrated that she couldn’t talk when she was having difficulty breathing, and then she was paralyzed. She didn’t recall feeling pain at any time during the surgery.
Close to noon, a mutual decision was made to proceed with a cesarean delivery, and the anesthesia team was notified. Within a few minutes, the anesthesiologist arrived. As he began to disconnect the epidural from the continuous infusion pump, Margaret had a moment to ask him a few questions. Margaret’s employment in healthcare and her previous work as an EMT gave her a deeper understanding of medical procedures. Consequently, she wanted more information about her daughter’s anesthesia; for example, she wondered whether she would be “completely out” or if she would receive “conscious sedation.” The doctor briefly explained that she would not be completely out, and in fact she may not be sedated at all. At 12:41 he dosed the epidural with 20 ml of the additional anesthetic medication.
Margaret was at the head of the bed, watching her daughter’s response, along with the nurse and the obstetrician. At 12:42 she recalls, “My daughter’s eyes got heavy and she murmured ‘mommy, mommy I can’t breathe.’” A moment later, the nurse declared “she’s unresponsive,” and immediately the team responded. There was little discussion, just action. “This is my baby girl,'' Margaret thought as she steadied herself on the bed rail. She briefly considered the scenario; how many hundreds of times have I stood at the head of a bed during a crisis? But now, this is my daughter.
Without even realizing what she was doing, Margaret instinctively helped disconnect her daughter’s monitors for rapid transport to the operating room. As they started rolling the bed toward the door she caught a glimpse of her son-in-law in the corner of the room- she had forgotten in the moment that he was even present. His eyes were “as big as saucers and I just assumed he was in shock,” Margaret recalls. One of the nurses tossed him the paper scrubs to put over his clothes, anticipating that he might get a chance to go into the operating room with his family, while Margaret, not wanting to disrupt the team, mouthed the words “go, go” to instruct him to follow his wife and the team toward the operating room doors. At 12:43, as her daughter’s bed was pushed into the hallway she heard the “Code Blue” alert on the overhead speaker and realized in horror that this was her daughter’s Code Blue. In that instant Margaret knew that her daughter’s life was in jeopardy. She felt her knees buckle as she watched the staff running with the crash cart (emergency cart) toward her daughter.
Meanwhile, her son-in-law, struggling to keep up with the moving team, was not allowed past the operating room doors. Instead, he was alone with only the frantic worry about his wife and baby’s condition. It would be hard to overstate the feelings of fear and helplessness family members experience in moments such as these. Knowing only that his wife’s life was in jeopardy, he texted his parents in the cafeteria saying “pray now.”
Margaret, too, was alone. After making her way to the couch in the corner of the room and pausing for a moment to catch her breath, she called her ex-husband and told him what was happening. She remembers only fragments of the conversation but was able to convey to him that their daughter “appeared to have had a reaction to the epidural medications” and was in the operating room. At 1 pm she was still on the phone when the charge nurse came in with news. “They are both alive, everyone is ok.” The nurse went on to tell her that her “granddaughter was born at 12:46, only 3 minutes from the time the code blue had been called. They delivered the baby while they were intubating her daughter. Your granddaughter is heading to the NICU (neonatal intensive care unit) and your daughter will be in the recovery room shortly.” Her son-in-law’s parents returned from the cafeteria, asking Margaret for all the updates. She doesn’t remember much of the conversations that occurred in those moments, but she does recall that it felt “odd” that she had been given the role of spokesperson or public information officer for everyone else despite having herself just experienced one of the most terrifying moments in her life.
Around 1:30 pm, several hospital administrators came in to offer explanations and check-in with the family. Margaret knew what this meeting was about. In fact, in her role as a healthcare worker, she had often initiated these conversations with families. Although the intent is to offer additional reassurance and support, if not handled deftly, these talks can leave a family feeling unsatisfied or even dismissed. In Margaret’s view, the meeting conveyed little more than “we’re sorry for your experience,” as if they were apologizing for poor service at a restaurant or a back-ordered item that didn’t arrive. In fact, even their attire- suits and dress shoes- struck Margaret as very “out-of-place” in the moment; she longed to see someone in scrubs or operating room clogs, like the charge nurse or anesthesiologist, who could offer more concrete information.
No one came to talk with her daughter (or other family members) about possible mental health consequences that could result after such a traumatic event. No mental health referrals were given and no one else from the administrative staff came to speak with them after that initial visit. What this family desperately needed was more than scripted apologies and a conjectured explanation of the events. They needed validation for their experience and the acknowledgement that this was an event that would be addressed and reviewed.
After the event, Margaret wrote a grievance letter to the hospital on her daughter’s behalf. She knew she couldn’t change what happened to her daughter, but perhaps she could prevent this from happening to any other woman. She carefully described the timeline, explaining that her daughter still has nightmares and routinely wakes up feeling like she can’t breathe. She experiences frequent episodes of panic, and now has to manage anxiety in addition to adapting to life as a new mother. Her daughter required an extended stay in the hospital for 6 days and her granddaughter required not only a NICU stay, but also treatment for a tibial-fibular fracture that was sustained during the emergency delivery. Margaret also requested a RCA (root cause analysis) of the event to investigate possible system-based errors that could have contributed to the adverse outcome. She also requested that the self-pay balance be waived.
The hospital responded with a form letter. It stated that there would be no adjustment to her balance and no need for any further review. And, as if to confirm that the event was over, at least from their perspective, they added: “We determined your medical treatment was appropriate.” In Margaret’s words, “It was awful!!” This form of dismissal only adds to the anger and frustration of an already traumatized family.
At the time of this initial interview, there had been no other communication. Meanwhile, her daughter was still paying off the $6,000.00 balance, a year and a half later.
Margaret had never assumed that anything other than an adverse reaction to the epidural medicines had caused her daughter to experience near complete cardiovascular collapse. She thought that it must have been an allergy to the medication or perhaps it was the wrong medication. When I pointed out that there were other potential causes of this situation such as a complete spinal block, she was surprised. I continued to explain that a complete spinal occurs when the medication given with the intent of being delivered to the epidural space actually gets delivered to the spinal fluid. In other words, the large volume of local anesthetic her daughter received could have been a spinal overdose. Margaret’s description of her daughter’s fragmented memories of the event are more consistent with this situation rather than an allergy or “wrong medication” error.
Margaret’s daughter shared with her after the event that she could still hear voices around her even though she could not move or speak. She distinctly remembered hearing the words “she's unresponsive.” Having grown up with a mom who was an EMT, she knew that the oxygen mask was keeping her alive, so when they removed it to place the endotracheal tube she recalled terror and panic. She was frustrated that she couldn’t talk when she was having difficulty breathing, and then she was paralyzed. She didn’t recall feeling pain at any time during the surgery.
If there had been a thorough review of this event, evidence may have surfaced supporting these other possible causes, prompting discussion and analysis into safer ways to administer anesthetic medications for non-emergent cases. The hospital may have then reconsidered their position on the issue.
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When I asked how she herself is currently doing, Margaret shared that she is still triggered anytime she hears a “code blue” call at work. The intense visceral physiologic response she experiences is immediate and she describes it as somewhat like having the “wind knocked out of you” combined with the urge to vomit. Her nightmares, initially occurring with some frequency, are finally starting to subside. Not surprisingly, she had a nightmare about the event the night before our interview. Until she connected her daughter’s trauma to her own heightened responses to her granddaughter’s birth, she hadn’t understood the magnitude of this event on her own psyche. The failure to connect the two most likely prevented her from receiving the appropriate therapy. If the relationship between previous trauma and current symptoms had been identified, perhaps Margaret would have been evaluated for PTS (post traumatic stress) symptoms and offered a different form of intervention.
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Margaret’s daughter still struggles with mental health issues from this experience. Perhaps she will feel comfortable sharing her perspective of her experience at a future time.
Margaret’s story illustrates how essential it is for us, as providers, to understand the impact that emergency situations have not only on patients but on families as well. Offering partners and family members transparent communication in a timely manner along with validation and genuine concern may help to minimize feelings of powerlessness and exclusion during these truly terrifying moments. We also need to realize that any events that provoke fear and anxiety can have profound long-term consequences that can affect mental health, interpersonal relationships and future fertility (for both partners.)
Emergencies and complications will always be a part of obstetrics. I’m sure that my colleagues would agree that we should always strive to prevent as many of these as possible. The way we prevent many of these complications is through critical analysis of adverse events to explore why and how an event could have happened. I heard a lecturer once say, it is awful when a negative event happens, it is an absolute travesty when no one learns from it. How can we possibly prevent the event from happening to someone else if we don’t explore the issue in-depth?
For those emergencies we can’t prevent, minimizing further harm should always be the goal. This includes consideration for potential emotional and psychological complications such as PTSD in patients and their significant others, and offering resources and referrals for mental health support to everyone involved.
We don’t currently know how many family members go on to develop severe mental health complications, such as PTSD, after a traumatic birth experience. If we can identify partners’ needs during these terrifying situations and develop protocols to support them, perhaps we could lessen symptom severity and help to promote mental health stability at a time when it is most crucial for the family.
Margaret’s story illustrates how essential it is for us, as providers, to understand the impact that emergency situations have not only on patients but on families as well. Offering partners and family members transparent communication in a timely manner along with validation and genuine concern may help to minimize feelings of powerlessness and exclusion during these truly terrifying moments. We also need to realize that any events that provoke fear and anxiety can have profound long-term consequences that can affect mental health, interpersonal relationships and future fertility (for both partners.)
Emergencies and complications will always be a part of obstetrics. I’m sure that my colleagues would agree that we should always strive to prevent as many of these as possible. The way we prevent many of these complications is through critical analysis of adverse events to explore why and how an event could have happened. I heard a lecturer once say, it is awful when a negative event happens, it is an absolute travesty when no one learns from it. How can we possibly prevent the event from happening to someone else if we don’t explore the issue in-depth?
For those emergencies we can’t prevent, minimizing further harm should always be the goal. This includes consideration for potential emotional and psychological complications such as PTSD in patients and their significant others, and offering resources and referrals for mental health support to everyone involved.
We don’t currently know how many family members go on to develop severe mental health complications, such as PTSD, after a traumatic birth experience. If we can identify partners’ needs during these terrifying situations and develop protocols to support them, perhaps we could lessen symptom severity and help to promote mental health stability at a time when it is most crucial for the family.
I am so grateful that Margaret shared her narrative with me. Revisiting painful memories for many is like reliving the experience, even if the event happened years earlier.