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Birth Trauma

September 28, 2014

Immediately after the event* best try to forget it and enjoy the baby

*First four words added 1 October 2014

Despite modern pain relief and liberal Caesareans, traumatic births still happen. Delivery sometimes has to be rushed, forceps don’t always go as planned, epidurals may fail, or the baby’s shoulders get stuck.  Even births which appear normal to the midwife, may be perceived as traumatic by the mother.

Such women should be treated sympathetically, but should we do anything more?  Should we talk about what happened, or offer extra counselling? Many people think so. But might talking do harm – perhaps by encouraging rumination and bad memories?

We shouldn’t just assume that talking/counselling does good. We should compare outcomes among women offered extra counselling and those who were not. The best such evidence comes from randomised trials and from systematic reviews of such trials. What does it say?

There does not seem to be a Cochrane review of the effect of counselling/debriefing after traumatic birth. But there have been other systematic reviews.  One (click here) found 8 trials, six showed no effect, one possible harm and one possible benefit.

Another more recent evidence-based review (click here) found “midwife-led debriefing after an operative birth was ineffective in reducing maternal morbidity and the possibility of contributing to emotional health problems could not be excluded”. Or to put it another way, it doesn’t do good and might do harm.

Outside pregnancy the many trials of additional psychological support/therapy after other types of trauma, have been collected into two Cochrane reviews

The first (click here) showed no benefit from brief psychological support (BPS). If anything there was a non-significant trend for more post traumatic stress disorder (PTSD) after the BPS.

The second (click here) showed no benefit from multiple sessions of early psychological interventions. The authors concluded that “multiple session interventions, like single session interventions, may have an adverse effect on some individuals”.

All the above refers to preventive counselling/debriefing soon after the event. Psychological treatment for the minority who are unlucky enough to develop long-standing distress is a quite separate matter.

But this research is the reason that in the short term, parents who have experienced traumatic birth should be encouraged to get on with their lives and avoid special counselling. For most of them putting the birth behind them and enjoying the baby is good therapy. Talking to a counsellor about what happened is as likely to do harm as good.

Jim Thornton

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31 Comments leave one →
  1. Sarah Davies permalink
    September 28, 2014 9:39 am

    The debriefing in these RCTs may have done more harm than good, but in those that I’ve read, debriefing was performed soon after the event (already known to be potentially harmful in other situations), and in the place where the trauma occurred – ie in the hospital.

    ‘Birth afterthoughts’ services, which women can access whan they are ready, and are in control of the timing/place, seem much more helpful.

    I worry about the phrase ‘encouraged to get on with their lives’; it’s akin to ‘you’ve got a healthy baby, what are you worrying about?’ which is patronising and minimises the distress many women feel regarding a damaging birth experience. PTSD after birth is underdiagnosed – if distress is dismissed, and women are advised to get on with their lives, PTSD may become chronic. Professionals should be listening to women, and opening up spaces for them to discuss their feelings.

    • September 30, 2014 6:40 pm

      Sarah, I think we’re saying much the same thing. Early talking/psychotherapy/counselling is probably ineffective and may do harm. Later on, if you’re unlucky enough to still have problems, the right sort of talking therapy, CBT I guess, may be effective.

      I’m an obstetrician. I’ve spoken to innumerable parents after birth trauma, stillbirth and other bad events. I tell them that we don’t offer routine counselling for a reason; human beings are resilient, most people come to terms with a bad event without counselling, and trials suggest that it may do more harm than good.

      I do encourage them to get on with their lives and, if they have baby, to enjoy it. This is not patronising. Nor is it dismissing their distress – at this early stage they haven’t got PTSD. They are shocked, frightened or sad. My aim is to reduce the risk of future distress.

      I don’t arrange follow-up just to see if they’re OK, but emphasise that if later they find themselves with anxiety,flashbacks or whatever they should request referral.

      I’d be delighted if someone could show that some sort of extra talking/counselling/debriefing was effective, but I’m not aware of any such evidence.

  2. September 30, 2014 8:17 pm

    I think this article could be very damaging for women who have suffered birth trauma to read. Better just forget it and enjoy the baby? How ridiculous! like asking someone who was just raped to forget it and carry on with life? As a previous sufferer of Birth Trauma and PTSD the very things that saved me were therapy, debriefing and talking about the experience. Being listened to and having my feelings be valid was so important. You are basically saying “At least you have a healthy baby” which is also something extremely hurtful and upsetting to say to a woman who has experienced birth trauma. Now as a Doula I also speak to many women daily who have been traumatised by birth and these women are joining groups and desperately searching out a place where they can speak and be heard.

  3. laura permalink
    September 30, 2014 8:33 pm

    “Best try to forget it”……
    if only it where that simple,
    as a new mother suffering from ptsd the thing that has got me through it it talking about it (almost obsessively).

  4. Springinmystep permalink
    September 30, 2014 9:06 pm

    Counselling was necessary and extremely effective for me. I know for a fact that my midwife counsellor and my obstetrician would strongly disagree with your opinion. Until you have carried a baby, nearly lost it, nearly died, had a nephrostomy for 3 months, received shoddy aftercare and then have to have bladder/ureter reconstructive surgery – please don’t speak for women worldwide in saying counselling is not effective.

  5. Shaz Hay permalink
    September 30, 2014 9:28 pm

    You honestly think that, after a traumatic birth, encouraging a woman to “get on with her life and enjoy her baby” isn’t patronising? Boy, am I glad you weren’t my obstetrician. That is a harmful thing to say to a woman in such a fragile state. Speaking to people about my traumatic birth was the only thing that saved me. Having my feelings validated (and being told that the hospital staff involved would be investigated for what they did to me) was one of the starting blocks of my “recovery” (I used the speech marks because I am aware that it will be a lifelong journey and, essentially, there won’t be a full recovery for me.) For the time that I kept everything bottled up, I’ve never felt more isolated and disconnected from my environment. The support group I joined saved my life and the women in that group are extremely special to me as they helped me when “professionals”, such as yourself, turned their back on me and said “Your baby is healthy, what’s the problem?!” I find this article worryingly naive. Coming from a healthcare professional, I am scared for the women who will be brushed off with such harmful words, not just by you but by others who may buy into this “research”

  6. harmed permalink
    September 30, 2014 9:51 pm

    I think the key here the 2nd to last paragraph “All the above refers to preventive counselling/debriefing soon after the event. Psychological treatment for the minority who are unlucky enough to develop long-standing distress is a quite separate matter.” I’m not sure immediate debriefing would have done me any good…I was still processing. It hit me a few weeks later. The lawsuit and EMDR about 6 months out did help immensely though.

  7. September 30, 2014 10:00 pm

    as someone that nearly died and lost my baby due to birth trauma that resulted in me having PTSD I find your comments hurtful and so a complete lack of understanding of birth trauma and PTSD. Thank god your not the one advising on what treatment women should get. After years of struggling and trying to access help I finally paid for counselling which was the best think I ever did. Would you tell a survivor of other traumas they too should just get on with life. How sadly uneducated you are.

  8. Sara Miles permalink
    September 30, 2014 10:02 pm

    And here is the reason there are so many traumatic births in the first place! Obstetricians, health care professionals who don’t have a compassionate bone in their body!
    What an absolute immbecile in my opinion & I think a trip back to college for some studying would be helpful.
    How dare you tell mums who have been through a horrific ordeal to move on from the birth & enjoy their baby.
    Try having a student midwife look after you, end up having an emergency c-section, no medical staff notice you are hemmorhaging for an hour & half, being rushed back to theatre where they fight to save your life all night, wake up the next day in ICU on a life support being told you had to have a hysterectomy. In one moment it went from the best day to the worst day of my life. My first baby is my only baby & I just have to move on from that and enjoy my baby?!?!
    My whole life was changed in that instant & you think I can just move on?
    The fact I almost died by losing 8 litres of blood that night also plays havoc with my mind & means I am petrified of death. PTSD has now been part of my life for 3 years.
    Yes I enjoy my son every single day, but don’t be so ignorant to think you can just move on.
    Get your head out of your obstetric arse & see what is happening around you!

  9. sarah fellows permalink
    September 30, 2014 10:06 pm

    Yes must agree, I was diagnosed with PTSD finally after 3 after my sons negligent Birth.. But couldn’t remove the trauma for another 4 years until after my sons case went to trial…Yes more than anything I wished I could of just forgot the Birth and got on with enjoying my son, I ended up losing my Social Work Career, my home, my 10 year relationship….In life there was nothing worse than not being able to not protect my son for his first hour of his life….I went on to having to TOP’s has I couldn’t cope with another labour, I feel you need more understanding how we have been affected with our Birth’s before setting out a insult like that one!!

  10. lorelei permalink
    September 30, 2014 10:14 pm

    I understand what you’re saying but I feel that you haven’t done your research, nor does it appear that you are able to listen to your patients. As a therapist I am concerned about the damaging effect this article might have on those who have suffered birth trauma and I didn’t have to check to know that it was written by someone who has never given birth.
    To those women who might be reading this, I urge you to ignore what this person has said and find an obstetrician/professional who actually understands what it means to give birth. It can sometimes feel like the whole world has the same opinion as this person and I promise it is not true. There are lots of brilliant professionals out there who can offer the support that you need.

  11. KarenHillyer permalink
    September 30, 2014 10:29 pm

    I would have LOVED to have enjoyed my baby following my traumatic delivery…………..unfortunately I was too busy performing physiotherapy on his paralysed right arm at EVERY nappy change, dealing with his projectile vomiting from his phrenic nerve injury and taking him to regular appointments with a paediatrician, orthopaedic surgeon, opthalmologist ( for his Horners syndrome) dietician for his failure to thrive and HIM undergoing 6 hours of plastic and re constructive surgery at a hospital 120 miles from our home in order to TRY to restore some function to his paralysed arm …………oh and also caring for my husband who suffered PTSD from watching the trauma and supporting him through losing his job as a firefighter because he could no long cope in stressful situations

    yes – enjoying my baby and getting on with my life was MY DREAM TOO !!!!!!!!!!!

    I find this article patronising and insulting in the extreme and quite frankly demonstrating a dreadful lack of empathy with patients – thank goodness my childbearing years are behind me

  12. Mary King permalink
    September 30, 2014 11:17 pm

    You are an arrogant & ignorant man. Let me give you some advice: Until you have experienced a traumatic birth please keep your overbearing & condescending opinions to yourself. I am unbelievably grateful that you weren’t anywhere near me when my son was born or after. I think you need to work on your people skills matey, take some lessons from the nurses & midwives around you.

  13. Kath permalink
    October 1, 2014 12:00 am

    I think you have made the classic mistake that I see so many health professionals make that a healthy baby is all that matters. Or the outcome justifies the means.

    The reality is that women need to be encouraged to separate their joy in having a healthy baby from their feelings about their birth experience. They are not the same thing and one can never justify the other. Does it not occur to you that when women are not enabled to do this, that having such an internal dissonance can cause immense psychological and emotional distress? Or do you make the same mistake as so many others that because a woman appears to be well externally, doing and saying all the right things, that therefore she cannot be genuinely distressed about her birth experience. This idea that a woman just needs to forget about what is causing her distress invalidates her on so many levels. If a counsellor or psychotherapist said this to a woman, they would, quite rightly, be called to account for their behaviour.

    As for the ‘studies’. You actually think that emotions about a significant life experience and whether any resultant therapy is useful can be measured quantatively? Really? You need to think that through and perhaps leave such comments to someone who actually knows about meaningful research relating to counselling and psychotherapy.

  14. Gill permalink
    October 1, 2014 12:06 am

    You come across as the worst kind of patronising Dr. The very last thing a woman who has suffered any kind of birth trauma needs to hear is this nonsense. Trust me. The ‘you’ve got a healthy baby and that’s all that matters’ message is damaging in the extreme. I really do pity your patients. Take a step back, do a skills audit and then do some reading on psychological first aid or let someone better qualified talk to the poor women.
    I nearly died (due to massive PPH and complications) in surgical delivery but it needn’t have led to PTSD and my emotional absence for my daughters life for a significant time if only I’d been offered some real psychological support. The just get on with it approach shames women who are already vulnerable and feeling guilty for having ‘failed’ at child birth into hiding just how bad it is and this compounds the issue. You need to stop believing your own hype and start listening to your patients.

  15. October 1, 2014 7:38 am

    Oh dear. Four words added to subtitle to clarify that this all refers to the immediate period after the traumatic event. I obviously should have made that clearer.

    Disappointed that no-one seems to have picked up on the point that talking therapy may do harm as well as good, and that strongly held opinions are not the way to decide which. Nor I’m afraid is qualitative research. We need good quality trials.

    The quality of those we have is poor. They have often not specified clearly what type of talking therapy they were comparing, followed everyone up, or reported all the important outcomes. It’s a shame.

    • Shaz Hay permalink
      October 1, 2014 8:27 am

      If I had been spoken to properly instead of the staff using your “Your baby is alive and that’s all that matters” I would have been much healthier. If they would have spoken to me like a human being rather than a vessel at the end of an assembly line, I would, without a doubt, have been much more connected with what was done to me. Instead, I was palmed off with the very statements that you, Sir, are palming other women off with. You can honestly have no idea how harmful your statement is. It disregards the mother’s feelings. It’s as if you people view it as, the mother has done her job, we’ve done our job, case closed. That is NOT the case. What you say to women in the immediate aftermath of these incidents is paramount. And yet, as with your ineptitude during the event itself, you see it as not being your job. It IS your job. If you have overseen a birth where the mother is clearly traumatised, you should take it upon yourself, not just as an OB but as a human being, to make sure that woman has every support available. You are failing your patients but, after my experience (and the experience of my amazing friends here) I am sad to say, this doesn’t surprise me.

  16. Gill permalink
    October 1, 2014 8:42 am

    Firstly what we need in the NHS is a change in the culture, to make a caring environment in which a mother can safely express how badly traumatic birth has effected her. Your ‘article’ seems to take it as read that such an environment exists and almost cries ‘moly coddling’ when the truth for many women is that zero care and emotional support or the wrong kind of well meaning ‘jollying along’ are provided.
    Support in the aftermath of trauma is what women need, if properly done talking therapy may not even be required if a mothers feelings and trauma are acknowledged and handled with care and dignity at the time and in the immediate aftermath rather than the current pervasive attitude that ‘a healthy baby is all that matters’ which so many of your peers espouse and that you seem to express here. Before you can start ‘good quality trials’ you need to start from a solid foundation of care and obstetricians, midwives and other staff need improved and radical training in the management of traumatised patients, then you might get away from a need for more therapy.

  17. thom permalink
    October 1, 2014 9:23 am

    As a man that has bean there for his partner during a traumatic birth this article is disgraceful and dangers to the women the thousands of people that are suffering with birth trauma.
    I am not going to go in to specifics but my wife went through a herific birth that was miss handled and befor everything we were miss informed about a number of things.(it is just the level of care that I have come to expect from the NHS)
    If you think that it is easy for someone with PTSD to put the “situation behind them and move on with there lives” then please go back to the books. There is no way to move on when you are throne back every time you fall asleep. What would you say to the fathers that the birth effects? When they are stood there helpless and unable to say or do anything to take the pain away, and then in the time after having to be the rock when all they feel like doing is just braking down. I wonted two children a boy and a girl but after the birth of my little boy I don’t want to put my wife through that turcher again. It doesn’t affect the amount I love my wife or two year old boy, but it affects wanting any more. I think you are a very closed minded individual and in my personal opinion you need to go back to university and start your studying from scratch. That way you might learn some compassion.

  18. Mary King permalink
    October 1, 2014 10:35 am

    Good to see you have admitted that the ‘research’ you’ve based your self important statements on is shaky at best. Also, I’d like to enquire what your qualifications are in the mental health field? I’m guessing I’d be correct in assuming zero??!
    Whether or not talking therapy is the best choice for immediately after the event is quite clearly not your main point. The title for your pathetic excuse for an article is ‘best try to forget it & enjoy your baby’. Saying this to a traumatised woman is very damaging.
    What IS a shame, is that you are in a position to be in contact with vulnerable women.
    Shaz is completely right. You are failing your patients.

  19. Shaz Hay permalink
    October 1, 2014 10:52 am

    I would love to know why my husband’s comment hasn’t been approved yet!! Had a funny feeling that it wouldn’t be!!

    • lorelei permalink
      October 1, 2014 2:34 pm

      I’d be really interested in another mans take on this, if he could maybe reword it in a more acceptable way without losing its feeling? 🙂

    • October 1, 2014 5:10 pm

      Sorry. Was doing other things. Previous posters get approved automatically, but first timers need a manual click. Hope it’s come through now.

  20. October 1, 2014 12:12 pm

    “Despite modern pain relief and liberal Caesareans, traumatic births still happen.” And sometimes, of course, a caesarean birth can be traumatic. Sometimes a birth with pain relief can be traumatic because, as you don’t need me to tell you, an epidural can increase the likelihood of interventions such as forceps and ventouse, which themselves come with risks attached.

    The line “even births which appear normal to the midwife may be perceived as traumatic by the mother” is very telling. The mother, after all, is the person who has given birth and therefore is the only person able to say whether her experience was traumatic or not. She doesn’t “perceive” it as traumatic; it *is* traumatic.

    The reason you’ve had such a strong response to this post is not because people are failing to understand the point about whether early counselling or debriefing is or isn’t beneficial, but because your post ignores the experience of the women themselves. As a doctor, one of the most valuable things you can do is listen to what your patients are telling you.

    I’ve written a fuller response here – my very first blog post in a new blog: http://birthtraumas.wordpress.com/2014/10/01/dont-tell-women-to-forget-traumatic-births/

  21. Kath permalink
    October 1, 2014 3:01 pm

    You’re also erronneous in assuming that relegating your assumptions to immediately after birth somehow validates your points. It doesn’t, and if anything just highlights your profound lack of understanding on this issue.

    You say yourself the quantative data is poor. We already knew that. It is not a subject in which is really possible to gather any robust quantative data because of the very nature of what psychological distress is. I think you will find that if you took the time to discuss this with those working in the field of psychotherapy and counselling, that this would explained to you in great detail. I would also suggest you look at some of the approaches to therapy, particularly social constructivism, gender issues and possibly even family systems theory in order to gain some understanding of why your post is so out of step with reality. You may also want to examine the research in relation to staff attitudes and patient compliance, and the impact of language on patients

    Perhaps you could clarify your thoughts on exactly how talking therapies are harmful. The problem with all of the studies you mention is that assumptions are being drawn without consideration to significant and critical factors like the needs of the individual, how the person debriefing or counselling behaves, the language they use, the relationship between the two, etc etc etc. You are making assumptions based on flawed research.

    Just give it up, Jim. Delete this post, educate yourself and try again when you’ve adjusted your thinking.

  22. October 2, 2014 12:54 am

    You’re right in that psychological debriefing in the immediate aftermath of a traumatic birth has not been shown to be helpful and may indeed be harmful. Trauma experts recommend something akin to ‘expectant management’, however, rather than “just try to pretend it didn’t happen”. Their evidence shows that people are best served by compassionate engagement, provision of information and connection with social supports.

  23. Kath permalink
    October 2, 2014 1:18 am

    Another major flaw in your thinking is you appear to believe that the physical event is the cause of the trauma. This is not necessarily the case. It may be a catalyst or a contributing factor, not always the direct cause. If you understood this, then you would also not be making uneducated remarks like ‘even births which appear normal to the the midwife, may be perceived as traumatic by the mother.’

    I don’t feel that you really have any grasp at all of what psychological trauma is beyond a set of criteria defined by American health insurance companies.

  24. Sophia permalink
    October 2, 2014 1:37 pm

    Although this article isn’t explicit in saying so, it does imply that women who have experienced a traumatic birth don’t ‘enjoy’ their children.
    My Health Visitor asked me, “So are you enjoying him now?”. That’s like a red rag to a bull.
    Of course you enjoy and love your child. The way in which they arrived in the world doesn’t affect that.
    This article is emotive in all the wrong ways. As an obstetrician I would hope that some credible and practical research could now help to inform this area of your study. Regards.

  25. ujipeople permalink
    July 26, 2015 4:29 am

    Why can’t women decide if their birth was traumatic and if they need extra support? The first week is such a fragile time and to be sent home to “enjoy your baby” mere hours after a traumatic and or physically damaging birth is to set mothers up for failure.

    Having suffered PND and PTSD I was so alone and confused in the days following my first birth. I was told to be proud of my unmedicated birth yet felt deeply traumatised. I was high risk for mental illness but was never offered any counselling in the early days of motherhood or checked up on.

    To be told to just enjoy your baby when you’re adjusting to life as a mother whilst recovering from trauma can be deeply damaging as we know all too well mother baby bonds are already one of the greatest casualties of PND and the lack of bonding can be a big source of guilt for women with PND.

Trackbacks

  1. Why you should never tell a woman who’s had a traumatic birth to forget it and enjoy her baby | birthtraumas
  2. Don’t tell women to “forget” their traumatic births | birthtraumas

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