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Pain, Suffering, and Trauma in Labor and Subsequent Post-Traumatic Stress Disorder: First of Two Posts by Penny Simkin, PT, CCE, CD(DONA)

February 15th, 2011 by avatar

Science & Sensibility welcomes new contributor, Penny Simkin, PT, CCE, CD(DONA).  Thank you for sharing your decades-long experience and expertise with us!



Introduction
After the health of mother and baby, labor pain is the greatest concern of women, their partners, and their caregivers. Nurses and doctors promise little or no pain when their medications are used, and feel frustrated and disappointed if a woman has pain. Most are also extremely uncomfortable with her expressions of pain during labor—moans, crying, tension, frustration – because they don’t know how to help her, except to give her medication.

An enormous industry exists in North America to manufacture and safely deliver pain relieving medications for labor. Hospital maternity departments are designed with elimination of pain as a primary consideration, complete with numerous interventions and protocols to keep the pain management medications from causing serious harm. When staff believe that labor pain equals suffering, they convey that belief to the woman and her partner, and, instead of offering support and guidance for comfort, they offer pain medication. If that’s the only option, women will grasp for it.

This brings me to the topic of my blog post today – Pain, Suffering, and Trauma in Labor.

Definitions of Pain and Suffering
If we check the definitions of “pain” and “suffering” in lay dictionaries, the two are often offered as synonyms of one another, which helps explain the fear of labor pain. It’s a fear of suffering. But if we consult the scientific literature, there is a distinction among pain, suffering and trauma. As described in Lowe’s fine paper on the nature of labor pain (1), pain has been defined as, “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (2) The emphasis is on the physical origins of pain.

Lowe also points out that “suffering,” can be distinguished from pain, in that by definition, it describes negative emotional reactions, and includes any of these: perceived threat to body and/or psyche; helplessness and  loss of control; distress; inability to cope with the distressing situation; fear of death of mother or baby. If we think about it, one can have pain without suffering and suffering without pain. We can all recall times when we have been in pain, but did not fear damage or death to ourselves or others, nor did we feel unable to cope with the pain. For many people, athletic effort, recovery from planned surgery, dental work, and labor are painful but these people do not suffer with them. This is because the person has enough modifiers (knowledge, attention to other matters or goals, companionship, reassurance, touch, self-help measures, feelings of safety and other positive factors) to keep her from interpreting the experience as painful. All pain is not suffering.

By the same token, I’m sure we can recall times when we have suffered without pain. Acute worry or anguish about oneself or a loved one, death of a loved one, cruel or insensitive treatment, deep shame, extreme fear, loneliness, depression, and other negative emotions do not necessarily include real or potential physical damage, but certainly cause suffering. Therefore, all suffering is not due to pain. In fact, it is these negative modifiers that turn labor pain into suffering.

Of course, the goal of childbirth education has always been to reduce the negative modifiers, and increase the positive ones. The goal of anesthesiology has been to remove awareness of pain, in the assumption that when there is little or no pain, there will be no suffering. I’ll get back to that point later in Part 2 of this blog.

Suffering and Trauma
According to the American Psychiatric Association, the definition of trauma comes very close to the definition of suffering. “Trauma” involves experiencing or witnessing an event in which there is actual or perceived death or serious injury, or threat to the physical integrity of self or others, and/or the person’s response included fear, helplessness, or horror. (3)  Neither suffering nor trauma necessarily includes actual physical damage, although it may do so.

One’s perception of the event is what defines it as traumatic or not. As it pertains to childbirth, “Birth trauma is in the eye of the beholder” (4), and whether others would agree is irrelevant to the diagnosis.

Birth trauma and Post-Traumatic Stress Disorder (PTSD) after childbirth
A traumatic birth includes suffering and may lead to PTSD, which (according to the APA) means that the sufferer has at least 3 of the following symptoms that continue for at least one month:

  • nightmares
  • flashbacks
  • fears of recurrence
  • staying away from the people or location involved
  • avoiding circumstances in which, it can happen again
  • amnesia
  • emotional numbing
  • panic attacks
  • emotional distress

One national survey found that 18% of almost 1000 new mothers (up to 18 months after childbirth) reported traumatic births, as assessed by the PTSD Symptom Scale, a highly respected diagnostic tool. Half of these women (9% of the sample) had high enough scores to be diagnosed with PTSD after childbirth. (5)

Other smaller surveys (using women’s reports as the criteria for diagnosis) have found that between 25% and 33% of women report that their births were traumatic. Of these, between 12% and 24% developed Post-Traumatic Stress Disorder (PTSD). In other words, between 3% and 9% of all women surveyed developed PTSD after Childbirth.(6–9)

As we can see, every woman who has a traumatic birth does not go on to develop the full syndrome of PTSD. If they have fewer symptoms than the three or more required for the diagnosis, they may be described as having PTS Effects (PTSE). Though disturbing, the women are more likely to recover spontaneously over time than those with PTSD. The question of why some women get PTSD and others do not is intriguing and multifactorial: the propensity to develop post birth PTSD has to do with how they felt they were treated in labor; whether they felt in control; whether they panicked or felt angry during labor; whether they dissociated; whether they suffered “mental defeat;” (that is they gave up, feeling overwhelmed, hopeless and as if they couldn’t go on) (9, 10). Another risk factor for developing birth related PTSD  is having a history of unresolved physical, sexual and/or emotional trauma from earlier in their lives.  Even though unresolved previous trauma is unlikely to be healed during pregnancy, most of the other variables associated with PTSD can be prevented “through care in labor that enhances perceptions of control and support” (9).

In Part 2 of this blog post, I will suggest practical ways to apply what we know about the risk factors for childbirth-related PTSD, and how we can address these  before, during, and after childbirth.  I will discuss prevention and reduction strategies which can collectively reduce the likelihood of traumatic childbirth and subsequent PTSD.

This blog post series will be featured in the Fall 2011 issue of the Journal of Perinatal Education.  For references, please contact Ms. Simkin directly at: penny@pennysimkin.com or reference the JPE issue:  Summer 2011 Volume 20, Number 3.

 

Post By: Penny Simkin, PT, CCE, CD(DONA)

Doula Care, Healthy Birth Practices, Healthy Care Practices, Patient Advocacy, Perinatal Mood Disorders, PTSD, Science & Sensibility, Uncategorized , , , , ,

  1. February 15th, 2011 at 08:53 | #1

    Thank you Penny for this post, and your continued efforts to help us understand this aspect of perinatal mood disorders. PTSD secondary to childbirth is so often misdiagnosed and misunderstood, and often effects the partner as well. I worked with a couple where the Dad was a veteran with 4 tours in Afghanistan—the birth had to be handled very mindfully for him as well.

    I would love to know your thoughts about how childbirth educators might address risk factors in a class for both mom and partner.

    Thank you again, and how wonderful to have your contributions here! Way to go, Kimmelin!

  2. February 15th, 2011 at 12:21 | #2

    Hi, Walker,
    Next week, in Part 2 of my blog post, I’ll offer suggestions for ways readers may reduce the likelihood of suffering with prenatal, intrapartum, and postpartum actions based on the information imparted in Part 1. I’ll look forward to your feedback on Part 2! — Penny

  3. February 15th, 2011 at 12:25 | #3

    Having suffered from my own PTSD as a result of traumatic births, I think it’s especially important for me to be reminded of where the pain comes from so that I am clear whose birth I am actually attending. I do my best to empty my cup before working with a mama and allow her to have her own experience without the burden of my birth story brushing up against hers.

  4. February 15th, 2011 at 13:10 | #4

    Kat,

    Your message here is an especially poignant one. Thank you for sharing and reminding us that in our own work with pregnant/birthing women, our past experiences can be equally heightened…we must remember to take care of ourselves as we care for others.

  5. February 15th, 2011 at 13:19 | #5

    @Kat Ogletree
    Kat, Thank you for your comment. While one’s own history of PTSD can be a burden, it can also bring empathy to our work with childbearing women. I’m impressed that you recognize your need to “empty your cup” to “allow her to have her own experience,” but I also hope you have a support network to confer with after births that trigger you.
    I think we need a blog on Vicarious Traumatization of the care team member!

  6. February 15th, 2011 at 13:40 | #6

    Dear Kimmelin and Penny,

    I DO have an astounding support system (Community Doula Network and the Birth Network of Monterey County). I also continue to work on my “own stuff,” using as many avenues as I can to reach the tender spots in my own heart. I would love for there to be a blog on “Vicarious Traumatization of the care team.” I would also like to have a conversation with other doulas who have used their own trauma as a doorway to compassionate care.

  7. February 15th, 2011 at 14:32 | #7

    Hi Penny, thanks for writing this! I became a doula, and am now a nursing student and a homebirth midwifery student BECAUSE of my own traumatic experience when having my son. I still suffer from PTSD because of it.

    Thanks for all you do!

    Stephanie

  8. February 15th, 2011 at 15:54 | #8

    @Stephanie
    Hello, Stephanie,
    I wish you well as you travel this demanding and rewarding journey. I do hope your PTSD will fade over time, or that you get just the help you need in healing, so that in the end you’re stronger than ever. Do attend to your own needs, as well.
    All the best, Penny

  9. February 15th, 2011 at 15:57 | #9

    @Kat Ogletree
    YOu may very well connect with others who reply to my post. Such a converstion among those who have had traumatic births may be very comforting. Peny

  10. avatar
    Tricia Pil
    February 15th, 2011 at 21:41 | #10

    Thank you so much, Penny, for your post raising awareness about postpartum PTSD, this sorely underrecognized, under- and misdiagnosed, and under- and mistreated condition. It is with sadness and chagrin that I admit that, even as a pediatrician, I had never even heard of postpartum PTSD–until it happened to me.

  11. avatar
    Teri Shilling
    February 15th, 2011 at 23:10 | #11

    Thanks for sharing this. You have a true gift in the way you write. Your ability to weave in the scientific evidence with the sensitivity that comes with your experience with educating/supporting/helping so many women.

    Do we really have to wait a whole week for part 2? I am looking forward to that!

  12. avatar
    Becky
    February 16th, 2011 at 07:14 | #12

    Penny, I’m not sure if I’m understanding your post correctly.

    “We can all recall times when we have been in pain, but did not fear damage or death to ourselves or others, nor did we feel unable to cope with the pain. For many people, athletic effort, recovery from planned surgery, dental work, and labor are painful but these people do not suffer with them. This is because the person has enough modifiers (knowledge, attention to other matters or goals, companionship, reassurance, touch, self-help measures, feelings of safety and other positive factors) to keep her from interpreting the experience as painful. All pain is not suffering.”

    “Therefore, all suffering is not due to pain. In fact, it is these negative modifiers that turn labor pain into suffering.”

    Make it sound as though labor pain itself does not cause suffering, but that it is only the absence of “positive modifiers” or the presence of “negative modifiers” that causes suffering. Am I understanding you correctly? If this is the case, I disagree. I don’t believe that labor pain always causes suffering, but in my experience it certainly can be strong enough to do so, even without additional factors. Also, most people undergoing dental work or recovering from planned surgery do take some kind of pain medication, even if they aren’t suffering from what pain remains.

    I’ve had four unmedicated births, two in hospital and two out-of-hospital with midwives. In my last labor I suffered. I had good support from my husband, my midwife and her assistant, yet the pain was overwhelmingly intense, quite different to my other labors. Thankfully, labor was blessedly short. I am not suffering from PTSD, yet I do find myself consumed with fear about my upcoming fifth delivery. I’ve lost the confidence I had about being able to handle the pain.

  13. February 18th, 2011 at 11:29 | #13

    Thank you Penny! I discuss the difference between pain and suffering with my doula clients prenatally. Your presentation of this topic is concise and clear. I will be referring my clients to this article! It is so valuable for someone who is at risk of PTSD, or even feelings of suffering in birth, to have good, knowledgeable support people at their side in birth. Thank you again.

  14. February 18th, 2011 at 12:51 | #14

    Becky, Thanks for pointing out my lack of clarity. I can see how my remarks may appear to deny that extreme pain can cause suffering. I think I should clarify that suffering occurs when one feels helpless, out of control, etc., due to extreme pain, which you did feel, or other things that I mentioned in my post. Extreme pain can cause people to suffer, of course, and none of the modifiers I listed will be sufficient. I don’t mean to belittle how severe pain can be. I want to re-iterate that “Traumatic childbirth is in the eyes of the beholder.” As I’ll state in Part 2, sometimes pain medication, namely the epidural or spinal, is the most effective modifier to prevent pain from becoming suffering. Unfortunately, with a very short labor, which you had last time, the epidural may take too much time to prevent suffering.
    I’m glad that you mentioned that you do not have PTSD, and I’m wondering if the excellent support you had from your husband, midwife, and her assistant might have prevented the trauma from becoming PTSD. Can you imagine what you might be feeling now if you had been alone or were treated unkindly at that time? As I mentioned in my post, feelings of being unsupported during a traumatic birth is associated with PTSD.
    I am concerned about the fear and loss of confidence that you are feeling about your upcoming birth. I’d like to discuss some options with you.
    Thanks, Melinda for your kind words.
    @Becky

  15. avatar
    canoe chick
    February 20th, 2011 at 19:12 | #15

    @Kat Ogletree
    Kat, I just wish to chime in about doulas who may “use their own trauma as a doorway to compassionate care”. I am a childbirth educator and doula who, after my second birth, had an absolutely horrible breastfeeding experience. For many reasons, that are not important here, suffice to say that I had every BF intervention one could have and STILL I gave up after 6 weeks, which broke my heart. I cried for a whole year over my lost breastfeeding relationship with my youngest baby. (exacerbated by PPD of course)…the point is, after lots of work, I am now able to see what a great breastfeeding support person I am because of that experience. (whoops, that sounds incredibly arrogant – sorry!) But I know that if I had struggled for a few weeks and ultimately been successful, it would have been harder for me to be supportive of women who are struggling. I would always, in the back of my mind, been thinking “oh, you didn’t get the right help” or “you didn’t try this” etc. which sometimes would have been true but would have prevented me from being as compassionate as I should be.

  16. February 23rd, 2011 at 00:39 | #16

    To all: Part 2 of this post is in the final stages of preparation and scheduled to post next Monday, 2/28/2011. You will NOT want to miss Penny’s recommendations on how to best help prevent the development of childbirth-related PTSD.

  17. avatar
    Susan
    February 23rd, 2011 at 14:30 | #17

    I am glad to see the subject of feeling in control and the emotional effect of a birth playing a large role in how one feels about it later, the development of PTSD, etc. That played such a huge role in my own births. My first was complicated, difficult and dangerous so my caregiver was shocked that I not only avoided surgery, but came through it smiling and happy. I was lucky to have found childbirth hypnosis, and the sense of control those skills gave me over how I responded to the circumstances of my birth were priceless. I had the presence of mind to literally pick and choose my responses to what was happening, and chose to be positive, peaceful and patient. I now teach Hypnobabies and see time and again how much it helps women to not only increase their comfort, but also experience their births in a positive, healthy way, even when things do not go as planned. The sense of calm and control, along with the additional tools/scripts designed to be used if complications arise help so many women enjoy a birth that they would have found traumitizing without the use of self-hypnosis.

  18. avatar
    Tara
    February 25th, 2011 at 00:59 | #18

    Thank you Penny for this series of posts. I just wanted to say that I went through 2 traumatic births, 2 miscarriages and 3 OK birth experiences (soon to be 4). It wasn’t until a year ago (after I decided to become a Doula) that I really started thinking about my experiences and how I dealt with them (or didn’t deal with them). I saught out help through Reproductive Mental Health and was basically told that I was like any other woman with bad birth memories (and that was all it was, memories) and the fact that I went on to have more children told her that I wasn’t in need of any help until well after this baby was born. I was also told that it wasn’t a good thing to be “labeled” as someone with PTSD. After that appointment I sat in my vehicle and cried because I didn’t know what to think and I still had a fear of ending up back at the hospital, instead of our plan of a homebirth, that wasn’t being recognized and dealt with. I decided that I was going to try to seek out a councilor who could help me (even a little) before this baby is born. I have to say that the councilor I saw was very understanding and willing to offer suggestions to me (EMDR). She also believes that traumatic experiences are in the eye of the beholder. For me there isn’t time for the main type of therapy, but she said there were some things I can do on my own. Finally, my feelings were validated by someone and I had something to work with. Sorry for going on. I hope to be able to finally heal from these experiences and get some things back on track. Like me, some other Moms may find themselves in this grey area of getting help, but it is there. Thank you again Penny for your passion to help women and families through this wonderful experience in their lives.

  19. February 25th, 2011 at 03:41 | #19

    Susan,
    You’re one of the many women who have found hypnosis to be extremely beneficial during labor. How great that you have gone on to teach it and spread its benefits to even more women.

    Tara,
    I’ve worried that counselors like the one you mentioned, out of their lack of knowledge, do more harm than good when they, as authority figures, discount a woman’s traumatic birth experience. This is one reason Phyllis Klaus and I wrote “When Survoivors Give Birth” –to inform therapists as well as other professionals and the public of the reality of traumatic birth and how to prevent it or heal from it.
    I think that Part 2 of my blog post will give you some concrete ways to prepare for your upcoming birth. I hope you can take steps to increase your confidence and line up the help you need to have a rewarding birth!Penny

  20. avatar
    Tara
    February 25th, 2011 at 12:34 | #20

    It is interesting though with the first experience because that is where women are suppossed to go in our area to get help with this and are being turned away. This person was also a psychologist specializing in this field. I found out afterwards that a friend of mine had the same experience with her and ended up on antidepressants for a while. She said she hoped I would have had a better experience. I find the whole topic of traumatic birth experiences and finding help very sad. I have been on forums where other Moms are expressing similar feelings (for themselves or partner), but don’t know what to do. My heart goes out to them.
    Susan, It was wonderful reading your post. I wish I had known about hypnosis before now. I have heard so many good things about it. I am looking forward to trying it with this baby and taking the classes to teach it to others.

  21. February 25th, 2011 at 12:58 | #21

    Tara,

    Have you tried accessing support through Postpartum Support International? Here is a good link to visit, to get started:
    http://www.postpartum.net/Get-Help.aspx

    Also, check this resource out, as well as this on-line daily support service through Postpartum Progress (which, in name, sounds more geared toward postpartum depression, but really provides support for any woman suffering from a perinatal mood disorder.)
    Keep your chin up, and keep seeking support until you find the type(s) of support that suit your needs. Help really is out there. Don’t give up hope.

  22. February 25th, 2011 at 14:11 | #22

    Dear Tara,
    Thank you for having the courage to share your experience–and know that it will help many, many others in ways you might never know. And as a doula, you will be of extraordinary help to women and men. I recently had a client whose partner had been active duty in Iraq, 3 tours. My work in this area helped me see he needed support as well, and I was able to refer him to mental health professionals in my area.

    That being said, I would just like to support Penny and Kimmelin in their thoughts for you. Going to PSI is an excellent idea, and reaching out to Katherine at Postaprtum Progress is a good idea too. I also wanted to honor your experience with the professionals in the past. In the beginning I had HORRIBLE (bad enough to deserve all-caps)experiences with “leaders” in the field of reproductive psychiatry. And women, and mothers, no less. I will never forget it. But, I also found extraordinary help from others in the field. It is a relatively new field, and most people (including shrinks) don’t know what perinatal mood disorders are, much less PTSD after childbirth. But that is changing with the help of people like you…I also tried EMDR and had a bad reaction.

    I wanted to also suggest you take a look at http://www.tabs.org.nz/. And http://www.solaceformothers.org Good information. Know that you are not alone.

  23. February 25th, 2011 at 15:39 | #23

    Penny,
    Thank you for writing so thoughtfully about postpartum PTSD. While I didn’t have that (I had postpartum OCD), the term “mental defeat” really resonates with me. After 4 hours of pushing, I definitely suffered mental defeat. I felt I couldn’t even get my son out, so I was already “failing” as a mother.

    Interestingly, I just read a piece over at Science-Based Medicine on pain during labor and epidurals. I’d be very curious to see what everyone here thinks of it. http://www.sciencebasedmedicine.org/?p=10765

  24. February 25th, 2011 at 17:23 | #24

    Oh my gosh! I was just writing a lengthy response to the thoughtful remarks we’ve had on my blog post. I left the page to look up something on the web, and it all disappeared. (That’s the 3rd time that has happened to me. I’m such a novice. . . I don’t know how to save my comments to come back to them later. Phooey. I don’t have time to go through it all again, except to encourage Katherine and everony to see Henci Goer’s comments ofn Grant’s book in praise of epidurals. Also see Michael Klein’s 3 part blog series on epidurals. There is more that one side to think about on the issues of widespread use of epidurals.
    Furthermore, I want to say that Walker’s and Tara’s comments show how har we have to go to educate the mental health “experts” on the powerful impact that birth has, and when that impact is negative, long-term suffering often ensues. When that impact is positive, it strengthens the mother’s self-confidence, empowers her, and gives her a great start in her role as a parent.

  25. avatar
    wendy davis
    February 27th, 2011 at 15:27 | #25

    Thank you Penny and Kimmelin for all of this – the wonderful writing, resources, sensitivity, and dialogue about PTSD related to childbearing.
    It takes a lot for survivors of any trauma to reach out, and it makes us all so sad and angry when providers make it worse. Tara – good for you for trusting your instincts when therapist #1 was completely off base, and for finding support from a wiser woman! Thank goodness for Penny Simkim and other pioneers who have led the way. I really believe now that all of us, working together, are starting to influence mental health experts and childbirth professionals. Women and their partners need ALL of their care providers to recognize that the physical and psychological aspects of childbearing and (childbearing loss)cannot be separated. Rock on, Lamaze!

  26. March 1st, 2011 at 18:32 | #26

    It is an incredible joy for me to witness the conversation that is now part of the childbearing community. We have connected our emotions with the physical process of the perinatal period by listening to the experiences of women. My generation only had “Our Bodies, Ourselves” to read, and consciousness raising groups…be proud of what you’re doing! Jane

  27. March 1st, 2011 at 18:35 | #27

    no changes

  28. March 1st, 2011 at 20:28 | #28

    Yes, Jane, it’s been a lonely struggles for so many years to bring postpartum issues to the attention of those who caould be instrumental in preventing and identifying them. Still today, it’s up to the woman or her social circle to recognize that something isn’t right for the woman (or 10% of the time, her partner!). A woman is unlikely to see her care provider for 4 to 6 weeks after the birth. A lot of serious problems can have developed by that time. And, although, thanks to your work and that of others, some care providers do screen for postpartum mood disorders. Those who don’t do so, however, leave a harmful condition unacknowledged and untreated. Thanks for being there and doing your valuable work.

  29. avatar
    Tori
    March 25th, 2011 at 15:29 | #29

    Beautifully done Penny!

  30. avatar
    Pam Washburn
    March 26th, 2011 at 18:19 | #30

    I firmly believe there is a difference between pain and suffering in childbirth. I also believe that “the sounds of labor” can also be misinterpreted and mistreated. I learned from Penny long ago that as long as it is rhythmic, it is ok. I try to support my moms in whatever they decide to do for their labor, but so many times I’ve had moms come in and say they want an epidural immediately. More times than not, after working with them, they gain control, gain confidence, feel supported and go on to have an anesthesia free delivery. This does not mean that I would withhold options if the mom insisted, but often they are so happy about what they were able to accomplish. I always keep in mind that this is a lifetime memory that is never forgotten, so I want their memories to be of how kind or understanding their nurse was. I always ask myself,”how will this be remembered?” Thank you Penny for all you have contributed to the childbirth world!!

  31. avatar
    Janelle
    April 6th, 2011 at 11:46 | #31

    This is a great article, and I would really like to read some of the references Penny lists. Would it be possible to fix the numbering of the references so they match the superscripts in the post? Thanks!

  32. October 9th, 2011 at 09:00 | #32

    Hi Penny -

    I am so glad you are out there working to help women & families. I so enjoyed meeting you and hearing your presentation on Birth Trauma in Seattle this September. I will be checking in here from now on. thanks for your wonderful spirit!

  33. January 19th, 2014 at 20:08 | #33

    This blog was… how do you say it? Relevant!!
    Finally I’ve found something which helped me. Appreciate it!

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