Finding Myself Again: Establishing a Midwife-Led Service to Treat Birth Trauma Susie Moore

Swansea University

Wales & South West Maternity Forum

18th September 2019

Cardiff

Aims of this presentation

To give some background to the incidence and neuroscience of birth trauma

To discuss Birth Trauma Resolution therapy and describe the implementation of a birth trauma clinic.

To present an overview of our evaluations

Birth trauma

Birth trauma has become increasingly recognised as a distinct mental health condition associated with Post Traumatic Stress Disorder (PTSD), and the term describes women who experience the symptoms of PTSD following childbirth but who may meet some, but not all, of its diagnostic criteria.

It is estimated by the Birth Trauma Association that 10,000 women per year present with PTSD as a result of traumatic birth.

There is increasing evidence in the UK, and in other countries, that traumatic birth can have a serious impact on mothers’ and fathers’ mental health with consequences for all their relationships

Features similar to PTSD

Distressing memories

Flashbacks

Nightmares

Anxiety

Physical symptoms

Avoidance of people of places

Loss of memory

Loss of interest in activities

Feeling disconnected from baby

Feeling disconnected from family and friends

Unable to express love or feelings

No hope or positive thoughts

Difficulty in sleeping

Outbursts of anger or irritation

Difficulty concentrating

Hypervigilance

Features particular to

birth trauma

Revisiting images of labour and birth

Fear of and avoidance of giving birth in the future

Poor self image and feeling inadequate

Relationship difficulties

Difficulty in breastfeeding

Lack of interest and avoidance of sex & shunning physical contact

Difficulty attaching to baby and the resulting guilt

Isolation and loneliness

Postnatal depression

Avoidance of medical treatments like smear tests

Triggers

Characteristic of PTSD is persistent re-experiencing of trauma. For birth trauma sufferers the new baby can be a reminder of the birth experience and trigger flashbacks

Neuroscience

Several parts of the brain are important in understanding how the brain and body function during trauma.

Forebrain (the prefrontal cortex);

The limbic system, which is located in the centre of the brain;

The brain stem.

When a person experiences a traumatic event, adrenalin rushes through the body and the memory is imprinted into the amygdala, which is part of the limbic system. The amygdala holds the emotional significance of the event (the intensity and impulse of emotion).

Rational – non rational

The rational part of our brain is the prefrontal cortex. This is the front part of our brain, where consciousness lives, processing and reasoning occur, and we make meaning of language.

When a trauma occurs, people enter into a fight, flight, or freeze state, which can result in the prefrontal cortex shutting down.

AWEN Birth Trauma Resolution

Service

Established two years ago

Two fully trained, accredited and experienced midwives

Free, self-referral

Over 80 clients seen so far

Usually 2- 3 sessions

profound impact on woman

Birth Trauma Resolution

Humans Givens Psychotherapy technique (course accredited by RCM)

Solution Focused – actually treat symptoms

Clients set their own goals

Assess emotional wellbeing

Use of relaxation techniques and self help encouraged

Lowering arousal

Reinforcing positive behaviours

Themes

Interventions in pregnancy & labour

IOL

MLU – CLU in labour

Perceived near death experience

Mother and / or baby

Bereavement

Miscarriage

Themes

IOL

Often focus on partner being sent home

Left alone

Frightened

Loss of control – not listened to

Interventions in labour

Midwifery led care Obstetric led care

Operative birth

Sense of failure

Loss of dignity

Lack of advocacy

Lack of early contact with baby

Lack of Advocacy / Compassion

“It’s as if some midwives don’t have vaginas”

“The doctor warned me that it would be painful and that she would not stop the sweep, even if I asked her to. It was the worse

experience of my life and the midwife just stood there as I screamed for her to stop”

“I felt like a piece of meat”

Lack of Advocacy / Compassion

“The hospital staff didn’t want me there. They were busy and I was sent away. They told me to go and sit on the smoker’s bench. I felt

exposed and silly as car drivers and passengers watched me in pain in the street.”

Themes

Perceived near death experience

PPH

Fetal heart anomalies in labour

Bereavement

Miscarriage

Near death experiences

“The midwife told me my baby was being taken to the morgue where it would be dark”

“There was so much blood. I can still see it now. It was like claret red”

“People still come up to me now and ask about the ‘love bite’ on my neck. It’s where the line went in. I’m reminded of it everyday

when I look in the mirror”

Case Study

Carrie self-referred for therapy when her first born was about two years old

Blaming herself for not achieving a normal birth

Felt robbed of a positive birth experience

Frightened to conceive again

Felt alone – lost contact with friends

Goals

feel ‘normal’

Summary of labour: MLC, prepared by hypnobirthing, attended hospital in early labour, frightened. Partner sent home. Left alone. Let’s

listen to Carrie’s story.

Case study:

Therapy – a summary

Session 1

Listening

No attempt to ‘justify’ or ‘explain’ actions

The woman’s story is accepted

She feels her experience is validated

emotional arousal reduced

Coached abdominal 7/11 breathing (deep breathing)

essential to success of treatment

Therapy

Session 2 – 1 week later

Returned a week later – visibly relaxed

Supported into deep relaxation

7-11 breathing

GVI – bespoke to woman

Rewind therapy

moving the memory from the stuck area in the brain to the

neo-cortex

stored as a ‘normal’ memory, detached from negative

emotional arousal

Therapy

Session 2

Completed session with ‘holistic’ releasing

Replacing negative thoughts with more positive ones – chosen by woman

confidence

Therapy

Session 3 – 1 week later

Attended in good spirits

Feeling completely different with neutral thoughts about the birth

Declined any further treatment

Intended coming back when she gets pregnant again

Less than one year later

Pregnant

Attended for relaxation and positive birth rehearsal

Support for VBAC

Testimonials

I never believed the service would have helped me in the way it did. It has made my day to day life so much easier. Thank you!

I appreciated the fact it was offered to me, even though I gave birth 2 years ago it helped resolve issues in a calm manner and specifically

addressed the feelings I had.

I found the whole experience quite cathartic and in the weeks and months after the therapy I have found myself feeling as if the event is now

in the past and overall actually feeling a lot more positive about potentially having another child in the future (something which I had almost ruled out previously because of having to give birth again).

Testimonials

It was great to have a safe space to speak openly and honestly about my birthing experience.

The therapist was completely non-judgemental and emphasised that

each woman's experience is personal to them.

Initially I was not sure if I would meet the threshold for birth trauma therapy; however, after the first session I realised that I had a lot of

negative associations with my birthing experience e.g. anxiety around hospitals.

Testimonials

The therapist worked on my anxiety with me and it took away a huge issue in my life which I didn't realise. I was always drowning in feelings of panic and worry of not getting stuff done, which I thought was normal. I know don't have that. My anxiety pops

back every now and again but I feel I know how to deal with it now so it doesn't become a issue.

It didn’t feel like treatment. Also the effect was so rapid and yet subtle. I only saw Suzie three times in total and yet

it has genuinely improved my life.

Moving forward

Continue to collect evaluation data through online questionnaire

Publication from this data – themes that contribute to birth trauma in relation to care given

Qualitative interviews

Future project with psychology department – sleep deprivation

Larger scale study across a geographical area to look at different approaches to birth trauma therapy for more robust and specific evidence base.

Any

questions…….?

Further Reading

Byrne, V., Egan, J., Mac Neela, P. (2017) What about me? The loss of self through the experience of traumatic childbirth. Midwifery, 51, 1-11.

Elmir, R. and Schmied, V. (2016). A meta-ethnographic synthesis of fathers' experiences of complicated births that are potentially traumatic Midwifery, 32, 66-74.

Griffin, J. & Tyrell, I. (2013). Human Givens: the new approach to emotional health and clear thinking. HG Publishing: Chalvington.

Mullen, J.(2107). Birth Trauma Resolution. Midirs Midwifery Digest. 27,3,345-348.

National Child Birth Trust. McKenzie-McHarg and Poote Dealing with post-traumatic stress disorder. Available from: www.nct.org.uk/McKenzie-McHarg and Poote Dealing with post-traumatic stress disorder.pdf Accessed 21.04.17

National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. Available from: www.nice.org. uk/guidance/indevelopment/gid-cgwave0598 Accessed 24.04.17

Reed, M., Fenwick, J., Hauck, Y., Gamble, J., Creedy, D. (2014). Australian midwives’ experience of delivering a counseling intervention for women reporting traumatic birth. Midwifery, 30, 269-275.

http://pattch.org/resource-guide/traumatic-births-and-ptsd-definition-and-statistics

https://www.rcm.org.uk/sites/default/files/Emotional%20Wellbeing_Guide_WEB.pdf

http://birthtraumaresolution.com/birth-trauma-information/biography/