Traumatic Labour - a shadow on the childbearing years

The health service is quoted (The Times Monday January 6th 2014) as saying that postnatal depression is more common than many people realise and cases can often go undiagnosed. It is estimated that 1 in 7 women experiences some level of depression in the first three months after giving birth. The article also cites fear of labour as a trigger factor, together with issues such as the stress of looking after a baby, hormonal changes after pregnancy and money or relationship problems.

How much more difficult it can be for women who have endured long, problematic or traumatic previous labours to avoid feelings of depression or failure.

Some years ago research was undertaken, questioning a large group of postnatal mothers in an area of South West London. The researchers were interested in finding out more about the difficulties experienced by women who endured particularly complicated labours. The research question was whether their distress was serious enough to be classed as Post Traumatic Stress Disorder. The response level was very high and some participants wrote letters or rang researchers to tell their stories. Many described feelings of guilt, thinking that they had ‘failed’ if their difficulties had resulted in a caesarean section. Some mothers described their experiences of pain and confusion about unpleasant medical interventions, feelings of helplessness, feelings of terror that they might lose the baby or even that they were dying themselves.  

The unreliability of epidural pain relief came as a shock to many women who had thought “if all else fails I can always get an epidural…” but in fact found that, when needed, an anaesthetist was sometimes unavailable. Other mothers described their distress when the longed-for epidural failed to work, or only worked partially. Medical intervention is necessary in many labours, but many such interventions (induction, acceleration, rupture of membranes, episiotomy or forceps delivery for instance) are associated with increased pain and trauma.

Of course, these procedures can be clinically essential and often save lives - but that does not mean that they are not experienced as brutal or frightening. Women described feeling ‘like a piece of meat’ or ‘a body just to be carted around’. ‘They only talked to my husband’ said one woman, ‘it was as if I wasn’t there or I was stupid’. ‘An animal would have been more gently handled’. In emergency mode medical staff do not always have time to explain or reassure but their very urgency can be frightening in itself. Many women describe the force and power of a forceps delivery as shocking. The most traumatised women often underwent emergency caesareans; elective (planned) caesareans didn’t figure in these stories and this would suggest it is not the procedure that is the problem, but the experience of panic and emergency. Women described the speed, the lack of explanation, the absence of anaesthesia, and the sudden perception of danger as being the trigger that caused them to panic. Once the crisis is resolved with the delivery of a healthy baby, it is assumed that the distress should be forgotten, and bad memories will fade…won’t they?

Not always.

Sometimes the panic doesn’t resolve and more worrying thoughts and feelings seem to haunt these unlucky women. Mothers described their postnatal life as difficult. Particular symptoms were a recurring theme:

• Re-living the experience in nightmares or flashbacks; being at the mercy of intrusive thoughts about the labour, of playing the experience like a repetitive film in their head.
• They described avoiding things that reminded them of their labour; one mother drove miles to avoid passing the hospital where she had her baby and avoided pictures or films of any hospital. Sounds and smells would make her break out into a sweat and start shaking. Postnatal check ups with the hospital or even a GP seemed intolerable and were thus avoided.
• Mothers described being ‘on edge’ all the time, constantly on the brink of tears and being irritable with everyone and finding it impossible to relax. There was often a tendency to scan the world for danger to themselves or their babies. One woman took her baby to the GP dozens of times, finding it impossible to believe that there was nothing wrong with him.
• Many women experienced panic attacks: ‘Panic would come from nowhere and I would start shaking, thinking I was having a heart attack’. Some women described having four or five panic attacks a day, or waking in panic in the middle of the night.
• Other women found it difficult to bond with the baby, or became so irritable with a partner that he could do nothing right. ‘He should have protected me, he shouldn’t have stood there doing nothing.’ said one woman. In these situations a couple’s relationship can be under enormous strain. Partners are often themselves traumatised by having had to watch, helplessly, bewildered and frightened by emergency situations.
• All of these experiences may lead to the development of concurrent postnatal depression – a real example of life adding insult to injury.

The unhappy truth is that all of this can go on behind a façade of normality as people, traumatised mother included, think ‘she’s only had a baby, what’s the big deal?’ and this can isolate her further - she may not be able to explain to friends and family as their own experience is of normal labour and she feels they will never understand.

It is vitally important that mothers with these experiences are listened to, are able to tell their story and be told they have a valid cause for their anguish. Over time a midwife or counsellor can explain the sequence of events to her in a situation of calmness and reassurance which can help to take the emotional ‘heat’ from the memories. Some maternity units run ‘Birth Afterthoughts’ services and a consultant involved in one of these commented: ‘These women need help because they have undergone a very real and frightening hardship’. It may take time, although panic attacks respond well to therapies such as Cognitive Behaviour Therapy.

The consequences of not receiving informed professional help can be tragic; a break up of family life, disruption of the mother/baby relationship or lifelong fear which causes a mother to put off, delay or sometimes avoid forever, having another child.