Trauma-Informed Care During Pregnancy and Birth

• By:  Emily Laubham
• Posted:  February 9, 2022
•   Share This

In a British Journal of Anaesthesia article, Tracey Vogel, MD and Sarah Homitsky, MD point out that about 8% of pregnant patients meet the criteria for post-traumatic stress disorder (PTSD), and up to 44% of women perceive their childbirth experience as traumatic.

That would seem to make obstetrics an obvious choice for the expanding field of trauma-informed care — approaches to health care that factor in the potential impact of trauma. Yet, the trauma-informed care clinic for obstetric patients launched by Allegheny Health Network (AHN) in 2021 is actually one of the first in the nation.

The clinic is a collaboration between the AHN Women’s Behavioral Health program, a part of the AHN Psychiatry and Behavioral Health Institute, and AHN Women’s Institute. Dr. Vogel, an AHN obstetric anesthesiologist, is the clinic’s director and physician lead. She is also a certified sexual assault counselor with Pittsburgh Action Against Rape (PAAR), and a founder of The Empowerment Equation, an online platform for patients and providers to communicate and find resources on birth-related trauma and the impact of past trauma on pregnancy and birth.

Understanding trauma

Emily Laubham: Trauma can take many forms for women, including domestic violence and structural racism. 81% percent of women nationwide report some form of sexual harassment and/or assault in their lifetime, and about 20% say they’ve experienced completed or attempted rape. Before we dig into the details of the clinic, can you give us a clinical perspective on trauma?

Dr. Tracey Vogel: You can think of trauma broadly as any event that overwhelms an individual’s ability to maintain a sense of control over themselves or their environment. It also overwhelms their ability to maintain a connection with others or make meaning out of a situation or event.

If you look at the Diagnostic and Statistical Manual of Mental Disorders, which is kind of the psychiatric bible, it defines trauma in terms of being exposed to serious threat or incidence of violence, sexual assault, or death. It allows not just for direct exposure — meaning it happened to you — but also witnessing an event that happened to a loved one.

More recently, they’ve started including events surrounding childbirth as meeting the criteria for trauma. It’s not that childbirth trauma is new — women have been talking about it for decades. It’s just that nobody was listening. Many women are also socialized to be quiet and not complain.

Emily Laubham: That’s so true. Birth is often presented like an impressionist painting — beautiful, but very few details. And although little girls are often taught to fear many things, childbirth is not one of those things.

Dr. Tracey Vogel: Absolutely. Social media doesn’t help, because people post almost exclusively about good experiences, reinforcing the misconception that every birth is supposed to be perfect, and women “aren’t allowed” to feel sad, frustrated, or traumatized, or have fears around childbirth. That said, it’s encouraging that more online sites and support groups are popping up that discuss traumatic events.

Emily Laubham: What impact does trauma have on a person’s health?

Dr. Tracey Vogel: Almost everyone experiences adversity, and many experience some level of trauma during their lifetime, but not everyone develops PTSD. What we’re talking about at the trauma-informed care clinic is significant, ongoing, unresolved trauma — people who can’t get rid of a fear-conditioned response and, because of ongoing psychological disruption, have physical, behavioral, and psychiatric manifestations.

Psychiatric manifestations include PTSD, depression, anxiety, or suicidal ideation. Behavioral manifestations include things like substance use disorders, eating disorders, or sexual promiscuity. People with trauma might lack coping skills or isolate themselves from family and friends. We also see physical manifestations like high blood pressure, cardiovascular disease, chronic pain, fibromyalgia, and chronic migraines. Autoimmune diseases can be rooted in a history of trauma, too.

Screening for trauma

Emily Laubham: What are the signs that an obstetric patient may have a history of trauma?

Dr. Tracey Vogel: Most women with trauma don’t present with a history of PTSD, because they’ve never been diagnosed. However, substance use issues may be a sign of past trauma. Behaviorally, we might observe that someone has difficulty during a vaginal exam or experiences increased heart rate or rapid breathing. Most commonly, trauma presents as mental health issues. For example, one day on our unit, six out of ten patients had a history of anxiety and depression. When I asked my residents at the time whether they had asked follow-up questions, none had — so part of trauma-informed care is teaching people the importance of making those connections.

Emily Laubham: Does the clinic do a formal screening for trauma or previous birth trauma?

Dr. Tracey Vogel: First, there is almost no precedent for this — we’re creating it as we go. We do have a tool I call the Labor Angel. It doesn’t screen specifically for PTSD, depression, or anxiety, but it includes questions from those categories, as well as asking directly, “Have you ever had a traumatic experience?” These are questions that typically haven’t been asked at any point in a person’s pregnancy.

We’re also offering instruction sheets to other obstetrics groups, maternal-fetal medicine groups, and nurses that spell out the type of people I’d like them to refer to us, including people who had a complicated or traumatic childbirth experience, and people who have significant anxiety or fear about childbirth, concern about pain management, substance use issues, or need one-on-one attention.

An obstetrics intake questionnaire I’m studying includes the question, “How afraid of childbirth are you?” If someone scores a 4 or 5 on a 1-to-5 scale, they should automatically get a referral. I think all women are nervous or a little daunted, especially if it’s their first birth — but a 4 or 5 is someone who finds childbirth terrifying or panic-inducing, and we want to address that as soon as possible.

Emily Laubham: Do women need to divulge the details of trauma for trauma-informed care to be beneficial?

Dr. Tracey Vogel: Absolutely not. It’s up to the patient. If I have enough indication that a person has experienced sexual trauma, for example, I can develop a plan and make certain reassurances regardless of whether they choose to share details.

Trauma-informed care during pregnancy, birth and postpartum

Emily Laubham: Once someone has been referred to the clinic, how does the trauma-informed care approach play out?

Dr. Tracey Vogel: Step one is to listen to and validate each person. My primary job is to help them understand that they’re not alone, I believe them, and whatever they’re feeling is real. The next step is to identify specific fears or concerns about delivery. Then we can create an individualized birth plan that addresses different scenarios.

We pay attention to different potential triggers depending on what the previous trauma is. Survivors of sexual assault can encounter many triggers — physical, emotional, psychological, and sexual — throughout the entire process. Intrinsic triggers could include pain, a change in appearance, feeling dirty, bodily fluids, or groaning. Extrinsic triggers could include bright lights, exposure, any sort of restraints, and much of what you see in an operating room. If they’re not prepared for these things, they can get caught in a significant acute stress response that can be very dangerous.

As part of some birth plans, we do virtual tours to desensitize and familiarize patients with certain environments. My plan could also involve keeping the patient warm or clothed as much as possible. In some cases, we might want to give them low doses of anti-anxiety or anti-nausea medicine. We definitely want to be on the same page for how we handle pain management. If they have mental health issues, I’ll ask whether they have a therapist and whether they’re on any medications. If necessary, we collaborate with our own behavioral health therapists.

Emily Laubham: What triggers do you have to be aware of and manage if a woman's previous trauma is birth-related?

Dr. Tracey Vogel: That also varies depending on the previous trauma. If the trauma was the loss of their baby, we would try to understand what happened in order to help them feel safe this time around. For example, hearing the baby cry immediately after birth might be extremely important. If there was a serious hemorrhage or bleed during a previous delivery, I offer to take women into our simulator center and work with them to understand bleeding in context, how much is appropriate, and maybe also take them on a virtual operating room tour.

If it was an anesthesia issue that created the trauma, they might present with a fear of spinals or say, “I just want to go to sleep for a C-section.” In this case, it might require counseling to work toward a different outcome. During a surgical birth, I want my anesthesia team to get confirmation that a spinal or epidural is working — they do four different checks. If it’s not working, or if the patient isn’t sure that it’s working, there shouldn’t be any pressure to stick with that type of anesthesia.

Emily Laubham: What about postpartum care?

Dr. Tracey Vogel: I usually follow up within a day or two of delivery and then again about two weeks post-delivery. I’ll reach out more often if I feel like there’s an issue, and of course we also make sure to continue treating pre-existing mental health issues. If there is a traumatic delivery, we make sure to follow them longer, but with the vast majority of patients, if the birth plan was executed properly, they will have had an overall positive experience.

A model for the future

Emily Laubham: How important is AHN’s multidisciplinary approach in terms of successful trauma-informed care?

Dr. Tracey Vogel: This is a very collaborative program. The trauma-informed care clinic cannot exist on its own — it has to be part of the broader obstetrics care program, anesthesiology, Women’s Behavioral Health, our Perinatal Hope Program, nursing. Integration is invaluable.

Emily Laubham: Do you see a future when trauma-informed care is integrated into all fields of health?

Dr. Tracey Vogel: Yes. Trauma-informed approaches exist in other areas, although it is limited — mostly HIV clinics and adolescent centers which were more attuned because of working with marginalized populations who faced a lot of trauma in their lifetimes. But there’s a growing awareness of the need for this, including to address health disparities caused by structural and cultural racism and trauma.

Emily Laubham: In addition to the trauma-informed care clinic, you are involved in research and advocacy. Can you talk about how that all blends together?

Dr. Tracey Vogel: The clinic is about each patient’s care and experience obviously, but it is also about changing the culture, including through training. For me, research and advocacy are about raising awareness and also making sure people are heard.

When I first started noticing issues around trauma and childbirth, I felt like I was on an island. There were advocacy groups out there, but traditional hospital-based obstetrics were slower to catch on. I started The Empowerment Equation platform because I felt like I needed to do more. If women want to share their story, it’s there for other women to read and know they’re not alone. And at the same time, it’s also a place where I can provide resources and compile and share research for other providers to help them better understand these issues and what to do, or not do, when working with people who have experienced trauma.

Emily Laubham: You mentioned training being part of the clinic’s work. Can you elaborate on that?

Dr. Tracey Vogel: Yes, to help staff understand trauma principles, I’m repurposing the knowledge I gained from Pittsburgh Action Against Rape (PAAR), where I was certified as a sexual assault counselor. I honestly wish that every provider could go through that training — I learned more there than I have anywhere else on my journey.

I’m also developing principles on trauma-informed care that can be tailored for different fields. The first module covers trauma, how it could present in obstetrics, common concerns, and why this is important. The second module is case exploration — teaching them to recognize red flags, as well as how to interact with patients, recognize acute stress responses, use grounding techniques, and identify/use body language. In a third module, I brought in actresses for a group of nurses, and we did different scenarios to help them practice their skills.

Emily Laubham: Is the training also on some level just helping providers get comfortable with the complexity?

Dr. Tracey Vogel: Yes, that’s a good point. Physicians tend to like things to be tidy, we crave control and understanding, but trauma is messy. We can’t see it or measure it, and even when we know it’s there, treatment doesn’t fit in a box.

I believe many physicians struggle with this kind of care because they see it as intangible, and that’s not necessarily true. If I can teach them what to say, what to look for, what to do, how to intervene, it’s not so intangible.

When it comes to preventing trauma in the medical field, there are very tangible things that can make a difference, like letting patients wear their own gowns, always knocking before entering a room, minimizing vaginal exams, limiting who performs those exams, and always letting the patient dictate the pace of the exam — if she says “stop,” you stop.

But to your point about complexity, every person is different, and every person comes from a different cultural context, so providers really need to listen and validate what each patient tells them. That’s where we start and what we have to keep coming back to.