Subsequent Childbirth

Subsequent Childbirth After a Previous Traumat Birth ‘Chery! Tatano Beck ¥ Sue Watson > Background: tne percent of pew ethers inthe Und States ‘who parted in ho Liserng to Matos! Petar Suvay screened pose for meeting te Diagnose and Sika Menu of Mental Ds, Feurh Eton ctetia fr posta toss disor afi ciith, Women who have had a taumae bith exparence repo fever subse Objective: The purpose of tis study was to descrbo the meaning of women’s expefences of subsequent chic tinh afer prvoustaumat bit > Methods: Phenomenology was the research destan used. An Intoretonal sample of 35 women patted in is te temet stu. Women were asked, "Please desorbe in as ‘much deal as you can remember your subsequent prog anc, abr, and deliver floning your previous aura tinh” Colaizz’sphenoerlogical data arly approach as used to analyze te sles of the 35 women. > suits: Data ands yisked four themes: (a) riding the ‘turbulent wave of panic dung pregnancy, (2) stateging atoms to red thor body and complete tho journey to mathartood c) binging reverence tthe biting process an empowering women; and (4) sil ese: the longed: for heaing bith experience > Discussion: Subsequent chibi aera prvi bith teura has the potential ei hea or eauraize women Duting regency, women need pomision ard enauragement fo lev ter prr uma tho Help rere he turdn of thir inion > Key Words: phenomenology postreunatc stess disorder (PTS0)-euosequent chit taunts cikbith L the United Stars, 9% of new mothers who participated in the Listening to Mothers Il Postarcum Follow-Up Survey sercened positive for mestng the Dizgnostc ard Statistical Manual of Mental Disorders, Fourth Ealition (American Peyhiatric Association, 2000) eiteria for post traumatic sis disorder (PTSD) afer childbinh (Decerca, Sakala, Cony, 8 Appichawm, 2008). In this survey, the mothers voices revealed a roubing pater of maternity eae. Nursing Research Jyh! 200 V5, No 4 ‘A large percentage of women giving bith in the United States experienced hospital care that di not reflect the best evidence for practice nor for women's preferences. The Institute of Medicine (2003) identified childbirth as a national healthcare priority for quality improvement. A maternity care quality chasm still exists (Sakala & Corry, 2007). Researchers and healthcare professionals at an interna~ tional meeting on curren issues regarding PTSD after child- bizeh recommended th ned for research focusing on women's subjective birth experiences (Ayers, Joseph, MeKenzie Metlacg, Slade, 8 Wijma, 2008). Olde, wan der Hart, Kleber, and van Son (2006) called for examining the chronic nature of childbicth-related posttraumatic stress lasting longer than 6 months afer birth. “The puspose of the current study was to help fill the knowledge gap of one aspect of the chronicity of birth trauma: women’s subjective experiences of the subsequent pregnancy, labor, and delivery aftr a traumatic childbitth Review of Literature “Traumatic childbirth is defined as “an event occurring due- ing the labor and delivery process that involves actual or threatened serios injury or death to the mother or her infant. The birthing woman experiences intense fer, help- lesinoss, loss of contol, and horror” (Beck, 20042, p. 28). For some women, a taumatic biet also involves petceiv- ing thie birthing experience as dehumanizing and stripping them of theie dignity (Beck, 2004a, 2004b, 2006). After 2 twaumatic ehildbith, 2% 10 21% of women mect the di agnostic criteia for PTSD (Ayers, 2004; Ayers, Harris, Sawyer, Parfit, 8¢ Ford, 2009), involving the development of three characeeritc symptoms stemming from the ex- posure to the trauma: persistent reexperiencing of the trau- mnatic event, persistent avoiding of reminders of the trauma and a numbing of general esponsivenes, and persistent i ‘eased arousal (American Peychiauic Associaton, 2000). Risk Factors Risk factors contsibuting to women perceiving theiechild- birth as traumatic can be divided into three, categories prenatal factors, nature and circumstances of the delivery, Ghergt Tatapo Beck, DNSe, CNM, s reson Scho! of Nuri, Unive of Connect Sor. Sue Watson, is Chairperson, Tratoma and Birth Srose, Auckland, Netw Zealavd 241 Copyright © 2010 Lippincott Willams & Wikins. Unauthorized reproduction of this article is prohibited.2A2_chidith Ate Provous Traumatic Bit and subjective factors during childbirth (van Son, Verkerk, van der Hart, ‘Nursing Research Juhu 2010 Ve #9, No 4 toms in family members, Catherall stated that it can have a more insidious effect Komproe, 8 Pop, 2005). Under the pre- A large percentage of of a disturbing milieu in the family. The natal category ate factors such a8 hiseo- iC orn members of the family may be’ close ties of previous traumatic births, prenatal giving: ae physically, but their ability to express. PTSD (Onoye, Goebert, Morland, Matsu, United States experienced emotions is limited. True closeness in & Wig, 2009) cid sexual bse and gspital care that did not th family aig and hes problem psychiatric counseling. Factors included solving is impaze. Abrams (1999) iden in the category of nature and circum: reflect the best evidence fied one of the central clinical character- stances af the delivery include a high level "jor practice nor for isis of intrgenecational transmission of medical intervention, extremely pain- : of trauma is the silence chat happens ful labor and delivery, and delivery type women’s preferences, in families regarding traumatic expet (Ayers etal 2009). Subjective risk fac wee ences. Abrams pleaded that the mul tors during childbirth can include fee: ings of powerlessness, lack of caring and support from labor and delivery staff, and fear of dying (Thomson & Downe, 2008). Long-Term Impact of Traumatic Childbirth Researchers are uncovering an unsettling gamut of long: term detrimental elfecs of traumatie childbrch nor only on the mothers themselves but also on theie relationships with infants and other family members, Mothers’ breastfeeding experiences and the yearly anniversary of their birth trauma can also be negatively impacted. Impaired mother-infant rlationships after traumatic childbirth are being confirmed in the leratare. For example, in the study of Ayers, Wright, and Well (2007) of mothers who experionced birth trauma in the United Kingglom, women described themselves as feeling detached and having feelings of rejection toward thei infants. Ncholls and Ayers (2007) reported two different types of mother-infane bonding in couples who shared that PTSD after childbicth affected their relationships with their children; they became anxious! overprotective or avoidanthejeting. Chldbireh-related PTSD also impacted their relationships with theicpartness, including, their physical relationship, communication, conflict, emo: tions, support, and coping. Long-term detrimental effects of traumatic childbirth «an extend also into women’s breastfeeding experiences. in their Internet study, Beck and Watson (2008) explored the impact of birth trauma on the breastfeeding experiences of 52 mothers. For some mothers, their traumatic childbirth led to distressing impediments that curtailed their breastfeeding attempts, such as feeling that their breasts were just ‘one more thing to be violated. Another aspect of che chronic effect of birth trauma was identified in Beck’s (2006) Internet study of the anniversary ‘of traumatic childbinh, an invisible phenomenon that mothers struggled with. Thiny-seven women comprised this inteena- ‘ional sample of mothers from the United States, New Zealand, Australia, United Kingdom, and Canada. Beck conchuded that 2 failure to rescue occurred for women as the anniversary approached, and al others focused on the celebration of the children’s birthdays. Ths failure to rescue led to unnecessary ‘emotional or physical suffering or both, atherall (1998) warned of secondary trauma in fami lis living with trauma survivors. The entice family is vul nerable to becoming secondarily traumatized. The long-term impact of trauma does not resuit necessarily in PTSD symp generational impact of trauma should not be underestimated, Posttraumatic Growth Researchers are reporting that traumatic experiences can hhave positive benefits ina person's life. Postraumatic growth has been documented in a wide range of people ‘who faced traumatic experiences such as bereaved parents {(Engelkemeyer & Marwit, 2008), human immunodet- ciency virus caregivers (Cadell, 2007), and homeless women with histories of traumatic experiences (Stump 8¢ Smith, 2008). “Posttraumatic growth describes the experience of individuals whose development, at leat in some areas, has surpassed what was present before the struggle with che crisis occurred. The individual has not only survived, but has experienced changes that are viewed as important, and that 0 beyond what was the previous situs quo” (Tedeschi 8c Calhoun, 2004, p. 4). It is not the actual trauma that is responsible for’ posttraumatic growth but what happens after the trauma. Tedeschi and Calhoun (2004, p. 6) proposed five domains of posttraumatic growth: “greater Appreciation of life and changed sense of priorities; warmer, more intimate relationships with others; a greater sense of ‘personal strength recognition of new possiblities or paths for ‘one’s life; and sprit development.” Childbirth can have an enormous potential vo help change how a woman feels about herself and can impact her tran- sition to motherhood (Levy, 2006). Attias and Goodwin (1999, p. 299) noted that a woman who survives a traumatie experience may be able to rebuild her wounded inner self “by having a child, transforming her body from a container of ashes to a container for a new human life.” A positive childbirth has the potential to empower a traumatized ‘woman and help hee reclaim hes life, ‘One study was located that touched on the positive srowth of women after a previous negative birthing exper ience. In Cheyney's (2008) qualitative stady of women in the United States who chose home births after experiencing a negative birth, three integrated conceptual themes emerged from their home birth narratives: knowledge, power, and intimacy. The power of theic home births helped heal scars of their past hospital births Positive grow after bieth trauma has yer to be investigated systematically by researchers. One of the knowledge gaps identified in this literature review focused on an aspect ofthe longterm effets of birth trauma: mothers’ subsequent childbirth. This phenomenological study was designed to answer the research question: Copyright © 2010 Lippincott Willams & Wikins. Unauthorized reproduction of tis article is prohibited.[Nursing Research lh! 2010 ol $8, No & ‘What is the meaning of women’s experiences of a subse ‘quent childbirth following 2 previous traumatic birth? Methods Research Design The term phenomenology is derived from the Greek word phenomenon, which means “to show itself.” The goal of phenomenology is to describe human experiences as they are experienced consciously without theories about their cause and as free as possible from the researchers’ un- examined presuppositions about the phenomenon under study. In phenomenology, researchers “borrow” other individuals’ experiences to better understand the deeper meaning of the phenomenon {Van Manen, 1984). "The existential phenomenological method developed by Colaizi (1973, 1978) was used in this Internet study. His ‘method is designed to uncover the fundamental structure of a phenomenon, that i, the essence of an expecience. An as- sumption of phenomenology is that for any phenomenon, there are essential structures that comprise that human expe- renee. Only by examining specific experiences ofthe phenomenon being studied can their essential structures be uncovered. Colaizzi's (1973, 1978) method includes features of Hiussee’s and Heidegger’ philosophies. Colaizai maintains that description is the key to discovering the essence and the meaning of « phenomenon and that phenomenology is Presuppositionless (Husserl, 1954}. Colaizi, however, holds a Heideggerian view of reduction, the process of researchers bracketing presuppositions and theie natural attitude about the phenomenon being studied. For Colaizzi (1978, p. $8), researchers identify their presuppositions regarding the phenomenon under study not o bracket them off 0 the side but instead to use them to “interrogate” one’s “belies, hypothe ‘ses attitudes, and hunches” abour the phenomenon to help formulate research questions. Colaizzi agrees with Merleau- Ponty (1956, p. 64) that “the greatest lesson of reduction is the impossibility of a complete reduction.” Individual phe- rnomenological reflection about the phenomenon being studied is one approach Colaizzi (1973) offers for assisting researchers to decrease the coloring of their presupposi tions and biases on their esearch activity. Because the phenomenon of subsequent childbirth after 4 previous traumatic bieth had not been examined system- aticaly before this current study, description of the mean ing of women’s experiences was the focus of this study. Before the start ofthe study, the researchers undertook an individual phenomenological reflection. They questioned themsclves regarding their presuppositions about the phe nomenon of subsequent childbirth after a traumatic birth and how these might influence what and how they com dlucted their research. Sample ‘Thicty-fve women participated in the study (Table 1). Sat- uration of data was achieved easly with this sample size. ‘Their mean age was 33 years (range = 27 to 51 years). All the participants were Caucasian and had ewo to four chil dren. The length of time since theie previous bisth trauma to the subsequent birth ranged from 1 to 13 years. Eight of the 35 women (23%) opted for a home birth for their Chitbith After Previous Trumate Bith 243, ‘County United States 8 8 United Kingdom 8 2 New Zealand 6 7 Asta 5 1 Canada 1 3 Martel status Maries Ey 98 Divorced 1 2 Single 0 ° Education High schoo! 3 8 Some cotege 5 5 Caloge dogios 8 8 Graduate 7 9 Missing 1 0 Delvery Vagal 2% n Cesarean 10 2 Diagnosed PTSD Yes 4 “0 No 19 % Missing 2 5 CCurenty under care of threpst Yes 8 2 No 2 63 Missing 5 5 subsequent births. OF these 8 mothers who gave birth at hhome, 4 lived in Australia, 3 in the United States, and 1 in the United Kingdom. Fourteen mothers (40%) had been diagnosed with PTSD after childbirth All the birth traumas were self-defined. Women were not asked if they had experienced other traumas before their birth traumas. Therefore, this was notan exclusionary criterion. The most frequently identified traumatic births focused on emergency cesarean deliveries, postpartum hemor- sage, severe preeclampsia, preterm labor, high level of medical interventions (ie. forceps, vacuum extraction, induction), in fant inthe neonatal intensive care uit, feeling violated, lack or respectful treatment, unsympathetic, nonsupportive labor and delivery staff, and “emotional torte.” Procedure Once institutional review board approval was obtained from the university, recruitment began. Data collection continued Copyright © 2010 Lippincott Wiliams & Wikins. Unauthorized reproduction of his article is prohibited,244 Chldbee Ater Preveus Teumatic Bth for 2 years and 2 months. Women were reeruted by means of a notice placed on the Web site of Trauma and Birth Stress (TABS; wrww-tabs.org.z} a charitable trust located in New Zealand, The mission of ‘TABS is to support women who have experienced traumatic chldbieth and PTSD because of their birth trauma. The sample citecia required that the mother had experienced a uaumatic childieth with a previous labor and delivery, that she was wiling to articulate hier expesience, and that she could read and write English. This intemational representation of participants was a strength of this recruitment method. A disadvantage, however, was that only women who had access to the Ineenet and who used "TABS for support participated inthis study. ‘Women who were interested in participating in this In- temet study contacted the frst author at her university e-mail address, which was listed on the recruitment notice. An information shect and directions for the study were sent by attachment to interested mothers. After reading these two documents, women could e-mail the researcher if they had ‘any questions concerning the study. ‘Women were asked, “Please describe in as much detail as you can remember your subsequent pregnancy, labor, and de livery following your peevious traumatic bith.” Women sent their descriptions of their experiences as e-mail attachments to the researcher, The sending of thee story implied ther in- formed consent. The length of time varie from when a mother first e-mailed about her interest inthe study to when she sent hher completed story to the researchers. The shortest rum- around time was 2 days whereas the longest was 9 months. If ‘women did not respond within a certain period, the researchers did not recontact them. The women’s wish not to follow Nursing Researeh Juhu 2010 Ve 8, Hod ‘through on participation inthe study was respected, Through- ‘out this procedure, the frst author kept a reflexive journal Data Analysis Colaizz’s (1978) method of data analysis was used. The order of his steps is as follows: written protocols, signifi cant statements, formulated meanings, clusters of themes, exhaustive description, and fundamental structure. It should be noted, however, that these steps do overlap. From each participant's description of the phenomenon, significantstate- ments, which are phrases or sentences that dicecly describe the phenomenon, are extracted (Table 2). For each significant statement, the researcher formalates its meaning. Hlere, Creative insight is called into play. Colaizzi cautioned that in this step of data analysis, ehe researcher must take a precari- ‘ous leap from what the participants said to what they mean, Formulated meanings should never sever all connections from the original transcripts. Iris in this step of formulating meanings that Colaizz’s connection to Heidegger can be seen. The next step entails organizing all the formulated _meanings into clusters of themes. At chi point, all the results to date are combined into an exhaustive description. This step is followed by revising the exhaustive description into @ ‘more condensed statement of the identification of the fun- clamental structure of the phenomenon being studied. The fandamental stractore can be shaged withthe participants to validate how well it captured aspects of theie experiences If any participants share new lata, they are integrated into the final description of the phenomenon. Member checking was done with one participant who reviewed the themes and No. Signiieant statements ‘One thing that noticed when Iwas a chid was tht when my parents got ogeher wth other ads, the talk ovenualy tuned to wo things: for my father (a Vietnam veteran) and tho otter men the tk tured tothe war and intresingly, tome as a smal chil or my ‘moter and fe over woron tho tk always tumed to chit 2 Iwas asf fom a young ae, fr mo, to connections between the Wo were drawn. A mani teled trough war, & women is esto through hibit 3 My ded, as abusive as ho was, was considered a “good man’ becausa held boon a good alder and so, | reasoned forward with & Chis intlignce, that al that really metered for a woman was fo be song and cazale in chidbirb, 4 And fed. nthe pas, with he previous two bits (parcuary wih the on tat rosutod in PTSD)—tats what it fl Be, fad at boing a worn. 5 | on thik that | am aloe in feeng | have a sneaking suspicion tat tis is prety univesal 8 Justas @ man who “tals” under lor in @ POW sivaton fees as though he's fed, a woman who ean “handle” toto stustons luring chicbirh folsiko she's fled. ts not tv. Butt fal tue 7 My ded received tv Purple Hea's anda Bronze Str cxing Vietnam. He, by most standards, would be considered her, Where ao my Purple Heats? My Bronze Star? fe fought a war, no less teryng, no less destroying but there are no ecccades, Atleast tats what fel ike, 8 | am vewed as awed If nt down ft strange that | fd L & D so teryng. 8 The matical ostabishment rinks that | am "ment" and! have na common grou on which to dscuss my chibith experiences wih “acral” women. 10 now, fv ted. And that makes me fee! icated and intr. ‘Ne PSD = posture seas dor Copyright © 2010 Lippincott Willams & Wikins. Unauthorized reproduction of this article is prohibited,[Nureing Research hist 2010 Vel 5, Not totally agreed with them. In addition, one mother who had hot participated in the study bur had experienced che phenomenon being studied reviewed the findings and also agzced with them, Results ‘The researchers reflected on the written descriptions pro- vided by the 35 women to explicate the phenomenon of their experiences of subsequent childbirth after a previous traumatic birth. These rellections yielded 274 significant statements that were clustered into four themes and finally, into the fundamental structure that identified the essence of this phenomenon (Table 3). ‘Theme I: Riding the Turbulent Wave of Panic During Pregnancy Fear, terror, anxiety, panic, dread, and denial were the most frequent teems used to describe the world women lived in ding theie pregnancy aftr a previous traumatic birt. 1 remember the exact moment I realized what was hap: pening. Iwas on my lunch break at work, sitting under a large oak tree, watching cars go by my office, talking ‘with my husband. T suddenly knew... I am pregnant again! I remember the exact angle ofthe sun, the shad: ing of the abjects around me. I remember looking into the sun, ar that tre, at the windows to the office think- ing, “NO! God PLEASE NO!" I felt my chest at once sink inward on me and take on the weight of » 1000 bricks. I was shore of breath, my head seared. All I could think of was “NOOO000000!” Another woman described in detail the day she took her pregnancy test, 1 took the test and crumpled over the edge of our bed, sobbing and retching hysterically for hours. Iwas dizzy. I was nauseous. Iwas sick. Tcould not breathe I thought ry chest would implode. I had a terrible migraine. I could not move from the spot where I had crumpled. I could not tale to my husband or see our daughter. I felt torn to pisces, shredded as shards of glass. I spent the next 2 trimesters hanging on for my life with suicidal Chibi Aer Previous Taumae Be) 24.5 thoughts but no real deste to carry them out through. I wanted to see my little gil. It was hell on eazth. Some women went into denial during the fist trimester of theic pregnancy to cope. Throughout ker pregnancy, one ‘woman revealed that she “felt numb to my baby.” Some women described how they turned their denial of pregnancy into something positive. One mukipara explained that after she was in denial for a few months, she then became determined to make things different this next time, and right at the end of her pregnaney she felt empowered by all that she had learned: “After 3 months of ignoring the fact that I was going to have 0 go through bieth again, 1 de cided I would treat my next labor and delivery as a healing and empowering experience.” Other mothers remained in a heightened state of ans iety throughout their pregnancy, and for some this anxiety escalated to panic and terror. Knowing she may have to {go through the same “emotional torture” she ended with her previous tcaumiatic birth, one woman shared, “My 9 months of pregnancy were an anxiety filled abyss which was completely marred as an experience due to the terror that was continually in my mind from my experience 8 years earlier.” As the delivery date gor closer, some mothers reported having panic attacks. ‘Theme 2: Strategizing: Attempts to Reclaim Their Body and Complete the Journey to Motherhood “Well, this time; T told myself things wvould be different, 1 actually started planning for this birch literally while they were stitching me up from the traumatic first birth,” Dur- ing pregnancy women described a number of different strategies they used to help them survive the 9 months of pregnancy while waiting for what they were dreading: la bor and delivery (Table 4). Some women spent time nur~ turing themselves by swimming, walking, going to yoga classes, and spending time outdoors. Keeping a journal throughout the pregnancy helped mothers because they had somewhere to write things down, especially if they felt that family and friends did not understand just how difficult this pregnancy, subsequent to their prior traumatic delivery, was, Inspirational quotes were placed around the house to read and motivate women, ‘Subsequent cdi ater a previous trauma bith far exceeds the confines of the actual labor and delivery, Dung the 9 merits of Pregnancy, women ride turbulent aves of panic, oor, and fear thatthe looming bth could be repeat o bre eronal andor physical torture they had endured wth their previous labor and defvery. Nomen statgized dung pregnancy how they could reclaim th boctes ‘hat had been voated and traumatizad by thel previous chicith. Women vowed to themselves tha ings woud be diferent and that his time they would complete ther joumey to motherhood. Moers employed sategis to try to ring a revere tothe biting process an reaty al hat hed gone so wrong with te pir cnicbith. The aay cf vaious statgies enlafed such acfons as hing doulas fr suppor tung labor and detivery, becoming avd readers of chidith books, wing a dotated bn plen leaming tinh hypnoss, inervening ‘obsteticans and mies abou ter plosophy of bit, doing yoga and drawing brbing at. AB these wol-designd srateyios didnot ‘ensure tat all worn wou experiance the healing chidhinh trey despertely iongad for. For the mothers whose subsequent chibith wes ‘a heaing experince, they rected their bodies, hada song sans of cnc, and the bith became an empowering experince. The eke ‘of caving supporters was cucal inher abor and delvery. Women were treated with respect, igri, and compassion, though their subsequent bith wes postive and empowecng, woren wer quick ont that eau never change te pat, Sil eusve for some Women ‘vas their longer neaing subsequent ith Copyright © 2010 Lippincott Willams & Wikins. Unauthorized reproduction ofthis article is prohibited246 chicory ater Povous Traumatic Bit, + Ving a dete bith plan + Meaty preparing for ith + Leming bth ypnods + Dong bith a + Weng postive alfmatons + Proprng or iting at home + Hing a doula for labor and dovory + Colbatng upcing itn + Avoiding utesounds + Tog not nk about upcoming bith + Reading books on heatypregnanoy and ith + Maging out your pels + Leaning bthrg pastors to open up the polls + Pring typos fr ebee + Researching bit caters and schodng fours + Intenenng obsetans and mis + Sxarcsng to hep baby gt the cores poston + Using Inet suppor group + Hing ate coach + Painting prov bith exparonco + Creaing "aati sheet witha possible concems and ten salons fr ter + Creating “Yes, I necessary No" shest for bor of wat tha roe wanted to hepeen + Detemining tle of supporters dg birth + Resarching hameopatic rere fo prepare body fr labor are bith + Developing tat to hep cape in labor + Dvalogieg ist wth healer provider Figure 1 is anillustration of one mother’s poster that she put up in her home. ‘Women strategized how to ensure that their looming, labor and delivery was not another traumatic one. As one rmuitipara explained, “I need to bring 2 reverence to the process so I won't fee! like a piece of meat lost in the system.” Attempts were made to put into place a plan that would attempt to rectify all that had gone wrong with the previous childbirth, Some women tamed to doulas in hopes ‘of being supported during their subsequent labor and delivery. Hypnobirthing, was a plan used by some women to keep the first traumatic bicth from being repeated, ‘Women reported reading avidly to understand the birth process fully. The mose frequently cited books were Re- bounding from Childbirth (Madsen, 1994), Birthing from Within (England & Hocowitz, 1998), and Birth and Beyond (Gordon, 2002). Mothers often engaged in birth art exercises. ‘Toward the end of pregnancy Idd the birth art exercises cut of the book Birthing from Within... {began to trust ‘myself. That will stay with me forever. That is mote than [Nursing Research hogs 2010 V9, No jst what I needed to birth the way I wanted to. That is ‘whar I needed to become a real woman. ‘Opening up to their healtheare providers about their previous traumatic births was helpfl for some mothers. Once clinicians knew of their history, they would address the mothers” concerns during each prenatal vist. Also sharing wit their parimers thee fears and insecurities around preg: nancy and birth helped women’s emotional preparedness ‘Theme 3: Bringing Reverence to the Birthing Process and Empowering Women ‘Three quarters of the women who participated in this Iner- net study reposted that their subsequent labor and delivery was cither 2 “healing experience” or at Jeast “a lor better” ‘than their peevious traumatic birth. Women became more confident in themselves as women and as mothers in that they really did know what was best for their babies and themselves. The role of supporters throughout labor and delivery was crucial. What was it that made a subsequent birth a healing experience? In the mothers* own words: as treated with respect, my wishes and those of my hhusband were listened to, I wasn’t made to feel like a picce of meat this time but instead like & woman experiencing one of nature's most wonderful events. Pain ceicf was taken seriously. First time around I was ignored. I begged and pleaded for pain relief. Second time it was offered bur because T was made to feel in contro, [was able to decline. Feria gation “What wo yo4 afi ‘dn Our arto tse ou ara Fen Donia ito sper athe no ‘het edn fed ete ‘iby dire yl ‘Stones nh mid of wr ay kad here Shen Cams| FIGURE 1. A poster of inpratlonal quotes by one moter Copyright © 2010 Lippincott Willams & Wilkins. Unauthorized reproduction of this article is prohibited.Mursing Resoareh uyhurest 2010 V8, No 4 1 wasn’t rushed! My baby was allowed to arrive when she was ready. When my fist was born, was told “5 ‘minutes o€ I get the forceps” by the doctor on call, I pushed so hard that I core badly. Communication with labor and delivery staff was so such better the second time. The first time the emergency cord was pulled bur no one told me why. [thought sy baby was dead and no one would elaborate. ‘Woren reclaimed their bodies, had a strong sense of control, and birth became an empowering experience. Only essential fetal monitoring and minimal medical intervention ‘occurred, Women were allowed to start labor on their own, and not be induced. Under gentle supervision of caring and supportive healthcare professionals, women were reassured to just do what their body felt like doing and to follow their body's lead. The number of vaginal examinations was kept at @ minimum, and women were permitted to walk around and choose the position they feit best laboring in, One mother described her healing birth: 1 pushed my baby into the world and I was shocked. I hhad never dared to dream for such a perfect delivery They let me push spontaneously and my baby was de. livered into my arms. My husband and I both eried with utter celief that I had given birth exactiy how I wanted to and my trauma was healed, For some women, the birth plan they had prepared during their pregnancy was honored by the labor and delivery staff, which helped them feel like they had some control and were a part of the birth and not just a witness. Bight women opted for home births after their previous traumatic birehs, and for six of them, ie did end in fulfilling their dream. Ie was as healing and empowering as [ had always hhoped for. T did not want any high tech management. ‘My home birth was the proudest day of my life and the victory was sweeter because [overcame so Very much to Another mother who had a successful home birth Iabored mostly in her bedroom under candlelight and music playing. She described itas very peaceful being at home surrounded by all her things. Her dog kept vigil by her side. She shared how it ‘was such a gentle way for her baby to be born. [My baby cred fora minute or two asiteling me bis birth story and crawled up my body and found my heart and left breast: My heart swelled with so many emotions-—love, joy, happiness, pride, relief, and wonderment. A couple of women explained that their subsequent birth was healing, but at the same time they mousned what they had missed out with their prior birth, The following, ‘quote illustrates this Even though it was an enormously healing experience, the expectations I had were unrealistic. What I went through doring and after my first delivery cannot be erased from memory. If anything with this second bicth being s0 wonderful, ie makes dealing with my fist birth harder. Tt makes it sadder and me angrier as before [had nothing to ‘compare itt. 1 didn't know how different ic could be ot Chitin Ater Previous Taumate Bich 247 hhow special chose first fewr moments are. I didn’t folly understand what had missed out on. So nowy 3 years later T find myself grieving again for what we went through, hhow I was treated and what! missed out on. Other mothers admitted that although theie subsequent births were healing, they could never change the past. All the positive, empowering births in the world won'e ever change what happened with my fist baby and me, (Our relationship is forever built around his birth ex. perience, The second birth was so wonderful I would go through i all sgain, bu i ean never change the past Theme 4: Still Elusive: The Longed-for Healing Birth Experience Sadly, some mothers did not experience the healing subsequent birth they had hoped for. Two women chose to try a home birth after their previous traumatic birth but did not end up with the healing experience they longed for. One mother did deliver at home, but because of posspartum hem: ‘orrhage, she was transported by ambulance to the hospital, tetttied she would not live to raise her baby. After laboring at home, another multipara who artmpted a vaginal birth after cesarean needed to be transported by ambulance for a repeat cesarean birth after she failed to progress. ‘When the ambulance arrived I felt rescued, 1 have never been 50 grateful that hospitals exist. The Blue light am- boulance journey was tevfying and I was in excruciating pain, By this poinc Twas trying to detach my head from my body, as Thad done years earlier when Iwas being raped. She went on to vividly describe that as she lay on the ‘operating table: swith my legs held in the aie by 2 strangers while a third mopped the blood between my legs I felt raped all lover again. I wanted to die. had failed as a woman, My privacy had been invaded again, I felt sick, ‘One multipara shared that although this birth had been a better experience, she would not say i was healing in relation to her frst birth that had been so traumatic. “The ‘contrast in the way I was treated just emphasized how bed the frst one was. Ihad no sense of healing until 30 years Javer when I received counseling for PTSD.” Discussion Healthcare professionals failure to rescue women during their previous traumatic childbirth can result in a troubling effect on mothers as they courageously face another preg nnancy, labor, and delivery. Subsequent childbisth after a previous birth trauma provides clinicians with not only a golden opportunity but also a professional responsibilty to help these traumatized women reclaim their bodies and ‘complete their journey to motherhood, ‘To help women prepare for a subsequent childbirth after a previous traumatic birth, clinicians first need to identify who these women are. There are instruments available to screen women for posttraumatic stress symptoms due to birth trauma, An essential part of initial prenatal visits should Copyright © 2010 Lippincott Wiliams & Wikins. Unauthorized reproduction of this article ie prohibited,2248 Chiddetn Ater Provius Traumatic Bith be taking time to discuss with women theie previous births. ‘Traumatized women need permission and encouragement 19 stieve thei prior traumatic births to help remove the busden ‘of their invisible pain. Pregnancy isa valuable time for health care professionals to help women recognize and deal with unresolved, buried, or traumatic issues. Women should be asked about their hopes and fears for their impending labor and delivery and how they envision this bigth. Ifa woman is exploring the possibility of a home birt, clinicians should {question the mother about her previous births. Opting for a hhome birth may be an indication of a prior traumatic birth (Cheyney, 2008). If women need mental health follow-up during their pregnancy, cognitive behavior therapy and eye movement desensitization reprocessing treatment are :wo options for PTSD because of bisth trauma, Treatment can be given in conjunction with a women’s family members to address secondary effects of PTSD. Strategies can be employed to help mothers heal and increase their confidence before labor and delivery. Clini- logical alternatives jor psychology (pp. 48-71). New York Oxford Universiey Pes. Dedlereg, E.R. Saka, C, Corry, MP &¢ Applebaum, S. (2008) ‘Naw mothers peak du National serve ress bighight woer’s ostpartio experince. New York: Chikibieh Conetsion, Engelkemeyer S-M, 8 Mar, S.J. (2008). Posteaumatic grow In bereaved parents. Journal of Traumatic Stress, 21(3), 344-346, gland, SHarowiz,R. (1998). Birthing from within, Aurquerque, NM: Patera Press. Gordon, ¥. (2002). Bireh and beyond. London: Vermilion. Huser, E. (1954). The esis of Europea sconces and tracer drcalphenomosology. The Hague: Martinus Nill Institute of Medicine. (2003). Board on Health Care Services Com ‘mittee om identifying privity areas for quality provements, ‘Washington, DC: National Academy Press Levy, M. (2006). Mateenty in the wake of terrorism: Rebirth or retraumatization? Journal of Prenatal ad Perinatal Pychology tnd Health, 20(3, 221-243, Madsen, L. (1994). Rebounding from childbirth: Toward emotional recovery. Wesrport, CT: Bergin & Garvey. ‘Mesle-Ponty, M. (1956). Whatis phenomenology? Crosscurrets, 6, 59-70, Copyright © 2010 Lippincott Wiliams & Wilkins. Unauthorized reproduction of this article is prohibited,Nursing Research uh 2010 Vol 88, No Nicholls K, & Ayers, 8 2007) Childbiet-relaed post travmatic ‘sess disorder in couples A qualitative study. Britsh Journal of Health Prychology, 120. 4), 431-509. ‘Olde, E, van der Hart, O., Kleber, R 8 van Soo, M, (2006) Post ‘waumatc stress folowing childbirth: A review. Clinical Psychol- ogy Review, 2611), 16 ‘On0¥6, J Mr Goebert, D., Morland, Ly Mate, Cy & Wright T. (2009). PTSD ane postpartum mertal hoalth in a sample of Cas ‘asian, Asian, and Pace Islander women, Archives of Women’s ‘Mena! Health, 12(6), 393-400. Sakala, C, 8 Coes, MP. (2007). Listening to Mothers I reveals maternity care qualiey chasm, Journal of Midwifery G Women’s Health, 52(3), 183-185. ‘Stump, M. , 8 Smith, JE. (2008). The relationship between post ‘uauinatic growth aid substance uve in homeless women with Chih Aer Prevous Traumatic Brh 249 histories of traumatic experience. American Journal om Addic- tions, 176), 478-887, Tedeschi, R. G, 8c Caboun, L. G. (2004), Posttraumatic growth: ‘Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), AB. ‘Thomson, G., 8c Downe, S, (2008), Widening the trauma discourse: ‘The lnk Berween childbirth and experiences of abuse. Journal of Paychosomatic Obstetrics and Gynaecology, 298), 268-273. \Vaa Manen, M. (1984), Practicing phenomenological writing, Phe nomenology + Pedagogy, 2(1), 36-6. ‘Van Son, My Verkerk, G. van det Hart, O., Komproes ls 8 PoP '. (2005). Prenatal depression, mode of delivery and perinatal Gissociation as predictors of postpartum posttraumatic ses: ‘An empirical study. Clinical Peyebology & Peychotberapy, 12(4), 297-312, Copyright © 2010 Lippincott Wiliams & Wikins. Unauthorized reproduction of this aticle Ie prohibited.

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