 This is the 19th session which is entitled Childbirth Traumatic Experience. This presentation came against the background that childbirth is a celebrated and positive stage in the woman's life. For some women, the experience of childbirth is not quite a positive, so positive and can adversely affect psychological health and well-being. The presentation will focus on all various issues surrounding this important issue. Our speaker is none other than Paula Miller. Paula is a qualified occupational psychologist, and she's pursuing her PhD at the Center for Maternal, Fetal, and Infant Research at the Ulster University in Northern Ireland. Paula takes on an interdisciplinary approach to her doctoral research. Focusing on the impact of birth trauma and maternal mental health and investigate the efficacy of an early intervention in reducing wide-ranging short and long-term effects, she is supported by her professors, Professor Sinclair, Professor Gillian, Professor McCulloch, and Professor Miller. And some of them are here supporting her. So Paula, I now hand over to you. Thank you so much. You're welcome. Good morning, good afternoon, and good evening to everybody. I'm so pleased to be here with you today. Thank you so much for joining us. Talking about childbirth, and childbirth as a traumatic experience today. When I sent my abstract for this talk back in January, I never would have imagined that we would be in a situation that we are all faced with today in the midst of the COVID crisis. I had originally planned on talking about childbirth as a traumatic experience, and now I actually, we are all of us living in an extremely uncertain and sensitive environment. And I just wanted to acknowledge this before we begin talking about birth trauma, because the environment in which we find ourselves in at the moment really does affect all of us in different ways. And it's great that we're really able to connect here on this platform today. I just also want to thank the mothers who are referred to in these slides. And I want to thank the authors and the work that I've referred to throughout. I'm going to discuss what a traumatic birth is. And I'll talk about the effects of traumatic birth experience on mother and infant, and various ways of reducing these effects, as well as the current evidence on interventions to alleviate psychological systems, symptoms associated with traumatic births. And then finally, we're going to finish with a guided stabilisation exercise. And this is going to be a bit of an experiential exercise, and I really encourage and invite everyone to take part in this. And as evidence has really demonstrated that it's effective in reducing stress symptoms. And I think most of us could do with that at the moment. We're just going to start off with a little poll. Just want to find a little bit about what your level of knowledge of perinatal mental health issues surrounding birth trauma is. So if you could, these, like A, B, C or D, your knowledge, introductory knowledge, intermediate and advanced. Paul, you need to click on the poll button. That's the one. That's the one. It has been a bit slower on and off today, so that might be it. You might have to scroll through the chat to get a feel for it then, I'm afraid. Introductory, mostly introductory and intermediate. That's great. That just gives me a little bit of an idea. If we know someone is upset or angry, we would usually ask, what's wrong? And that really implies that there's something wrong with that person, but in a traumatology model, because adverse reaction to an adverse event or experience is actually perfectly normal. So it's really about looking at the subjective experience and acknowledging the reaction to it and processing that reaction to find some sort of meaning and higher order resolution to the traumatic experience. The mental health problems we see as the result of the original trauma or upsetting event, which actually causes the disturbing memory to become unprocessed in the brain and it remains stuck in the brain and unresolved. So the individual who has experienced a trauma looks at life in a certain way through this trauma lens. In the traumatology model, we try to help people move through the traumatic experience and really get to the root of the problem for resolution. So how do we process information in a trauma model? Information is processed through the brain. I don't know if anyone has heard of the McLean's triune model of the brain. I'll just talk a little bit about that. So we have the primitive brain, which is otherwise known as the reptilian complex and this is the system of the brain. It's the cerebellum basically connects with the brainstem back at the brain and it's responsible for the most basic survival function. So we're looking at body sensations, responses, the automatic functioning of the heart, right breathing, body temperature. And so these areas of the brain perform really important unconscious activity. We don't know about it. We're not aware of its performance. So for example, if we touch an object which is really hot, our hand will automatically move away from it and that's our primitive reptilian brain in action. That's really fast, quick unconscious sort of evaluation of sensory stimuli and it's the automatic instinctive response to it's a fear response. Then we have the limbic system which is known as the emotional the mammalian brain and it's the reactive part of us that initiates that fight, flight or freeze response and reaction to stress or stressful situation. So the key areas of the limbic brain or the hippocampus, the amygdala and the hypersalvas and this part of the brain is responsible for our emotions and our memories and our habits and it's really essential for decision making. So these four are really fast subconscious evaluation response system that's designed to keep us safe. And then finally, the higher order level of the brain is the neocortex and it deals with language and imagination and those conscious activities that we're aware of for reasoning and rationalizing and decision making. So the amygdala in the emotional part of the brain the limbic system, it's like a security checkpoint to the airport and the amygdala scans for any threats or danger and if it identifies that the information that's coming in is safe and isn't threatening it will then allow that information to come through into the higher order of the brain up to the neocortex and allow us to make clear choices and rational decision making. Here it's then integrated into the other parts of the brain. So if there is a traumatic response to an event the amygdala will not send those signals through to the higher order of the brain which then affects decision making and the trauma memory will then become stuck in the limbic brain. So if the trauma remains unresolved it can actually remain there for a long period of time and it can start to cause symptoms of stress symptoms and post-traumatic stress disorder. That just gives a little bit of a background on what trauma is. So how do we associate trauma with such an amazing life event, giving birth? I mean if that picture is just so adorable with the creation of a new life and giving birth to offspring is an incredibly amazing experience for a woman and also for those witnessing it. And Donald Winnicott, he is a pediatrician and psychoanalyst, he was especially influential in the field of object relations theories and developmental psychology. And Winnicott realized his famous no such thing as an infant and it really highlighted the fact of the baby's dependency on parents and the high, the baby's sense of self really is dependent on the parent's emotional state. So the parent's infant relationship was really the core of his contribution to psychoanalysis. And actually if the mother or the father experienced a trauma there that will directly influence the child. And similarly, a community in which that child lives experiences a trauma. Again, this will affect the family, the child. And if we zoom out the town, the city, the country, if the world as we are at the moment experiences a trauma or a humanitarian crisis, then the child will also be affected in a whole systems theory. So what we do, especially during these uncertain and difficult times, we'll go through a stabilization exercise later on that you might find helpful in your own self-care routine as with midwives and of course students and researchers. If we just move on to what is a traumatic birth, what exactly is it? So I have a few definitions here. This definition offered by NICE, which is the National Institute for Clinical Accidents. Traumatic birth includes births, whether preterm or full term, which are physically traumatic and births that are experienced as traumatic, even when the delivery is obstetrically straightforward. So it's the perceived experience of the birth, which is seen as being traumatic. And that's perfectly plausible. As well as the physical trauma experienced. Other authors, there are various different explanations of traumatic birth and birth trauma. Greenfield here says it's the emergence of a baby from its mother in a way that involves events or care, which cause deep distress or psychological disturbance, which may or may not involve physical injury, but results in psychological distress or an enduring nature. And Penny Stinkin, who is the co-founder of PATCH, that's the Prevention and Treatment of Traumatic Birth. And Penny says that a birth is said to be traumatic when the individual believes that the mother or her baby's life was in danger, without a serious threat to the mother's or her baby's physical or emotional integrity existed. Birth trauma association suggests that birth trauma is actually a shorthand phrase for post-traumatic stress disorder after childbirth. And sometimes this is referred to as postpartum post-traumatic stress disorder. And in most cases, what really makes birth traumatic is the fear that you or your baby are going to die. So post-traumatic stress disorder induced by childbirth is real. And as I said, it is sometimes referred to as postpartum post-traumatic stress disorder. But for a diagnosis, we need the criteria on A of PTSD as in the diagnostic and statistical manual of mental disorders. And so that's the American Psychiatric Association. And that's the DSM-5 criteria on A. So the person needs to have had exposure to actual or threatened death, serious injury, or sexual violence by direct exposure, witnessing the trauma, or learning that a relative or close friend was exposed to a trauma, or any sort of indirect exposure to details of the trauma. Which could be, outside of the birth trauma or renal, could be first responders or medics, or midwives who have witnessed a traumatic event. And then we have the International Classification of Diseases. And their criteria on A in terms of classification is that the individual needs to have had exposure to a stressful event, or a situation of exception threatening or horrific nature, likely to cause pervasive distress in almost anyone. This is a quote by a lady with lived experience of post-traumatic stress disorder for childbirth. I had a traumatic birth. I was so petrified that my son would die, but in my head, it was easier not to love him just in case. We have symptoms which are specifically related to PTSD following childbirth. That includes re-experiencing and reliving aspects of the trauma, that's intrusions, alterations in arousal and reactivity, so hypervigilance, difficulty in concentrating. We were talking earlier about the Olympic brand and the higher order, neocortex, avoidance, avoidance of trauma related thoughts, feelings and reminders of the memory, negative alterations in cognition and mood, feeling, difficulty feeling any sort of positivity, blame, exaggerated blame on the person themselves or on others, extreme negative thoughts and sometimes feelings of isolation. These are some examples of negative thoughts and cognitions that can arise from a traumatic birth. So we have feelings of threats to safety. My baby or I am in danger. And so if one of the ladies that you're working with is feeling like this, you can empathize with her feelings and questions and really focus on what she needs to do and help her accept what's going to happen to her, so in terms of epidural cesarean or instrumental delivery, you help her focus on what she needs to do to get through the birth, you're handling the situation that she's in, she finds herself in. And that empathy is really so important. I'm letting her know that she is so important in the process that she needs to take part and she is very much in control of what she's doing. We talk about lack of control. I am powerless. I have no control over my body. At that point, you may perhaps need to take charge and calmly give her attention and guide her through the rhythm and the breathing through contractions and think about her particular preference and pain medication. And if she prefers to avoid medication, perhaps it's a good idea to before the birth have some sort of a code word to say if a labor is going to be too long and difficult and she might want to change her mind she really wants to pay medication. So that means that she can really, she can complain without people misinterpreting her complaints as quite as from medication. Defectiveness, I'm a bad mother. I was not good at giving birth. And really in that instance, what you can do, you can assure the woman that really all births are so very different and she worked as hard as she possibly could throughout birthing her child and make sure that she knows what she did do well and give her some sort of positive feedback on any aspect of her birth. Prevalence rates of traumatic birth, 25, 54% of women report their birth as traumatic. And but a small percentage of those go on to develop post traumatic stress disorder. There's a lot of variability in those figures because of the variability in the populations that have assessed. Recent survey conducted in the UK here by Make Birth Better, 343 women showed that 30% of new moms suffering from mental or physical trauma following their birth are not actually being offered the support that they need to cope. 75% felt that they didn't get the support they needed following a traumatic birth experience. And a survey of 332 maternity and mental health professionals reported that 63% felt that the main barrier to birth trauma prevention is lack of knowledge. 62% said that birth traumas could be caused by the most reported training need by staff at the moment. Well, that was 2019. There are a number of risk factors that are associated with post-traumatic stress sort of following childbirth. So the labor experience itself, so if the lady feels in terms of her subjective experience that it was traumatic and horrendous and horrific, that's obviously going to increase her risk of developing post-traumatic stress disorder following birth. Mode of birth is extremely important. There is a very high rate of association between obstetric instruments delivery and serine post-traumatic stress disorder following childbirth. Fear of own or baby's life, previous trauma, so adverse childhood experiences that there's a strong association with adverse childhood experiences and PTSD following childbirth. It can be a trigger. Childbirth can actually be a trigger for various memories involved in those adverse experiences sort of previously being suffered. Previous psychological problems increases the likelihood of post-traumatic stress disorder and service delivery. So we're looking at the way in which care is delivered during delivery. So the nice clinical guideline which has been updated February 2020 suggests that during birth that healthcare professionals should be understanding and afterwards they should offer women advice and support if they would like it and they should not offer therapy. Those reliving the experience with evidence suggests that this isn't helpful. And so nice, they conduct systematic review and this was the conclusion that they went to in terms of care following traumatic birth. I'm not sure if you can see this, it actually just demonstrates the care pathways set out in the nice guidelines for serine treatment or perinatal mental health problems. So here in the UK for anxiety, tocophobia, fear of birth and post-natal depression we have clear pathways for post-traumatic stress disorder. It's not quite so clear. The recommendation is to follow the post-traumatic stress disorder adult guidelines. And the adult guidelines suggest firstly offering peer support. So peer support groups are just so very, just excellent, they're really helpful and there's some fantastic peer support groups out there. I have some resources at the end of the slide and that I can distribute freely. You can just let me know if you'd like them. I'm following on from peer support, the first instance, psychoeducation. So talking to the lady about what happens a little bit like the triune brain model that we talked about before. That's really helpful for women to understand what exactly has happened and the process of high trauma moves through the brain and why perhaps she's feeling the symptoms that she's feeling. Offer flexible modes of delivery. So prevention within one month if symptoms of post-traumatic stress disorder or acute stress disorder with CBT, narrative therapy, prolonged exposure therapy. But one of the things with that is that we don't want to offer any sort of therapy that involves reliving the experience. So prolonged exposure therapy perhaps isn't ideal for a woman who has experience of traumatic birth. After one month, offer all of these therapies. It says nice suggestions, including EMDR. And EMDR is eye movement desensitisation and reprocessing. Just moving on to treatment interventions proposed from high stress disorder post-partum. Just going back to the survey that was conducted by make for a better of 343 women. What kind of support did you get? And so here we see a debriefing, 31% health visitors, we're listening because it's 9%. And community mental health team, 15%. 10% for women will refer to a different mental health psychological therapy service. 9% will give them advice in a different direction. And if you refer for therapeutic help on the NHS, what kind of therapy did you have? 47% received CBT, 7% received EMDR, 3% received support of the phone, 2% online support. 41% were offered other support, which included group support, home visits, or counselling in general. When women were asked, did your treatment resolve your mental health suffering? 13% of women said their trauma was resolved. 54% said to a certain extent. And 33% said that their trauma was not resolved. So this data really demonstrates the need to have a good look at the current system and what is being offered to women who actually are in preventing treating and resolving women's mental health suffering as a result of trauma. The midwives were also asked, what would most enable you to feel more confident in preventing, recognising, managing and treating birth trauma. And 332 responded, 59% felt the spoke training, their own service. 9.9% wanted access to birth trauma-related resources. 55% identified that access to special advice would be helpful. And 62% wanted specific skills, like grinding techniques. So here we have the International Society for Traumatic Stress Studies. And they have suggested for, as a result of evidence-based guidelines, the most highly effective standard treatment is trauma-focused CVT and EMDR for post-traumatic stress disorder. This is where at the time, so I'm just moving through the slides. And current treatment interventions for PTSD postpartum. So looking at the evidence from systematic reviews, there is really inconclusive evidence in terms of debriefing and whether debriefing is actually effective in reducing symptoms. Some studies have demonstrated a small effect in terms of reducing symptoms. And some have not demonstrated any effect at all. Other psychological interventions that have demonstrated an effect for reducing symptomology are expressive writing, mid-free-led counselling, EMDR, cognitive task falling birth. And they demonstrated that the symptoms did reduce, but they did not prevent or treat the occurrence of clinically diagnosed post-traumatic stress disorder. Working with clients to process trauma, it's not a mechanical process of following a set of instructions or a routine type of therapy or intervention. One of the most important aspects of the treatment is actually the presence of the therapist, the counsellor and the midwife or the healthcare professional who is delivering the intervention. And Rogers, his famous quote is really the fact that what is the most important element of any therapeutic relationship is unconditional, positive regard. And what does that mean? Jerome Frank, he talks about what makes an effective therapy. And he suggests an emotionally charged relationship, a therapeutic environment and a rationale that provides an explanation for symptoms, a procedure to resolve those symptoms. And Professor Miller, his model of Kale, which is a Gaelic term that can be translated as victorious people, which we'll just work through. The first aspect is connections, between yourself and the woman in terms of allowing the woman to be vulnerable in a really safe environment and a safe way. You can encourage the lady to ask questions and talk about possible alternatives or a firm. That connection between your woman and yourself is just so important. Or to relationship, that upholding and defending her whenever she needs you to advocate for her and offering her emotional support and encouragement throughout the birth. Really acknowledging how your lazy is feeling and explaining what's happening and what's really needed to correct the situation if it needs to be corrected. And that reassurance is so important for her. Empower, that connection really enables your lady to achieve the journey and the birthing journey, powering her to really develop her confidence and the ability to give birth to her baby. It's a natural process and she can do it. Empathy, empathize with her feelings and really question and focus on what she needs to do to maintain her baby's well-being. And then moving on to the three Ls. And the three Ls represent how we aim to bring about that therapeutic dynamic. Listen, really consider her what she wants regarding pain medication. Love, compassion, respect. It's just such a key part. Medically care, learn. We're learning all the time and resilience is actually really vitally important factor in protecting the woman from post-traumatic stress to water following birth. Resilience includes various different aspects and learning is one of those and gathering as much information as you can and being as prepared mentally as she can. Moving on to treatment interventions. Yeah, so I wanted to touch on the new evidence that has just come through for EMDR as effective as an early intervention. So this particular intervention was delivered within days of birth and within one session it reduced symptoms of post-traumatic stress and prevented those post-traumatic stress from developing. Paula, just asking you to wind up at this time sorry to interrupt you. Intervention. It's really, it's been found that 70% of course relating to perinatal mental health are actually related to the infant and post-traumatic stress disorder is no different. There are a wide ranging short and long-term effects, so you can see them all here. Depression, all the comorbid perinatal mental health disorders, mother's physical health neuroendocrine, fibromyalgia, irritable bowel, mother-infant relationship, which is so important, the infant's cognitive development, behavior temperament, social and emotional development are all affected by post-partum post-traumatic stress disorder. I just want to finish with this slide with the iceberg and I'm sure many of you have seen this particular picture before and the human mind is really, it's made up of 12% conscious mind, which is the surface and the tip of the iceberg and the idiot percent, which is the subconscious mind and that's what's under the surface and this includes all the triggers and the relational patterns and the true feelings and the raw emotions and it's really those emotions that they're targeting when they're looking at post-traumatic stress disorder what is underneath the surface. I just want to say thank you so much for joining me today. I apologize we didn't get to do our stabilization exercise, but if you do want to email me I have the exercises that are recorded and you can take yourself through them they are really helpful and I would encourage you and invite you to do those if you're in time. Thank you so much for coming and happy day of the midwife. Thank you so much Paula so Paula have come to the end of her presentation and I see where we have a question Paula what are some of the questions that midwives can ask new moms about in guiding the screening process I would assume to prevent or to identify if they were if they perceive that their birth was traumatic. How do we go about doing that? That's a really good question Cynthia well firstly if we're looking at post-traumatic stress disorder there needs to be the criteria on A so if the mother feels that her birth has been traumatic and her experience has really affected her then that's a qualifying criteria on A and then following on from that in terms of diagnosis she would need to speak to her GP and perhaps get a referral for a full diagnosis there are self-help groups and community groups available that she could go to to get support in that area at the moment we don't have any screening any routine screening for post-traumatic stress disorder so that's a really good question and with trauma and within a traumatology model we actually see not just post-traumatic stress disorder but all of the other comorbid disorders that go alongside PTSD so post-partum depression for example is routinely screened for which is fantastic and it's great but sometimes PTSD and those stress symptoms can be overlooked and if the stress symptoms and the PTSD is not resolved we continue to have these symptoms of avoidance which can make treatment and resolution extremely difficult does that answer your question we have a lot to do in terms of screening and identifying symptoms following traumatic birth and it's really as as midwives it's really important to advocate for women who have experienced a traumatic birth in terms of really getting the correct diagnosis and also the correct treatment thank you so much I see many questions coming in your presentation has generated a lot of questions unfortunately we are not able to take any more questions but I just want to say that persons are asking for your email so you could put that in the chat if it's okay with you and we will continue alright so congratulations thanks so much Cynthia