With astonishing insight, Netflix titled their 2020 film exploring birth loss, “Pieces of a Woman”. Insightful because at every level, birth trauma involves disconnection, a breaking into pieces marked by a sense of shame. Pieces of information about the mother and baby that were not joined enough to prevent what happened.
The disconnection from anticipated joy, the disconnection from staff, baby, loved ones, and shockingly, the disconnection internally; muscles and tissues in the pelvis torn apart, sections of the brain shutting down and disconnecting from one another.
The window of MRI into traumatised brains displays the silent void in areas responsible for recognising emotions and enabling them to be processed. We may feel horrified that birth trauma sufferers feel shame and make wildly illogical accusations of blame towards themselves, but this is how the traumatised brain operates in a bid to protect itself. As a pelvic health physiotherapist who wants to walk with women as they ‘knit together’ their pieces, I would love you to join me in unshaming the experience of birth trauma and the details of treatment.
What is Birth Trauma (and why is it so entwined with shame?)
The language around birth trauma cueing shame is profound. Disbelief over the seriousness of the diagnosis or disgust at a choice of Caesarean birth are common, and can be traced back historically. As far back as the Latin roots of the words for genitalia and their nerves, there is a union between shame and the pelvic structures. The etymological dictionary records that “vulva” comes from the Latin word pudenda, which means “thing to be ashamed of”. The pudendal nerve supplies feeling and function to pelvic floor muscles, labia and vaginal tissue. The male equivalent was later translated in Old English as scamlin, or “shame limb”. There is little surprise then, that on top of the shame reaction common to trauma sufferers, birth trauma sufferers can experience extreme shame, self-loathing or disconnection from their pelvic area or whole self. Common phrases spoken by women in my clinic are: “I’m too afraid to look down there”, “Numbness is better than pain” or “It’s disgusting”. Not “my vagina”, but “it”.
Our larger cultural story is one of denying trauma exists or masking language about it. Known as shell shock in WW1, all reference to this term was banned by official military decree in the UK at the time. It is no small achievement then, that research with returned veterans in the 70s labelled “psychotic” finally led to an official diagnosis of Post Traumatic Stress Disorder (PTSD) in 1980 (2). In 1990 the revised definition for PTSD made provision for birth trauma by including “‘witnessed or confronted’ with serious threat or injury”.
It is of monumental significance that organisations like the Australasian Birth Trauma Association (ABTA) exist. Their online presence clarifies what birth trauma is and how to get help. It covers the physical trauma to pelvic joints, organs, pelvic floor muscles or large tears of the perineum (perineal tears can end up involving more than the skin and the muscles near the vagina but can extend inside the vagina or to the anus and rectum). Importantly ABTA also explains the psychological trauma from experiencing or witnessing threatened or actual injury to the mother or baby during birth.
Dads and partners can have birth trauma too, and it’s not measured by the degree of damage to a person’s pelvic floor. Links to support services can launch a healing journey, mapping the breadth of professionals often needed: perinatal psychologists, colorectal surgeons, maternal mental health nurses and pelvic health physiotherapists to name a few.
Unshaming Birth Trauma
Part of unshaming the experience of birth trauma, is acknowledging the spectrum of severity. It may be several months of exhaustion and challenging thoughts that seem to relate clearly to a larger perineal tear. It may be years of triggered episodes of frozen panic with a legion of immune and mental health consequences when the physical injury seems comparatively small.
The engine pulsing behind trauma is our constant evaluation of what an event or sensation means. If I injure my knee, it may not mean much for who I am as a person, unless I earn money or sanity from running. Tear my pelvic floor muscles from the bone during an unexpected forceps delivery and it means many staggering things. My organs tied to dignity are under threat because I can’t stop my bladder leaking when I cough. My sexual identity is at sea because my perineum has been cut so I no longer relate to what I see and feel down there. Or I feel disgust when I should feel arousal.
I know these things because I am a physiotherapist that works with women who experience birth trauma. But I also know this from my own experiences of birth drama. After what seemed an exquisitely calm birth, I turned around to receive my third child into my arms. Instead his waxen form was being raced from the room for emergency care and resuscitation. He had days of the highest level care in the Neonatal Intensive Care before doctors could tell us he would live. It was more days before we could touch him, let alone feed. Yet because I had seen many more go through much worse, I ignored the trauma and tried to evade the shame. Like many women in our culture, I failed to see the connection with my sexual health or my panic in the next pregnancy. Birth trauma means such a loss of health.
The impacts to health are significant, however birth trauma doesn’t mean enough to us as a culture. There’s no clear social currency. What I mean by social currency is the often unspoken, social agreement that anticipates and allows for the significance of what people may be going through. Think about the social response to obvious or well-understood conditions. The way we adjust work expectations for someone with a broken leg. The shift in social expectations for someone with a well-understood disease. The tricky thing about birth trauma, is that it’s often invisible, and usually poorly understood. This means the difficulties with child bonding or the emotional aftermath of birth trauma is not anticipated, and thus support is not offered, and or even sought by the person experiencing the trauma.
This could be because it feels private or embarrassing. A torn pelvic floor means that settling a baby or navigating the hardness of a poo is a nightmare that sucks any energy for menu planning or small talk to connect with other mums. Birth trauma means an immune system behaving like it’s backed in a viral corner, a mind disconnected from confidence, a body that may have lost its ability to control wee, poo, sit painlessly, enjoy sex or ‘feel like itself’.
Unshaming the experience of birth trauma may mean saying things like:
“Let me bring you a meal, I know it’s been months, that’s normal.”
“Feel free to accept or ignore this invitation for a mums’ group catch-up, I will pop in when you feel ready.”
Most of all, if someone is brave enough to share some of their struggle avoid the trinity of making someone feel worse.
1. Silver lining
Bréne Brown’s fantastic talk on empathy explains the nuance well. The problem with ‘silver lining’ is trying to point out the positive angle or outcome from the horror. It usually starts with “well at least…” Well at least you and the baby survived. Well at least you still have some pelvic floor muscle. Followed by a good dose of inspirational poster worthy, “the only way is up”. These types of responses are not helpful.
2. Diminishing or denying
A diagnosis of PTSD due to birth trauma is still rarely validated. The common-ness of birth, plus the frequency of injuries and difficult experiences is part of the issue. Many find it hard to believe that something as common as birth could trigger something as severe as PTSD. Raised eyebrows of disbelief are potent tools to hold a sufferer in frozen shame. It can stop people suffering the effects of birth trauma from getting the help they need.
3. Hero-ing health providers
Another important way to open a space for conversation about birth trauma is avoiding shifting the narrative in a way that heroes the role of health care providers. I am cautious about using the language of ‘perpetrator’ because it is enormously loaded, and unfair given the good intentions and complex load for obstetricians, midwives and other health professionals involved in women’s birth care. However, there is an important distinction to be made here when the response to women sharing about their birth trauma is met with the virtues of the birthing staff. It sends a powerful message of the worthiness of staff in comparison to the person feeling unworthy of love and care.
Unshaming responses can include:
“I don’t have the right words, thanks for telling me.”
“Has there been any helpful information I could read to know how to be a better support to you?”
Or for those for whom honesty is a simpler poetry, “That is totally s@8**y” will do.
The vacuum of healthy conversation around birth trauma may be why women blurted their terrifying stories to pregnant women in the past. Such a trigger of painful fear! Yet the search for a safe space to process birth trauma is not new at all. In chintzy loungerooms in 1980s Australian suburbs, older women began to meet regularly in the hope of processing their births many decades on. All had physical injuries related to their birth that could have been lessened by good treatment at the time. They spoke of accidental leakage of urine (incontinence) and prolapses (organs like the bladder, uterus or rectum coming down in the vagina or protruding out the vagina). They sang a familiar anthem: “I wish there had been education about pelvic floor muscles then”. We have come a long way when it comes to treatment options, but we still have a long way to go when it comes to understanding the stigma around birth trauma.
Treatment options for emotional and physical birth trauma need to be open and comfortable. Let’s unshame some details of birth trauma treatment.
Early Awareness and Support
From day one there needs to be awareness and support. Perineal swelling and stitches will need compression from thick pads or a support garment, gentle ‘pulsing’ pelvic floor exercises (if any), ice limited to ten minutes or less and good furniture and bolsters to support excellent posture and breathing patterns. Extra manual support will need to be applied (though a pad or hand pressed to the perineum or sitting on something firm) while pooing, coughing or sneezing. Small, soothing movements are great; standing still for long periods isn’t. Support might be asking the midwife to read your birth transcript with you and answer some questions, or calling the maternity social worker to listen to some of your alarming thoughts.
Ongoing emotional support
As the weeks progress, the support team will need to continue and expand. Emotional therapies need to be trauma informed. Ask ‘how’ the psychologist is trauma informed. A variety of approaches, including equine therapy, sensorimotor integration and Eye Movement Desensitising and Reprocessing may be used. Prepare to try more than one; ‘finding the right psychologist is like buying a good pair of jeans. Even if they look awesome online you need to try a few on before you get a good fit’.
Ongoing physical support
Physical therapies whether from a GP, urogyneacologist or pelvic physiotherapist should present the range of treatment options and put the client in control of choosing the type and pace of treatment. There will be muscles that are both tight and weak. Ligaments and muscles may be torn or stretched. Sometimes it will be enough to use devices like pessaries (silicone ‘splints’ in the vagina) alongside muscle relaxation and strengthening. Sometimes a careful dietary and supplemental recipe is needed for a poo that is not too hard or loose to avoid leakage or straining. Sometimes electronic feedback or balloons will be used to retrain pooing (defecation if you want to feel fancy). Sometimes a sex toy will be used to limit the depth of a partner’s penetration, or to help relax muscles. Sometimes medications will be used for nerves that are really angry and sensitised by the injury and stress hormones. Sometimes surgery will be needed. Always, feeling safe and respected during treatment is needed.
There is hope ahead!
Allowing for ups and downs is so important. There will be harder months. Recent research showed a slump in mental health scores six months after significant perineal tears – more so for the women with medium tears (1). At ten months, women struggling to manage a prolapse will be faced with a much heavier baby going through separation anxiety, wanting to be held with no concern whatsoever for destroying mum’s recently improved sensation of bulging in her pelvic floor. Yet perhaps most challenging is considering pregnancy or birth again.
These are the types of conversations we need to have. The good news is, just like those with major injuries in other body areas or suffering from other kinds of trauma, transformation comes with kind support and treatment. With the right care team, healing can triumph. The traumatised mind can emerge with deeper insights that create amazing connections with others. Once again, meaning is key. But when it comes to healing, it’s not what the injuries mean, but the meaning of one’s life that limits the power of the trauma. A commitment to valuing what your life means; what one enjoys, offers to their community and one’s capacity to delight in others. Good psychologists draw this out and motivate rehabilitation because the valued life knows it needs to be well. Minds reconnect with pelvic floors, sex becomes a new playground of intimacy, and exercise gradually becomes more and more satisfying. Best of all, preparing for another birth can become safe.
Three Steps to Unshame Birth Trauma sufferers preparing for birth
Let’s un-shame birth trauma by giving sufferers helpful control.
1. Birth Preferences supported and informed
Firstly, choosing the mode of delivery with all the needed information. Last month our Australian Commission into Safety and Quality in Health Care published new guidelines to reduce the risk of large perineal tears and provide better treatment should they arise. These guidelines are based on an intervention bundle that has been followed by teaching hospitals since 2017 and has shown encouraging results. It includes risk factors that indicate when a Caesarean section would be a safer birth choice due to the risk to the perineum or pelvic floor muscles.
2. Freedom to ask questions
Secondly, being allowed to ask as many questions, from as many professionals as are needed. Fears need to be addressed until they no longer dictate thoughts and emotions about birth. Asking questions needs to be welcomed and normalised. Even if it’s expressed in an anxious way, it’s a step towards health, and provision needs to be made for the extra time these questions take.
3. Build a team
Thirdly, and most importantly, choosing pregnancy and birth carers. We have the privilege of being in a country where public health includes the right to a second opinion. Rather than being made to feel difficult, someone who seeks a second opinion is practicing the very sense of control needed for reconnecting the pieces of their mind and body. Could we dare to say “good on you” to a birth trauma sufferer who says: “I would like a second opinion”.
Kind honest words, support and extra time for sufferers of birth trauma. Please? Unshame.
About the Author
Liz Lush is a mother to 4 children born in variety of pelvic floor and challenging ways. She has been Childbirth Educator since 1998 who is still awed at the privilege of working with women to listen to their bodies. Currently Liz is the Senior Pelvic Health Physiotherapist at All Women’s Health where she has the delight of working with women of all ages. Follow on Instagram @allwomenshealthphysio and Facebook, All Women’s Health – Physio and Fitness.
- Beaumont T and Phillips K, Showcasing a model of care for women who sustain an obstetric anal sphincter injury at an Australian tertiary hospital, A & NZ Continence journal, 2021, Vol 27, no 2.
- Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma.
Centre for Health Care Strategies – Key Ingredients for Successful Trauma-Informed Care Implementation
Australian Commission on Safety and Quality in Health Care – Third and Fourth Degree Perineal Tears Clinical Care Standard
Earlier version published at SRC Health. Reposted with author’s permission.