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Birth Trauma Can Cause Women to Develop PPD & PTSD
A Discussion About Birth Rape and Its Results
We all know that birth trauma can occur in infants, but what about women? For years women have been suffering in silence from birth trauma that results from their treatment during labor and delivery of their child. The feelings some women have about their negative experiences are overwhelming, so much so that some women suffer from PTSD afterwards. Some women refer to their treatment as birth rape, especially if they had instruments placed inside them without their consent.
Some believe people use the term 'birth rape' to sensationalize their trauma and feel it is disrespectful to actual rape victims. The pain these women feel is just as real, and they are just as much victims as anyone else. One dictionary definition of the word rape is "to violate or abuse." State laws about rape usually consider any forceful penetration of the vagina or rectum to be rape. Ladies suffering from birth trauma display some of the classic symptoms of rape victims, including silence and shame about their ordeal.
This can include having Q-tips, speculums, scissors, forceps, vacuums, fingers, hands, and other objects inserted into a woman's vagina or being given an enema, IV, epidural, or C-section without her consent. Having one's water broken is another example of doctor's taking control, which is basically what rape is all about. Being coerced, manipulated or deceived so that one will be obedient and go along with these treatments is another form of birth rape. Some even consider making rude and discouraging remarks to influence the mother rather than empower her to be included in the definition. Moving a mother into certain positions without asking and telling her what to do are further examples of mistreatment.
Some deny the existance of birth trauma in mothers or believe that they or exaggerating, especially being that misconduct is rarely reported. Some 54% of women in one study had grounds for a complaint but did not file, which is a classic behavior of a person experiencing PTSD. Some go as far as to suggest that postpartum PTSD is caused by past sexual assault that is refreshed as a result of the traumatic birth, though many victims of birth rape have no history of abuse.
Anywhere from 3-10% of postpartum women suffer from PTSD after birth which can lead to postpartum depression. Six months later the rate is about 1.5%. Forty-three percent of those women develop postpartum depression. The American Psychiatric Association recognizes any event that causes "fear for the life of bodily integrity of the person or a loved one" to be cause for PTSD, and birth can definitely meet that requirement.
Among the symptoms of birth-induced PTD are obsessive thoughts about the birth; panic near the birth location; and flashbacks, nightmares, and disturbing memories of the birth. Generally feeling sad, afraid, anxious, or irritable can also be caused by PTSD. Some mothers with PTSD may behave differently toward their children, particularly the ones associated with the specific birth that caused the PTSD. Symptoms can last for a year but usually subside within a few months. It can take a lifetime for the wounds to fully heal, and relapses often occur.
It is recommended that birth professionals empower women to prevent birth trauma. Give her control. Show her that she is valued. Treat her with respect. Ask permission anytime you are performing an intervention or even touching her. If she asks you to stop, do so immediately. Above all, listen to her, and show her that you care about her and not just her baby. They also recommend a period of 'debriefing,' where the woman is encouraged to talk about her experience. This can be therapeutic and also help her recognize ways in which she was mistreated. She can chose then to confront the abuser, file a claim, or just walk away knowing that at least someone understands, believes, and recognizes the abuse.
Perez, "PTSD After Birth" Childbirth & Family Education, Inc. URL: http://childbirthfamilyeducation.org/cfe/PTSDafterBirth.htm
Dr. N. George,"Articles about Post Partum PTSD" Tabs.org URL: http://www.tabs.org.nz/pdfdocs/tabsptsdreviews.pdf
20 Years of Birth Stories
Having been in birth since 1982, I am often asked to share my birth stories. I am finally writing them down. Please, if you are pregnant or nursing, use your discretion when reading. Not every story is perfect, but I write real life... as it happened, not as I would create it now. These stories have made me who I am... as a woman, a mother, a doula, and a midwife.
Saturday, August 07, 2004
A Different Kind of Pain in Childbirth
Note before beginning!
This can be seen as a VERY negative post. Even in that light, there absolutely is a balance... a mirror image of the goodness and love and kindness I have seen in birth, too. But this blogspot isn't the space for that. I will do that another time. This is for enlightenment of a different sort.
As most who are reading this blog know, I am also processing issues surrounding birthrape and how midwives (not just OBs and nurses) facilitate the birthrape experience for women.
(a definition in the making)
Birthrape: The experience of having fingers, scissors, and/or tools put/pushed/shoved inside a woman's vagina or rectum without her direct (or indirect) permission.
Being coerced, manipulated, or lied to regarding the health and safety of the baby or themselves so the midwife is able to do something to the mother's vagina, rectum, cervix, or perineum, usually with excuses; rarely with apologies.
Some find the definition expanded to:
The midwife taking the woman's Power by using disparaging comments, unsupportive expressions, speaking around her as if she is unable to hear or process requests or information.
Even though consent forms are signed in the hospital, birth center, and at home, consent for care does not include the manipulations or coercive words to get women to obey the caregiver.
I thought it was time I shared some of the thousands of comments I have personally heard that have facilitated birthrape over the years.
I share them and am writing about them and speaking about them and nearly screaming about them in the hopes that midwives will hear what they are saying that is sending their clients into therapy, pushing them to depressions that require medication and alternative therapies, keeping them from coming back to the midwife at all because of her Power Hunger and covert misogyny. Too many women (in my opinion) find Unattended Birth their only acceptable option after their experiences with professional caregivers in birth.
You see, most midwives talk a good game. They will say any number of things in pregnancy to lead the woman to believe she (the mom) is in control. I have sat through hundreds and thousands of prenatals with midwives and listened to the party line about how they believe in a woman to know, how they will "let" them labor how they want, how they will limit vaginal exams, etc. And then, when labor is in full swing, I sit by (or participate) in the amazing disregard for the woman's prenatal wishes and dreams of an unhurried, unfettered, un-directed birth.
I am not a part of the delusion or lies anymore.
* Women in labor don't really want to use their birth plan.
* Women in labor aren't able to verbalize their needs.
* Women in labor don't know when they need to pee or drink or eat.
* Women in labor don't know when to change positions.
* Women in labor can't make decisions.
* Women in labor want an epidural.
* Once labor kicks in, they all want epidurals.
Directives That Disembody Her Being
* Lift her leg.
* Move her to the bed.
* Grab her knees.
* Put her feet in the stirrups.
* Put her hands on the grips.
* Push her head to her chest.
* Push her chin to her chest.
* Put pillows under her head.
* Put pillows under her butt.
* Pull her down to the edge of the bed.
* Push with her so she knows how to do it right.
* Count for her so she knows how to do it right.
(while these next phrases end in periods and question marks... almost exclusively, the following words have been shouted at women... an exclamation mark is more appropriate, but there aren't enough in the computer to add them all)
Comments That Negate Her Intelligence
(spiritual, physical, emotional, and intellectual)
* You aren't pushing right.
* Push like this.
* Quit making noise.
* No, push longer.
* Push like you are having a bowel movement.
* Push the watermelon out.
* Push the bowling ball out.
* Don't push in your chest, push in your butt.
* Push like you mean it.
* What are you doing?
* Can't you push harder?
* Have you ever been raped? (asked in labor)
* Are you an abuse survivor? (asked in labor)
* Have you been abused? (asked in labor)
Coercive and Manipulative Remarks
* I need to get in there.
* pressing knees apart - I need to do a vaginal exam.
* C'mon, just let me see what is going on.
* I'll do it quick and fast, I promise.
* I promise to be gentle.
* I just want to feel the baby's position.
* I just want to see how dilated you are.
* You asked me to be your midwife, now let me do my job, okay?
* I'm a woman, too, I know how it feels... I promise to be gentle.
* I remember how vaginal exams felt in labor, I promise to be gentle.
* Do you want the baby to come out or not? Just open your legs.
* Are you sure you are ready to be a mom?
* You had no problem opening your legs 9 months ago.
* Just let me break your water, it will speed things up.
* If I break your water, the head will be applied better on the cervix.
* If I break your water, prostaglandins will stimulate things nicely.
* Here, drink this. (as Gatorade with cytotec is given to the mom)
* You might feel a pinch. (as pitocin is injected into the vaginal vault)
* I am just wiping up some stuff. (as pitocin on a gauze is pushed inside the vagina or rectum)
* Here, drink this. (as blue and black cohosh are given without consent)
* Here, put these under your tongue. (as homeopathics are given without information or consent)
* I'm just feeling your cervix... it might hurt a little. (as manipulations to the cervix are done... from stripping the membranes to manual dilation)
* I'm just feeling your cervix. (as cytotec is put onto the cervix)
* Do you want your baby to die?
* You don't know the seriousness of the situation.
* You have been a martyr long enough.
* Just take the medication.
* Just get "your" epidural.
* Would you like something for the pain? (in the middle of a contraction)
* This will take the edge off.
* It doesn't do anything to the baby.
* If you were my daughter/sister/mother....
* I have had three scheduled cesareans myself! I don't know what you are complaining about. (being wheeled into the OR)
* Stop whining.
* Why are you crying?
* What is wrong with you? Are you trying to hurt your baby?
* In this day and age, no one needs to suffer in childbirth anymore.
* Mothers and babies died without hospitals 100 years ago.
* Let me call the anesthesiologist... just talk to him about your options.
* No, you can't eat... just in case you need a cesarean... and your labor is rather slow moving.
* No, nothing by mouth after 7 centimeters. (or any number the caregiver randomly pulled out of her ass)
* Only ice chips.
* Oh, Bradley... they always have cesareans.
* You wanted a homebirth? That's child abuse!
* Are you one of those La Leche League people who nurse until the kid dates?
* Do you vaccinate? (after discussion of no erythromycin in the baby's eyes)
* You want your baby to go blind? (after refusal of erythromycin in baby's eyes)
* Your baby might bleed to death. (after refusal of Vitamin K injection for the baby)
* It's just antibiotics.
* God, you have terrible veins!
* Where are your veins?
* (to the Licensed Midwife during a transport, a nurse asks) Do you know how to take a blood pressure? Did you do any?
* Why did you wait so long?
* Why did you get here so early?
* You aren't in labor.
* How would you not know if your water broke or not?
* Can't you stop moaning?
* Be quiet!
* Oops, your water broke! (while using fingernails or fingers to break it on purpose)
Whispering to Other Birth Attendants
• My god, I wish she would hurry up.
* I am so bored!
* She is going so slow.
* I wish she would let me break her water.
* My baby needs to nurse, I need to go home.
* My boobs are going to burst if I don't go home and nurse. She needs to hurry up.
* I am so tired.
* I want to go home.
* I am going to talk her into letting me break her water so she will hurry up.
* I am going to talk her into letting me manually dilate her so she will hurry up.
* I need her to hurry up.
* She's holding back. There must be some emotional barrier we haven't found yet.
* I bet she was abused. Look how she: keeps her legs together/cries with exams/doesn't want us to touch her/doesn't take her clothes off/won't take her shirt off/won't relax enough to let the baby out/is afraid to be a parent/hasn't worked through her issues/has body image issues/has eating issues/is fat/is thin/lives in her head/isn't in touch with reality
* She is so noisy.
* She is too quiet.
* She needs to let go.
I am exhausted writing this much pain. I know there are hundreds of thousands of remarks that have been said that I haven't been witness to and I encourage women who have had them said to them to email me privately so I might start a list that lets caregivers know what not to say to women during pregnancy, labor, birth, and postpartum.
Email to: Barb Herrera - firstname.lastname@example.org
Your names, of course, are completely private. Your words, however, need to be heard!
Let's shout together.
My mind cannot stop the thinking about the birthrape issue and NO ONE in my life, not even my partner, wants to hear one thing about it. A childbirth educator friend said she would talk and we could process, but she is a client of mine, albeit my hypno-therapist, but I have horrid feelings of guilt I have begun exploring about HER birth. She has told me she loved her birth, even when I sobbed speaking about how I hated what I did to her at her birth (retrospectively; after my hands-off birth). It doesn't make my heart rest any easier... well, maybe a little.
I can't stop diarrhea-ing.
I think the insanity and birthrape guilt are separate and together. Maybe I am paying for my past now instead of later.
Just dig in.
As I learned to be a midwife, I did horrible things to women in the name of education. I have held women's legs open ("to get the baby out"). I have pulled placentas out ("to learn how to get one out that needs help or if the mom is bleeding"). I have squished a woman's belly until I could nearly feel her spine, which is, actually, the wording used by the teachers (plural): Push until you find her spine ("to keep her from hemorrhaging and expel clots"). I have pulled placentas until cords have fallen off. I have grabbed women's nipples and shoved them into their babies' mouths. I have done vaginal exams on women who were screaming NO! I have coerced women to allow me into their vaginas for exams. I have done "finger forceps" [a misnomer] (using my fingers to press the ischial spines open wider for a baby to come through faster). I have ruptured membranes because I needed to learn how. I have manually dilated cervices that did not need to be touched because I needed (or thought I needed) to learn how to do it in an emergency. I have manually dilated a cervix on a woman having a waterbirth (and I wasn't wearing gloves) and got her cervical flesh under my fingernails.
As a doula and student, I stood by and watched as women screamed to be left alone. I watched midwives with 3 inch fingernails shove cervices from 3-10 in a few minutes. I watched as women had cytotec inserted into their vaginas secretly. I watched as women unknowingly drank cytotec from Gatorade bottles. I witnessed pitocin being secretly injected into the vaginal vault to projectile a baby in second stage arrest. I witnessed pitocin being put on gauze and put in women's vaginas without their knowledge. I watched as the gauze was put in their rectums without their knowledge. I have seen women sutured who might not otherwise need it simply because someone needed training. I have seen OBs cut an episiotomy because they are in a hurry. I have heard evil things coming from OB's mouths towards clients and stood by and said nothing. I have heard even more evil things come from midwives and stood by and said nothing. I have seen and heard women be screamed at to shut up, grow up, that she asked for it by opening her legs 9 months ago, that she gets what she deserves. I have seen a woman slapped by a midwife. I have seen a midwife, on more than one occasion, hang a baby upside down and slap the baby up and down the back to revive him/her. I have seen, on more than one occasion, midwives take a fainted woman's nipples and twist them nearly off to revive the woman.
I have seen many illegal maneuvers that have saved women trips to the hospital and have learned amazing amounts of information that I would never use unless a woman or baby were dying in my arms. I have NOT done other equally unethical acts... have not ever cut an episiotomy because I needed to practice... have not sutured because I needed to practice... have not ever used forceps or vacuum extractor. I have learned how to birth a baby in the caul. I have learned how to sit and wait from long second and third stages. But it doesn't remove one iota of the pain I feel. There is no catharsis.
I am the enemy of many women. I am their pain. I embody it. I created it. I am more filled with shame than there are words to describe.
Does it make any difference that I have grown to not do these things? Did I have to walk that path to get where I am? Why did I love the learning I experienced? Why did I get high from all the energy and the uncertainty? Do I really believe I wouldn't be the midwife I am today if I didn't know all I know? Am I better able to speak the language of the enemy because I am the enemy? Do I have any right speaking to the women whose hearts bleed and whose bodies are mutilated?
I pray to find the balance of peace and forgiveness... all within my Self.
Unknown, "A Different Kind of Pain in Childbirth." Navel-gazing Midwife. URL: http://navelgazingbirthstories.blogspot.com/2004/08/different-kind-of-pain-in-childbirth.html
Post Traumatic Stress Disorder
With the advances in nutrition and fluid replacements, most women survive hyperemesis gravidarum with fewer life-threatening complications. However, being treated and surviving hyperemesis can cause psychological problems for some people.
Survivors of hyperemesis may have problems with self-esteem, intimacy, guilt, and conditioned food aversions. Women may experience anxiety and depression related to receiving inadequate treatment for hyperemesis, fear of the hyperemesis recurring in future pregnancies, and having to face the fear of harm or death to herself and/or her unborn child when pregnant. Some survivors of hyperemesis experience trauma-related symptoms, such as avoiding situations, continuously thinking about problems, and being over-excited. These symptoms are similar to symptoms experienced by people who have survived highly stressful situations, such as combat, natural disasters, rape, or other life-threatening events. This group of symptoms is called post traumatic stress disorder (PTSD) or post traumatic stress syndrome (PTSS). It is more common in women than in men.
People with histories of hyperemesis are at risk for PTSD. The physical and mental stress of having a potentially life-threatening disease (threatening them or their unborn child), not being believed by health professionals, receiving treatment for hyperemesis, and living with unexpected and possibly uncontrolled threats to one's body and life (and one's unborn child) during pregnancy are traumatic experiences for many hyperemetic women.
Hyperemetic women experience pain, distress, extreme fatigue, muscle weakness, incessant nausea and/or vomiting. The sensation of suffocation that accompanies forceful, unrelenting retching or vomiting can be quite traumatic. In fact, inducing that sensation is a torture technique that is documented to cause psychological trauma.
Hyperemetic women also may undergo painful and invasive procedures, as well as be faced with possible guilt as they decide whether they can continue the pregnancy when they are so sick. Relationships are strained and she may feel misunderstood and alone. They may be in the hospital for a few days or weeks, leading to feelings of frustration, isolation and loss of control. They may be unable to care for themselves or their family for weeks or months. These experiences may lead to feelings of helplessness, especially for women who have certain risk factors, such as having little social support, experiencing a trauma, being victimized in the past, or having a history of mental disorder.
Applying PTSD to Hyperemesis Gravidarum
One problem health professionals have in determining if a hyperemetic woman has PTSD is figuring out what exactly is the cause of trauma. Because the hyperemesis experience involves so many upsetting events, it is much more difficult to single out one event as a cause of stress than it is for other traumas, such as natural disasters or rape. For hyperemesis women, the stressful incident may be related to frequent episodes of vomiting, many relapses with a worsening of symptoms, painful or stressful procedures, fear of death, loss of unborn child, complications such as severe infection or convulsions, scary scenes such as vomiting blood, treatment delays or insufficient treatment, and not being taken seriously. Some women may also experience abandonment and abuse, causing further trauma.
PTSD is defined as the development of certain symptoms following a mentally stressful event that involved actual death or the threat of death, serious injury, or a threat to oneself or others. These events may include being diagnosed with a potentially life-threatening illness. In the case of hyperemesis, the illness threatens the baby and mother if left untreated or inadequately treated. Many hyperemetic women fear death, especially those with more severe symptoms that do not respond to prescribed treatment.
These events may cause responses of extreme fear, helplessness, or horror and may trigger PTSD symptoms. These symptoms include re-experiencing the trauma (nightmares, flashbacks, and interfering thoughts), continuously avoiding reminders of the trauma (avoiding situations, responding less to people, and showing less emotion), and being continuously excited (for example, having sleeping problems or being overly defensive, watchful, or irritable). Other common emotional responses include unhappiness, guilt over actions taken or not taken, and overwhelming loss. It is common for some women with hyperemesis to experience this for months or years after pregnancy.
In hyperemesis, as in other stressful major life events, over-excitability, avoiding certain thoughts and reminders, and having intrusive thoughts may occur during or after pregnancy. The number of women with these symptoms is unclear and has not been studied to date. It has been estimated that approximately 10% of women with hyperemesis have severe symptoms. Thus, the number with PTSD may be close to that number, or perhaps greater. It is not uncommon for women to seek information on hyperemesis for many years postpartum, trying to get answers to their questions. They may even become quite emotional discussing or thinking about their experience for years afterwards.
Childbirth is also a known risk factor for PTSD. If the childbirth experience is perceived as traumatic due to complications or difficulties, the risk of PTSD is likely greater in women with hyperemesis. Future pregnancies may bring about significant anxiety and panic attacks, symptoms of PTSD. PTSD is often overlooked or undiagnosed in women with a history of hyperemesis. Instead, they may be diagnosed with depression and anxiety that may be chronic.
In studies of cancer patients, some have these symptoms even 6 years after their last treatments. It is unknown how long women with hyperemesis will experience symptoms. Some hyperemesis survivors may have higher levels of general mental distress. People with a history of PTSD may be at risk for developing ongoing emotional problems.
Symptoms typical of PTSD may be seen in family members of hyperemesis survivors. These symptoms may be due to family members having to face the woman or baby's possible death, as well as witnessing painful treatments and relentless vomiting. It is not uncommon for children to have anxiety and fear the death of their mother. Behavioral changes may result especially if the child is not reassured and their world is greatly altered by the mother's illness. These symptoms may lessen over time, however, assistance may be needed from health professionals.
Causes and Risk Factors
As many as one-third of people who experience traumatic events may develop PTSD. It is caused by an extremely upsetting event; however, this one event alone does not explain why some people get PTSD. Not everyone who experiences these upsetting events develops PTSD. For some people, mental, physical, or social factors may make them more likely to experience it. PTSD symptoms develop due to both adapting and learning.
Adapting explains the fear responses caused by certain triggers that were first associated with the upsetting event. Triggers (such as, smells, sounds, and sights) that occurred at the same time as symptoms (for example, bathroom cleaners smelled while vomiting) may cause anxiety, upset, and fear when occurring alone, even after the trauma has ended. Once established, PTSD symptoms are continued through learning. That is, avoiding certain triggers continues because this avoidance prevents unpleasant feelings and thoughts.
The most critical factors in determining which women develop PTSD due to hyperemesis seem to be the severity and duration of the symptoms. The suddenness of the onset and the level of threat to her or her unborn child's life and health are also important.
While the type of event is the main factor in how a person responds to a traumatic event, other individual and social factors may also play a role. Previous psychological problems, history of trauma, high levels of mental distress, and ineffective coping skills have been linked to a risk of PTSD. Genetic and other biologic factors (for example, hormone changes) may also make some people more at risk for PTSD. The amount of social support available has also been shown to affect the risk of PTSD, and may influence severity of hyperemesis as well.
Factors That May Increase The Risk Of PTSD After Hyperemesis Gravidarum
• Medical Complications
• History of mental illness
• Prolonged symptoms
• Severe symptoms
• Sudden onset
• Delay in diagnosis/care
• Inadequate treatment
• First HG pregnancy
• Genetic/biological factors
• Hormone levels
• Stress level
• Social support
• Coping skills
• Painful procedures
• History of trauma
• Loss of unborn child
• Perceived threat to self
• Disbelief by others of severity
• Inability to care for self/family
Women with hyperemesis should be assessed for signs of anxiety and depression during pregnancy and after delivery. At the same time, she should be evaluated for signs of PTSD. This is especially true in women with a history of hyperemesis and/or other traumas. Future pregnancies may trigger a return of PTSD symptoms. While these women may have problems adjusting to a recurrence of hyperemesis and its treatment, their PTSD symptoms may vary, and be greatest at the beginning of pregnancy or possibly postpartum. She may avoid intimacy for fear of pregnancy. This further strains her relationships. Postpartum depression may also be more prevalent among these women and screening should be done at intervals after delivery.
Family members should also be educated on signs to watch for to ensure these women get the help they need. Symptoms of PTSD usually begin within the first 3 months after delivery, but sometimes they may not appear for months or even years afterwards. Therefore, hyperemesis survivors and their families should be involved in long-term monitoring.
Some people who have experienced an upsetting event may show early symptoms without meeting the full diagnosis of PTSD. However, these early symptoms predict that PTSD may develop later. Early symptoms also indicate the need for repeated and long-term follow-up of hyperemesis survivors and their families.
Diagnosing PTSD can be difficult since many of the symptoms are similar to other psychiatric problems. For example, irritability, poor concentration, increased defensiveness, excessive fear, and disturbed sleep are symptoms of both PTSD and anxiety disorder. Other symptoms are common to PTSD, phobias, and panic disorder. Some symptoms, such as loss of interest, a sense of hopelessness, avoidance of other people, and sleep problems may indicate the woman has PTSD or postpartum depression. Even without PTSD or other problems, normal reactions to unrelenting vomiting/retching and treatment of a potentially life-threatening disease can include interfering thoughts, separating from people and the world, sleep problems, and irritability.
The chronic and sometimes disabling effects of PTSD mean the disorder needs to be identified and treated quickly. However, the avoidant symptoms that appear with PTSD often keep the woman from seeking help. Further, signs of postpartum depression may make an accurate diagnosis challenging. Health professionals may be too quick to treat the depression since she has recently been pregnant, and fail to assess further and accurately diagnose PTSD. Therapies used are those used for other trauma victims and involve more than one type of therapy.
The crisis intervention method tries to lessen the symptoms and return women to their normal or pre-pregnancy level of functioning. The therapist focuses on solving problems, teaching coping skills, and providing a supportive setting for the woman.
Thinking-behavior methods may be helpful. Some of these methods include helping the woman understand symptoms, teaching coping and stress management skills (such as relaxation training), reforming one's thinking, and trying to make the woman less sensitive to conditioned aversions.
Support groups may also help people who experience post-traumatic stress symptoms. It may be impossible to find a group of women who have experienced hyperemesis. However, there are several online support groups that may be supportive. Some mental health professionals specialize in women's health and may be most experienced in working with women suffering from complications of pregnancy.
For women with severe symptoms, medications may be used. These include antidepressants, antianxiety medications, and when necessary, antipsychotic medications.
Updated on: Aug. 09, 2006
© Celia Kitzinger, 2005
Flashbacks, nightmares, panic attacks: why?
© Celia Kitzinger, 2005
Department of Sociology
University of York
Management of the Labour Ward Course:
Theoretical Component of the ‘Preparing for Obstetric Leadership on the Labour Ward’
Special Skills Module
Royal College of Obstetricians and Gynaecologists
British Maternal and Fetal Medicine Society
3-7 October 2005
For some women, giving birth is a severely traumatising event. This can be the case whether or
not their labour was ‘objectively’ difficult and whether or not there was medical mismanagement.
For them, something has gone very badly wrong. They describe feeling shocked, outraged, or
emotionally numb for months or years after the birth; their continued distress leads to impaired
relationships with their children and partners. They may decide that they could never endure the
experience of having another baby – or, pregnant again, they relive the anguish of the first labour
with agonizing intensity as they prepare for the next.
The Birth Crisis Network was set up by birth educator and activist Sheila Kitzinger in 1999 and is
a nationwide network of women who advertise a ‘help line that women can ring if they want to talk
about a traumatic birth’. Around 300 Birth Crisis calls have so far been taped with permission for
use in research and training. Here are some extracts from the calls.
((Birth 12 years ago, pregnant again)) It was horrific. I was treated like a foolish
child, bullied, coerced into an epidural at 1cm, threatened with the death of my baby
every time I tried to make a decision. I still have nightmares about the consultant
shouting into my face and the long journey down to theatre where they put me under
a general anaesthetic for a caesarian as I was hysterical. I thought I had buried my
experience under ‘oh well you had a healthy baby’ but it has all come rushing back –
the hopeless, helpless feeling of that first delivery. I just want to be treated with some
respect this time around and not feel like a piece of meat.
I was pushing for hours to no avail, flat on my back, numb from the waist down and
feeling that my vague pushes were killing my unborn daughter. I started to die
inside. My daughter was posterior brow presentation and I continued in 2nd stage
labour actively pushing for over six hours. My daughter was distressed and her
heartbeat kept disappearing. An episiotomy was cut, two by the midwife, one by the
registrar without my consent and without so much as eye contact with me. My
daughter was born flat, resuscitated, apgar 2, and taken out to intensive care. I
asked to see my daughter when I was stitched up, the midwife said, ‘you aren’t going
anywhere until your notes are written up’. For three hours I asked to see my baby
and was told no, left in the delivery room with my parents to care for me – the
midwives were far too busy writing a more palatable version of my notes, totally
contrived. I went to see my baby and I didn’t recognize her, felt no bond, nothing.
She wasn’t my baby. My baby had died. I had killed her – in my mind my efforts to
give birth had killed her... My life is in tatters. I was tortured, traumatised, my
daughter’s life endangered and my body damaged permanently and I don’t even
warrant an apology.
© Celia Kitzinger, 2005
Nothing from the birth of my first child prepared me for what it would be like with my
son. It was the worst experience of my life. I am still in shock. I still suffer from mad
rages. I’m at the end of my tether and I still feel such a failure. I’m totally scared of
having any more children. I am hurting my marriage and causing damage to my son
but I don’t know what to do about it.
My analysis of the calls to the Birth Crisis Network reveals recurrent themes in women’s
descriptions of the ongoing after-effects of their labour experience:
flashbacks: sudden intense experiences in which they relive the feelings of the birth,
often triggered by subsequent medical encounters:
When my son was about a year old my mother went into hospital for a minor op – it
wasn’t even the same hospital – but I went to visit her and it was almost like I was
just whizzing through this tunnel back through time and I was just like in panic you
I took my son for his injections and the doctor was just like wielding the needle and I
just got this horrible, horrible feeling about it – and that the last time I saw a needle
wielded like that was when they were putting me under and I wasn’t sure whether I’d
come back again. So I nearly passed out at the doctors.
Every night I dread going to bed because my dreams are like a videotape of the birth
playing over and over in my head and I wake up drenched in sweat and screaming.
I have very frequent nightmares about being tortured, some as graphic as in the birth
itself. I don’t like to be in bed long. I generally sleep between four and five hours
altogether. I tend to wake frightened.
panic attacks and hyperarousal
I’ll suddenly feel panicky and hysterical for no reason – a chance remark from an
acquaintance about someone’s pregnancy, a programme on TV, a child crying – it’s
like I’m ready and waiting for something terrible to happen and daren’t relax or lower
I’m terrified that something will happen to my baby and that I can’t keep her safe. I
see-saw between feeling completely emotionally numb or paralyzed and a horrible
sense of urgency and desperation or raw anger bubbling around just under the
surface that I don’t know what to do with.
Flashbacks, nightmares and panic attacks are amongst the symptoms of PTSD and around a
third of the callers to the Birth Crisis Network report having been diagnosed with Post Traumatic
Stress Disorder (PTSD). This is not a new problem: there are written accounts of similar
symptoms that go back centuries and the experience it describes has been documented in
combat veterans of WWII and in holocaust survivors. Careful research and documentation began
after the Vietnam war and the diagnosis was formally accepted by the American Psychiatric
Association in 1980. Research on post-natal PTSD has established an incidence between 1.7%
and 5.6% (Ayers & Pickering 2001). A study in a London hospital found that 2.8% of women had
PTSD at 6 weeks postpartum and 1.5% at 6 months – which means around 10,000 chronic cases
annually in the UK. Other women don’t develop the complete disorder but are distressed, angry,
© Celia Kitzinger, 2005
traumatised. Suicide is now the leading cause of maternal death one year post-natally for women
in the UK (Drife & Lewis 2001: 13). prevention means recognising the types of practices in
childbirth that are commonly associated with trauma and changing them. There is now a
developing research field on the causes of trauma after childbirth and the Birth Trauma
Association UK has suggested that PTSD incidence should be included as a performance
indicator for the obstetric services.
Childbirth – even difficult childbirth, painful childbirth, and childbirth involving obstetric
interventions - does not have to be traumatic. It can be joyful, satisfying, even ecstatic. A woman
can emerge from the experience confident and empowered, even after an instrumental delivery or
an emergency caesarian. Many women who have described these traumatic births have also
experienced births that were joyous and – when they came after a traumatic birth – healing. In
listening to women describe both their traumatic and their non-traumatic experiences of birth we
can begin to identify which practices may underpin post-natal PTSD and cause distress to many
What causes this distress?
Women can be traumatized by labour regardless of the method of delivery (a couple of callers to
the Birth Crisis Network were seeking help in dealing with traumatic births at home) – but invasive
obstetric procedures such as emergency caesarian sections, inductions and instrumental
deliveries are more likely to be perceived as traumatic. What is crucial, however, is not the
procedures themselves but women’s sense of control and informed choice. When women do not
understand why the procedures are necessary, what they involve, or what their options are, when
they feel (at best) disempowered and (at worst) as though they are being lied to or manipulated
into procedures they do not want, then the labour becomes a traumatic event.
They had to perform an episiotomy and ventouse. They didn't discuss this with me
and the doctor was very abrupt and uncaring. He didn't talk to me or explain
anything or ask to do anything. I didn't understand what was going on.
The baby was ‘delivered’ (not born) at 2:20 PM. He finished stitching me about 3:10
PM. He did not talk to me or to my husband, not even to state the sex or condition of
the child. He talked only to the assistants, asking for suture material and so on. At
no point did he say what he had done, nor why he did it. He made no mention of the
episiotomy or its extent. He did finally say ‘You can take them away now’ to
I was just a case to them. They didn’t speak to me, only about me.
Doctors, and above all midwives, accompany women through a major life transition. How they do
this affects the way a mother feels about herself, her baby and her partner for long after the
event. Even when a woman believes that her care was medically competent and that
interventions were necessary, she can be traumatised by uncaring, hostile, or degrading
treatment from caregivers.
She stood at the bottom of the bed filling in forms; she wouldn’t meet my eyes or talk
to me; when I asked her what was happening she told me it was all under control
and not to worry.
He went out leaving the curtains open and me with my legs wide apart in stirrups. I
was forced to lie like that while the hospital cleaners washed the floor. I felt
© Celia Kitzinger, 2005
They took no notice of me at all but kept fiddling with the dials on the monitor and
complaining to each other that it wasn’t working properly.
The single most important recurrent theme in women’s descriptions of their traumatic
labours is their feeling of disempowerment -- helplessness, humiliation, violation,
dehumanization; feeling they were bullied, lied to, manipulated, that their wishes were overruled,
that they had been tethered to machinery and ignored, and that painful or damaging
– and in their view, often unnecessary - actions had been performed on their bodies
without their informed consent.
Other themes include:
agonizing physical pain with no capacity to manage or control it:
“I was howling with pain. I though I was dying – I felt stripped of humanity and might
as well be dead.”
believing that they or their baby would die (some women whose babies had been
taken to intensive care believed for some time after birth that their babies had died
because nobody had explained to them where they were)
separation from their baby immediately after birth - in one case for 10 days while the
mother was in one hospital and the baby had been moved to another.
Pain, fear of death, and separation from the baby were made unbearable in a context which they
experienced as defined by uncaring and inhumane treatment by people who trivialized their
suffering, denied them pain relief, and who failed to communicate what was happening or to
explain the procedures. After births like these, women’s attempts to wrest back control over their
own bodies and to reclaim their own dignity as human beings includes both, on the one hand, the
demand for elective caesesarian, and, on the other, the demand for home birth. As one woman
I had no intention of having anything further to do with the medical profession. I was
so humiliated with my treatment that I felt totally isolated and ashamed.... I did not
have any antenatal care with the second child. I was so frightened of repeating the
misery of the first child’s birth that I refused care... My husband and I delivered our
next two children at home.
These traumatic births are subjectively like the sorts of experiences that cause PTSD in other
contexts where people have endured horrible events caused not by natural disasters or ‘acts of
god’ but by other human beings – in survivors of war, rape or torture. Part of what causes the
trauma is not the pain, the suffering, the fear, or the loss – severe as all these may be – but the
outrage and horror that other people caused it (or at least did not alleviate it). But unlike the
victim of rape or torture, the post-natal woman is expected to feel grateful to those who delivered
her baby – and may in fact find herself torn between anger at the management of her labour, and
gratitude that she and her baby survived.
What is needed?
The primary prevention of post-natal PTSD rests on proper acknowledgement of women’s basic
human rights in the birth process. Researchers and activists in this area highlight the importance
enabling women to make their own choices
supplying complete information
respecting their wishes
fully informing women of the options, procedures and risks associated with obstetric
when emergencies arise, full explanation and sensitive treatment.
all of which are more achievable with continuity of care and one-to-one care.
Some women may be especially at risk of PTSD – especially those who have had previous
traumatic experiences the memory of which may be triggered by the birth: women who have
© Celia Kitzinger, 2005
experienced physical or sexual abuse in childhood, women who have been raped. Research
makes quite clear however that it is not only these women who suffer post-natal PTSD, and that
treating ALL women with humanity and respect would go a long way towards helping those who
are particularly vulnerable. A woman who had been raped as a teenager described how a doctor
‘ushered in a gaggle of students to stare at my genitals without my consent – it brought back the
horror of the rape all over again’. But no woman should have to endure this affront to her dignity.
Women who talk about their traumatic experience of birth are often told: ‘put it behind you, be
grateful you’ve got a healthy baby’; or ‘it’s just your hormones’. Or it is implied that they are mad,
crazy, unbalanced and over-reacting. Birth Afterthoughts schemes and other ‘debriefing’
exercises can help – although they sometimes treat women not as patients but as potential
The growth in research and training on post-natal PTSD is making it less likely that traumatized
women can be dismissed or their concerns trivialized, and more likely that medical professionals
will be held accountable.
Accountability – in the context of PTSD – is not merely about the medical management of labour.
It is about the capacity of obstetricians and midwives and other caregivers to behave with
humanity - and with respect for the essential rights and dignity of the labouring woman.
Ayers, S. and Pickering, A. (2001) Do women get posttraumatic stress disorder as a result of
childbirth? A prospective study of incidence. Birth 28(2): 111-118.
Drife, J. and Lewis, G. (2001) Why Mothers Die 1997-99: The Confidential Enquiries into
Maternal Deaths in the UK. London: RCOG Press.
Laurence, R. 1997. Post-traumatic stress disorder after childbirth: The phenomenon of traumatic
birth. Canadian Medical Association Journal 156(6): 831-835.
Robinson, J. (2002) Post-traumatic stress disorder: A consumer view, Pp. 313-322 in Maternal
Morbidity and Mortality, edited by A.B. MacLean and J. Neilson. London: RCOG Press.
Soderquist, J, Wijma, K, and Wijma, B (2002) Traumatic stress after childbirth: The role of
obstetric variables, Journal of Psychosomatic Obstetrics and Gynecology 23(1): 31-39.
Information about the Birth Crisis Network is available on:
Thyroid Disorders and Pregnancy
P. Becks, MD, FRCP(C)
Assistant Professor of Medicine
St. Joseph's Health Centre, University of Western Ontario, London, Ontario
Gerard N. Burrow, MD, FRCP
Vice Chancellor for Health Sciences and Dean, School of Medicine
University of California, San Diego, La Jolla, California
Thyroid Disorders and Pregnancy
Thyroid disease is present in 2-5 percent of all women and 1-2 percent of women in the reproductive age group. Not unexpectedly, thyroid problems are common in women who are pregnant. In this article we will view pregnancy broadly to include the antepartum (before pregnancy) and postpartum (after pregnancy) periods, as well as pregnancy itself. Both the baby's and mother's well-being are equally important. In this review we will outline our approach to the common thyroid disorders encountered in pregnancy based on questions frequently asked by our own patients.
Spectrum of Thyroid Disease in Pregnancy
Several of the thyroid disorders which tend to occur during pregnancy are autoimmune in nature. By this we mean that the body develops antibodies directed against thyroid cells, which then affect the way the thyroid gland functions. Antibodies which damage the thyroid cells may result in lymphocytic thyroiditis (inflammation of the thyroid), also known as Hashimoto's disease. These damaging antibodies can reduce the function of the thyroid and lead to hypothyroidism. On the other hand, your body can make antibodies against thyroid tissue which can stimulate thyroid cell function. In this case, hyperthyroidism due to over-function of the thyroid (Graves' disease) may be the result.
Postpartum thyroiditis is a recently discovered problem that spans the spectrum of both hyper- and hypothyroidism. This condition, which tends to occur immediately after pregnancy, may produce antibodies which damage thyroid tissue, thereby releasing thyroid hormone passively into the bloodstream and producing hyperthyroidism. During the recovery phase, thyroid levels may fall, producing either temporary or permanent thyroid failure. Since this condition is common, occurring in 8-10 percent of all women after pregnancy, postpartum thyroid testing is advisable for all women.
Thyroid nodules, goiters, and other thyroid problems are also sometimes first detected in pregnancy but are less common.
Thyroid Disease in the Mother During Pregnancy
Hypothyroidism. If hypothyroidism is suspected in a pregnant patient, the physician can perform a TSH blood test. Just as in non-pregnant women, the TSH will be increased if hypothyroidism is present. If a woman is already being treated with thyroxine when she becomes pregnant, she should continue to take this medication during pregnancy. Thyroxine is safe to take and is well absorbed during pregnancy. Although there is usually no need for a dose change, some women require somewhat higher doses when they are pregnant. Physicians generally monitor the TSH level to detect even mild hypothyroidism and increase the thyroxine dose, if necessary.
Hyperthyroidism. Thyrotoxicosis (hyperthyroidism) during pregnancy, most often due to Graves' disease, presents a challenge for diagnosis and treatment because of unique fetal and maternal considerations.
The risk of miscarriage and stillbirth is increased if thyrotoxicosis goes untreated, and the overall risks to mother and baby further increase if the disease persists or is first recognized late in pregnancy. The diagnosis is suggested by specific physical signs such as prominent eyes, enlarged thyroid gland, and exaggerated reflexes, and is confirmed by markedly elevated serum thyroid hormone levels. As noted above, radioactive iodine scans or treatment are never performed in pregnancy. However, if a thyroid scan is inadvertently done in pregnancy, this should cause little concern, since the amount of radioactivity delivered to the fetus is barely above the background level in the environment
On the other hand, if radioactive iodine treatment is inadvertantly administered in pregnancy, this raises concerns about the radiation effects on the developing fetus in early pregnancy. The amount of radiation may approach levels which can be harmful and, after appropriate counseling, some patients may opt for a therapeutic abortion. Still a number of completely normal infants have been born in this situation. Later in pregnancy radioactive iodine can destroy the fetal thyroid, but this is probably not a sufficient reason to end the pregnancy, since recognition and treatment of hypothyroidism shortly after delivery usually assures normal growth and development in the child.
The treatment of choice for thyrotoxicosis during pregnancy is antithyroid medication, either propylthiouracil or methimazole, since radioactive iodine cannot be used. Propylthiouracil (PTU) remains the drug of choice, since it does not cress the placenta as well as methimazole. The initial goal is to control the hyperthyroidism and then use the lowest medication dose possible to maintain the serum thyroid hormone levels in the high normal range. In this way the smaller doses of medications are used, and there seems to be little risk to the baby. If a mild allergy to one of these medications develops, the other medication may be substituted. If there is a problem with taking pills or more severe drug allergy, then an operation may be performed to remove most of the thyroid gland. This is usually done in the middle part of the pregnancy. Fortunately, it is rarely necessary.
The natural course of hyperthyroidism in pregnancy is for the disease to become milder or remit totally near term. In many patients antithyroid medications can be tapered to low levels or even discontinued. For those patients who are not so fortunate, it is important to maintain control of the hyperthyroidism throughout pregnancy to avoid severe thyrotoxicosis (thyroid storm) developing during labour and delivery. If this does develop, additional acute treatment with beta-adrenergic blocking drugs such as propranolol (Inderal) and high doses of nonradioactive iodine are used. Long-term treatment with these agents is not advised in pregnancy, although some physicians use propranolol when the disease is first diagnosed to control symptoms until the antithyroid medications have had a chance to work.
Fetal Thryoid Disease
Antithyroid medications, nonradioactive iodine and, very rarely, maternal thyroid antibodies can all cross the placenta and cause hypothyroidism in the baby. Nonradioactive iodine, which is present in some medications, including some cough medications, can cause a goiter in the fetus, making delivery difficult or causing respiratory obstruction. For this reason, iodine containing drugs should never be used in pregnancy except in the case of thyroid storm. Unfortunately, there is no simple blood test to assess the baby's thyroid function in the womb, although measurements of thyroid hormone or TSH levels in the amniotic fluid sac have been used in research studies. Plain X-rays sometimes show delayed bone development in fetal hypothyroidism, but this test is usually not recommended. Screening for hypothyroidism at birth, now done routinely in North America on all babies, identifies the need for early short- or long-term thyroxine treatment, with excellent long-term follow-up results.
Fetal thyrotoxicosis (hyperthyroidism) occurs occasionally due to transfer of maternal thyroid-stimulating antibodies across the placenta. Most often, the mother herself has hyperthyroidism which is being treated with antithyroid drugs that also passively treat the baby by crossing the placenta. Sometimes, however, the mother's thyrotoxicosis occurred in the past and was controlled by either radioactive iodine treatment or an operation in which the mother's thyroid gland was removed. In such a situation the mother has less thyroid tissue and cannot be hyperthyroid, even though she continues to have thyroid stimulating antibodies in her blood. Since the mother is well, fetal thyrotoxicosis may not be suspected. Clues to the presence of fetal hyperthyroidism are fetal heart rate consistently above the normal limit of 160 beats per minute and the presence of high levels of thyroid stimulating antibodies in the mother's blood.
All women with Graves' disease or a history of Graves' disease should be tested for thyroid-stimulating antibodies late in pregnancy. The consequences of untreated fetal thyrotoxicosis include low birth weight and head size, fetal distress in labour, and neonatal heart failure and respiratory distress. Administration of antithyroid drugs to the mother during pregnancy can treat the baby in this situation. Close follow-up and continued treatment is required after delivery.
Postpartum Thyroid Disease in the Mother
Pre-existing Thyroid Disease. For pre-existing hypothyroidism, thyroid hormone treatment is continued after delivery and breast feeding is encouraged. Thyroid hormones do not get into breast milk in significant amounts.
Graves' disease (hyperthyroidism due to a diffusely overactive thyroid) is prone to relapse or worsen in the postpartum period. If that happens, antithyroid drugs can be started or their dose increased, or radioactive iodine can be given if the mother is not breast feeding. Women taking PTU (propylthiouracil) may breast feed, since little of this drug crosses into the milk. Nursing is also possible for women who take methimazole, although more of the drug gets into breast milk. In both cases the baby's thyroid function should be monitored. Definitive therapy with radioactive iodine should be considered, although many breast-feeding women will wish to postpone this, since some of the mother's radioiodine crosses into her baby through the breast milk.
Postpartum Thyroiditis. Postpartum thyroiditis may occur in 8 to 10 percent of women. This disease also occurs in the nonpostpartum period, as well as in men, and is probably an autoimmune thyroid disease related to Hashimoto's thyroiditis. Typically, it consists of a temporary period of hyperthyroidism lasting from six weeks to three months postpartum, followed by hypothyroidism between three and nine months after delivery. Women at risk include those with a previous history of postpartum thyroiditis or those who can be shown to have thyroid antibodies in their blood but are not taking thyroxine. Usually, no treatment or only symptomatic treatment is required for the hyperthyroid phase, and a short course of thyroxine treatment for six to twelve months is sufficient for the hypothyroid phase. Some women do not recover from the hypothyroid phase and, therefore, require long-term thyroid replacement therapy.
During the first three months after delivery, symptoms of fatigue, depression, and impairment of memory and concentration are common and often unrelated to a woman's thyroid hormone level. However, after this time, hypothyroid women have more of these symptoms and may feel better if their hypothyroidism is corrected by thyroid hormone treatment.
Not every women who has an emotional disorder after pregnancy will be found to have thyroid dysfunction as the cause of her problem. Thus in one recent clinical study, no increased incidence of thyroid dysfunction was found in a group of women with postpartum psychoses. Nevertheless, it is still reasonable to perform thyroid tests (including a TSH blood level) in those women who do experience emotional disorders following pregnancy.
In dealing with thyroid disease in pregnancy, the physician and patient should be aware of problems that occur before and after, as well as during the actual pregnancy. There should be equal concern for the welfare of both the mother and baby. Fortunately, most thyroid conditions can be recognized, problems can be anticipated, and effective treatment is available. The outcome is almost always a healthy one, for both the mother and her baby.
Transient Increase in the Risk of Breast Cancer after Giving Birth
Mats Lambe, Chung-cheng Hsieh, Dimitrios Trichopoulos, Anders Ekbom, Maria Pavia, and Hans-Olov Adami
Background The effect of pregnancy on the risk of breast cancer is not clear. We tested the hypothesis that the risk of breast cancer increases transiently after pregnancy but then falls to a level below that of age-matched nulliparous women.
Methods We conducted a case-control study of a nationwide cohort in Sweden, using a computerized record linkage between the Cancer Registry and the Fertility Registry. The study subjects were women born from 1925 through 1960 who were resident citizens of Sweden at the time of the 1960 census. A total of 12,666 patients with breast cancer were compared with 62,121 age-matched control subjects. We used conditional logistic regression to estimate odds ratios for the development of breast cancer at different ages, according to maternal age at first delivery (in uniparous as compared with nulliparous women) and age at second delivery (in biparous as compared with uniparous women).
Results Uniparous women were at higher risk of breast cancer than nulliparous women for up to 15 years after childbirth and at lower risk thereafter. The excess risk was most pronounced among women who were older at the time of their first delivery (odds ratio 5 years after delivery among women 35 years old at first delivery, 1.26; 95 percent confidence interval, 1.10 to 1.44). Women who had two pregnancies had a less striking increase in risk.
Conclusions Pregnancy has a dual effect on the risk of breast cancer: it transiently increases the risk after childbirth but reduces the risk in later years. In women with two pregnancies, the short-term adverse effect is masked by the long-term protection imparted by the first pregnancy. A plausible biologic interpretation is that pregnancy increases the short-term risk of breast cancer by stimulating the growth of cells that have undergone the early stages of malignant transformation but that it confers long-term protection by inducing the differentiation of normal mammary stem cells that have the potential for neoplastic change.
From the Department of Social Medicine (M.L.) and the Cancer Epidemiology Unit (M.L., A.E., H.-O.A.), University Hospital, Uppsala, Sweden; the Department of Epidemiology, Harvard School of Public Health, Boston (C.H., D.T., A.E., M.P., H.-O.A.); and the Cattedra di Igiene, Facolta di Medicina di Catanzaro, Universita di Reggio Calabria, Catanzaro, Italy (M.P.).
Cervical Cancer Diagnosed Shortly After Pregnancy: Prognostic Variables and Delivery Routes
ANIL K. SOOD, MD, JOEL I. SOROSKY, MD, NINA MAYR, MD, BARRIE ANDERSON, MD, RICHARD E. BULLER, MD, PhD and JENNIFER NIEBYL, MD
From the Divisions of Gynecologic Oncology and Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Radiation Oncology, and Pharmacology, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
Objective: To compare the prognoses of women diagnosed with cervical cancer during pregnancy with the prognoses of those diagnosed within 6 months after delivery and to assess the effect of vaginal delivery on recurrence risk and prognosis.
Methods: A matched case-control study of women with cervical cancer diagnosed during pregnancy or within 6 months of delivery was performed. Fifty-six women had cervical cancer diagnosed during pregnancy and 27 within 6 months after delivery. Controls (cervical cancer diagnosed at least 5 years since last delivery) were matched one-to-one with cases based on age, histology, stage, treatment, and time of treatment.
Results: Among postpartum women, four had stage IA disease, 15 had stage IB1 or IB2, and eight had stage IIA or higher disease. Eleven had radical hysterectomies and 14 had radiation therapy. Two with stage IA1 disease were treated with vaginal hysterectomies. One of seven patients who had cesareans developed a local and distant recurrence. In contrast, ten of 17 (59%) who delivered vaginally developed recurrences (P = .04). In multivariate analysis, vaginal delivery was the most significant predictor of recurrence (odds ratio [OR] 6.91; 95% confidence interval [CI] 1.45, 32.8), followed by high stage (OR 4.66; 95% CI 1.05, 20.8). The survival for patients diagnosed in the postpartum period was significantly worse than for controls.
Conclusion: Women diagnosed postpartum had worse survival than those diagnosed during pregnancy and were at significant risk of recurrent disease, particularly if they delivered vaginally. Therefore, pregnant women with cervical cancer should be delivered by cesarean.
Invasive cervical carcinoma during pregnancy is relatively uncommon but remains the most common malignancy associated with pregnancy. Its incidence is about 0.05% among all pregnant women. Thus, most institutions have limited experience treating these women.
Pregnancy is a good time for cervical screening because cytology routinely is done during prenatal care. However, 48–49% of cervical cancers associated with pregnancy are diagnosed within 6 months of delivery. Most authors have combined women diagnosed postpartum with those diagnosed during pregnancy. It is extremely unlikely that all these women developed new cancers subsequent to delivery. Approximately half of cervical cancers associated with pregnancy are incorrectly diagnosed during pregnancy, the reasons for which have not been explored. The effect of delivery mode on outcome and prognosis has been described only in small case reports.
Most authors agree that pregnancy does not alter the outcomes of women with cervical cancer. Some suggested that prognoses might be worse for women diagnosed in later pregnancy. Concerns about vaginal delivery through a cervix with malignancy include hemorrhage and tumor dissemination at delivery. Some authors have recommended that cesarean be performed solely for obstetric indications. Most studies have not analyzed separately the women who were diagnosed postpartum. The objectives of our study were to evaluate the outcomes of women diagnosed with cervical cancer during pregnancy and within 6 months after delivery, to identify possible reasons for lack of diagnosis during pregnancy, and to assess the effect of vaginal delivery on recurrence risk and prognosis.
POST PARTUM GALL BLADDER PROBLEMS
Second to appendicitis, gall bladder removal is the most common surgical condition encountered during pregnancy, says Dr Christy Dibble, director of the Gastrointestinal Endoscopy Service Program in Women's Digestive Disorders at Women and Infants Hospital in Providence, Rhode Island. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) notes that women between the ages of 20 and 60 are twice as likely to develop gallstones as are men.
Pregnancy, as well as estrogen and birth control use, put us at a higher risk for developing gall bladder problems. In fact, Dibble says two to four percent of pregnant patients are found to have gallstones during their pregnancy ultrasounds.
Symptoms are often called a gallstone "attack" because they occur suddenly -- often following fatty meals and during the night. According to the NIDDK, symptoms typically include:
- Steady pain in the upper abdomen that increases rapidly and lasts 30 minutes to several hours
- Pain in the back between the shoulder blades
- Pain under the right shoulder
- Nausea or vomiting
- Abdominal bloating
- Recurring intolerance of fatty foods
- Gas and indigestion
If, in addition, you experience any of the following symptoms, you need to see a doctor immediately:
- Low-grade fever
- Yellowish skin or whites of eyes
- Clay-colored stools
During an attack, the the stone gets in the way, and the gall bladder "pushes against the blockage of the stone, which causes pain. Then the gall bladder relaxes, and the pain goes away," Bowen says. "After a while, if the gall bladder continues to be inflamed, the patient may get intermittent episodes of abdominal discomfort causing nausea, belching, etc. Then the gall bladder is scarred and inflamed even further. [It] gets worse over time."
Surgery to remove the gall bladder (cholecystectomy) is the most common treatment for stones; more than 500,000 Americans undergo the procedure each year. (Those who have gallstones but no symptoms usually do not need treatment.)
Most commonly, the surgery is done with a laparoscope, using a procedure that can be performed during pregnancy. The surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. Outside of pregnancy and when a laparoscope can't be used, a large incision across the abdomen is necessary. This is called "open surgery," and is required in only about 5% of gall bladder operation.
Epidemiology of and Surveillance for Postpartum Infections
Deborah S. Yokoe,* Cindy L. Christiansen,† Ruth Johnson,‡ Kenneth Sands,§
James Livingston,* Ernest S. Shtatland,† and Richard Platt*†
*Channing Laboratory and Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; †Harvard Pilgrim Health Care, Boston, MA, USA; ‡Harvard Vanguard Medical Associates, Boston, MA, USA; and §Beth Israel Deaconess Medical Center, Boston, MA, USA
The epidemiology of postpartum infections has not been well characterized. In part this is because of the limitations of surveillance systems, which usually monitor infections that are recognized during hospitalization. Most postpartum and nonobstetrical postsurgical infections, however, occur after hospital discharge . Decreasing lengths of hospital stay may further compromise detection of these infections.
Accurate assessment of the epidemiology of postpartum infections has been hampered by the limitations of surveillance systems for identifying these infections, particularly infections detected after hospital discharge. In our study population, use of inpatient and ambulatory surveillance methods revealed that postpartum infections requiring medical attention were common following both vaginal delivery (5.5%) and cesarean section (7.4%). Mastitis and urinary tract infections accounted for >80% of these infections. The proportion of these infections directly attributable to health-care practices cannot be determined from the information available. Our study also does not address whether these infections were associated with modifiable (and therefore potentially avoidable) risk factors, for example, suboptimal administration of perioperative prophylaxis during cesarean section or bladder catheterization.
Nearly all postpartum infections became manifest after hospital discharge (94%). Furthermore, most (74%) of these post discharge infections were diagnosed and treated entirely in the ambulatory setting without the patients' returning to the hospital where they delivered for evaluation or treatment, emphasizing the need for post discharge surveillance methods that are not dependent on hospital-based data.
In conclusion, our results indicate that postpartum infections requiring medical attention are common and that most postpartum infections occur after hospital discharge, so that use of routine inpatient surveillance methods alone will lead to underestimation of postpartum infection rates. Use of automated information routinely collected by HMOs and insurers allows efficient identification of women who are very likely to have postpartum infections that are not detected by conventional surveillance. Information resulting from more complete surveillance could be used to identify settings with unusually high or low infection rates to identify practices associated with lower infection rates. This information could then be used to focus, motivate, and assess the effectiveness of practice changes aimed at improving infection rates in all settings. Additional research is needed to evaluate the generalizability of this surveillance methodology to other health-care provider and insurer systems and to assess resource utilization associated with these infections.
Changes in healthcare-associated infection rates in French maternity units from 1997 to 2003
Ayzac L., Vincent A., Girard R., Caillat-Vallet E., Chapuis C., Dumas A.M., Gignoux C., Haond C., Launay C., Tissot-Guerraz F., Fabry J., units surveillance networks
Objectives: Healthcare associated infection (HAI) incidence rates after delivery range from 0.26% to 20.3% according to the mode of delivery, the maternity activity, women risk factors. Data on HAI surveillance in maternity units are lacking. The Mater Sud-Est Study Group is a HAI continuous surveillance network on maternity units located in south eastern France. We report changes in risk-adjusted HAI rates over a 6-year long surveillance period in this maternity units network.
Methods: 161,077 vaginal deliveries and 37,074 cesarean deliveries were included in the surveillance between January 1st 1997 and December 31st 2003. We studied the changes in four HAI: endometritis and Urinary tract infection (UTI) after vaginal deliveries, surgical site infection (SSI) and UTI after cesarean deliveries. We used a logistic regression modeling to estimate risk-adjusted HAI rates. The year of delivery was considered as a risk factor. The trend of risk-adjusted HAI rates over the study period was studied by a linear regression of the year-of-delivery odds ratios for each targeted HAI.
Results: The rate of endometritis and UTI after vaginal deliveries was 0.3% (534/161,077) and 0.5% (728/161,077) respectively. Over the study period the decrease in endometritis odd ratios was statistically significant. We found no statistically significant trend in vaginal delivery's UTI.
The rate of SSI and UTI after cesarean deliveries was 1.5% (571/37,074) and 1.8% (685/37,074) respectively. Over the study period the decrease in SSI and UTI odd ratios was statistically significant.
Conclusion: These findings highlight the positive effect of participating in a surveillance network for infection control and for improvement of care.-------------------------------------------------------------------------------------------------------
Does a Cesarean section delivery always cost more than a
Vahé A. Kazandjian PhD MPH,
C. Patrick Chaulk MD MPH,
Sam Ogunbo Ph
and Karol Wicker MHS
There is evidence that average total charges per episode of child birth depend on maternal plus child length of stay, neonatal intensive care unit (NICU) utilization, maternal race and mode of delivery. In particular, when maternal and child records are linked, this study suggests that when adjusted for maternal characteristics, the cost of vaginal deliveries followed by NICU utilization may be higher than the cost of Cesarean sections and NICU utilization.
Cesarean section, one of the most frequently performed surgical procedures on women, is rising globally and in the USA. Much of the current Cesarean section literature focuses on reporting geographic and hospital-specific variations, but little has been published about the clinical and demographic characteristics of the patients, and even less about the economic consequences of a Cesarean section delivery compared with a vaginal delivery [e.g. the total hospital charges and length of neonatal intensive care unit-NICU stay] of a birth episode. To examine these relationships further, three urban Baltimore hospitals volunteered in 2004 to participate in a retrospective chart review that linked mother and child hospital records.
1172 mother–child records were randomly selected and data regarding maternal co-morbidities, age, infant weight along with transfer to neonatal intensive care units, and economic data were extracted from the mother and child charts.
Average total charges for vaginal deliveries [maternal plus total baby charges that includes NICU utilization (X $17 624.38)] may be higher than average total charges
for Cesarean sections [maternal plus total baby charges that includes NICU utilization (X $13 805.47)]. Specifically, maternal race – being African American – was indirectly associated with overall charges through its association with mode of delivery and NICU utilization patterns. The presence of maternal co-morbidities – Herpes Simplex Virus, hypertension and diabetes – most probably influenced babies’ hospital stay charges as well as NICU charges when transferred to NICU following both vaginal and Cesarean section deliveries. Thus, prenatal care targeting co-morbidities management may reduce the odds of a newborn’s transfer to NICU thus avoiding greater lengths of stay, medical care and charges. Recommendations for obstetrical practices as well as health care policy on their charges should not assume that Cesarean section deliveries are always costlier than vaginal deliveries.
Obstetrical & Gynecological Survey.
55(8):476-477, August 2000.
Malouf, Andrew J.; Norton, Christine S.; Engel, Alexander F.; Nicholls, R. John; Kamm, Michael A.
As many as one-third of women suffer damage to the anterior part of the anal sphincter at the time of their first vaginal delivery, and perhaps a third of these have new bowel symptoms. This is one of the most common causes of fecal incontinence. This study examined the long-term outcome in 55 consecutive women who were followed for at least 5 years and for a median of 6.5 years after anterior overlapping anal sphincter repair. Thirty-two of them underwent repair shortly after delivery, and the other 23 underwent repair in middle age. Seven of the 46 evaluable patients (15 percent) had required additional surgery for fecal incontinence, and there was one outright failure. Of the remaining 38 patients, 27 (71 percent) reported improved bowel control, 23 of them by at least 50 percent when rating their symptoms on a scale of 0 to 10. Five others had not improved, and six reported that their condition had deteriorated. None of the patients were fully continent when last evaluated, but six had no fecal urgency, and eight were free of soiling. Twenty-five of the 38 patients found that their symptoms restricted their lifestyle to some extent. Patient self-ratings of improvement a median of 15 months after surgery predicted long-term outcome.
These findings suggest that the results of overlapping anal sphincter repair performed in women with obstetric damage deteriorate over time. Patients should know preoperatively that although they are likely to improve to some degree, perfect continence is rare and new evacuation problems are a possibility. Many of these patients will be satisfied by even slight improvement in their symptoms.
Taking The Shame Out Of Pudendal Neuralgia
Main Category: Women's Health /
Article Date: 23 Oct 2006 - 11:00 PDT
What could possibly be worse
than struggling with a painful condition and feeling ashamed to discuss the
problem because of its intimate nature? Such is the case for many suffering
with pudendal neuralgia, a little known disease that affects one of the most
sensitive areas of the body. This area is innervated by the pudendal nerve,
named after the Latin word for shame.
Due to the location of the discomfort combined with inadequate knowledge, some physicians make reference to the pain as psychological. But nothing could be further from the truth. Unfortunately, discussing the condition with gynecologists, urologists and neurologists often proves fruitless since most know nothing about the condition and therefore cannot diagnose it.
What is Pudendal Neuralgia?
Pudendal neuralgia is a chronic and painful condition that occurs in both men and women, although studies reveal that about two-thirds of those with the disease are women. The primary symptom is pain in the genitals or the anal-rectal area and the immense discomfort is usually worse when sitting. The pain tends to move around in the pelvic area and can occur on one or both sides of the body. Sufferers describe the pain as burning, knife-like or aching, stabbing, pinching, twisting and even numbness.
These symptoms are usually accompanied by urinary problems, bowel problems and sexual dysfunction. Because the pudendal nerve is responsible for sexual pleasure and is one of the primary nerves related to orgasm, sexual activity is extremely painful, if not impossible for many pudendalites. When this nerve becomes damaged, irritated, or entrapped, and pudendal neuralgia sets in, life loses most of its pleasure.
Where is the pudendal nerve?
It lies deep in the pelvis and follows a path that comes from the sacral area and later separates into three branches, one going to the anal-rectal area, one to the perineum, and one to the penis or clitoris. Since there are slight anatomic variations with each person, a patient's symptoms can depend on which of the branches are affected, although often all three branches are involved. The fact that the pudendal nerve carries sensory, motor, and autonomic signals adds to the variety of symptoms that can be exhibited.
Pudendal Neuralgia and Depression
One of the most common symptoms that accompanies pudendal neuralgia is severe depression. Some people with the disease have committed suicide due to the intractable pain. For that reason, it is important to consider antidepressants, as they can help lessen the hypersensitivity of the genital area in addition to relieving bladder problems. Certain anti-seizure drugs reportedly help to alleviate neuropathic pain while anti-anxiety drugs provide substantial relief of muscle spasms and assist with sleeping.
Uninformed physicians are reluctant to prescribe opiates for an illness that shows no visible abnormality, yet the desperate nature of genital nerve pain requires that opiates be prescribed for these patients. While medications are not always satisfactory, they do help take the edge off of the pain for many people. Until the correct treatment is determined, it is imperative that patients with pudendal neuralgia receive adequate pain management since the pain associated with this illness can be intense.
Treatment depends on the cause of distress to the nerve. When the cause is not obvious patients are advised to try the least invasive and least risky therapies initially.
-- Physical therapy that includes myofascial release and trigger point therapy internally through the vagina or rectum assists with relaxing of the pelvic floor, especially if pelvic floor dysfunction is the cause of nerve irritation. If no improvement is found after six to twelve sessions, nerve damage or nerve entrapment might be considered.
-- Botox is now used in medical settings to relax muscles and shows promise when injected into pelvic floor muscles; though finding a physician adept at this treatment is difficult.
-- Pudendal nerve blocks using a long-acting analgesic and a steroid can reduce the nerve inflammation and are usually given in a series of three injections four to six weeks apart.
-- If physical therapy, Botox, and nerve injections fail to provide adequate relief, some patients opt for pudendal nerve decompression surgery.
There are three published approaches to pudendal nerve decompression surgery but there is debate among members of the pudendal nerve entrapment community as to which approach is the best. Since there are advantages and disadvantages to each approach, patients face considerable confusion when deciding which type of surgery to choose. Because there are only a handful of surgeons in the world who perform these surgeries, most patients have to travel long distances for help. Moreover, the recovery period is often painful and takes anywhere from six months to several years since nerves heal very slowly. Unfortunately, early statistics indicate that only 60 to 80 percent of surgeries are successful in offering at least a 50 percent improvement. Patients whose surgeries are not successful or who do not wish to pursue surgery have the option of trying an intrathecal pain pump which delivers pain medication locally and helps to avoid some of the side effects of oral medications. Others pursue the option of a neurostimulator either to the sacral area or directly to the pudendal nerves. These are relatively new therapies for pudendal neuralgia so it is difficult to predict success rates. Some pudendalites have devised ingenious contraptions for pain relief ranging from u-shaped cushions cut from garden pads all the way to balloons filled with water, frozen, and inserted into the vagina. Most have a favorite cushion for sitting and many have special computer set-ups for home and office use in order to avoid sitting. Generally speaking, jeans are a no-no, so patients revise their wardrobes to include baggy pants and baggy underwear - if they are able to tolerate wearing underwear.
Clearly more research is required to find effective methods to better manage the pain and debilitation of pudendal neuralgia. But in the meantime, friends and family close to those who have this devastating illness play a huge role in helping patients cope, thereby maintaining the best quality of life possible. Support, love and understanding are of primary importance for those suffering with this affliction.
Written by: Ms. Violet Matthews
Ms. Violet Matthews has a Bachelor's degree in nursing and has been an active member of a Pudendal Neuralgia forum for 2 years. Having suffered with Pudendal Neuralgia, she has seen a 75% improvement in quality of life since her pudendal nerve decompression surgery in France two years ago. Married with two children, Ms. Matthews resides in Southwestern United States. You can usually find Violet at pudendal.info/phpBB2
American Journal of Obstetrics & Gynecology
May 2005, 192:5
Pudendal nerve stretch during vaginal birth: A 3D computer simulation
Objective: The purpose of this study was to determine the increase in pudendal nerve branch lengths using a 3D computer model of vaginal delivery.
Study design: The main inferior rectal and perineal branches of the pudendal nerve were dissected in 12 hemi-pelves from 6 adult female cadavers. Their 3D courses were digitized in the 4 specimens with the most characteristic nerve branching pattern, and the data were imported into a published 3D computer model of the pelvic floor. Each nerve branch was then represented by a stretchable cord with a fixation point at the ischial spine. The length change in each branch was then quantified as the fetal head descended through the pelvic floor. The maximum nerve strains ([final length minus original length/original length] x 100) were calculated for 5 degrees of perineal descent: reference descent from the literature, 1.25 cm and 2.5 cm caudal and cephalad. The effect of alternative fixation points on resultant nerve strain was also studied.
Results: The inferior rectal branch exhibited the maximum strain, 35%, and this strain varied by 15% from the scenario with the least perineal descent to that with the most perineal descent. The strain in the perineal nerve branch innervating the anal sphincter reached 33%, while the branches innervating the posterior labia and urethral sphincter reached values of 15% and 13%, respectively. The more proximal the nerve fixation point, the greater the nerve strain.
Conclusion: During the second stage: (1) nerves innervating the anal sphincter are stretched beyond the 15% strain threshold known to cause permanent damage in appendicular peripheral nerve, and (2) the degree of perineal descent is shown to influence pudendal nerve strain.
Foetal distress and birth interventions in children with developmental delay syndromes: A prospective controlled trial
Robin Pauc, and
aTinsley House Clinic, Main Road, East Boldre, Hampshire SO42 7WT, UK
bYeovil Chiropractic Clinic, 142 Sherborne Road, Yeovil, Somerset, UK
Received 6 October 2005; revised 23 July 2006; accepted 24 August 2006.
Objective To investigate the incidence of birth intervention/foetal distress in children with developmental delay syndromes (attention deficit disorder, attention deficit hyperactivity disorder, dyslexia, dyspraxia, obsessive compulsive disorder, Tourette's syndrome of childhood, autistic spectrum disorders).
Methodology A population of 100 children aged 4–15 years and diagnosed with developmental delay syndrome(s) were investigated using a parental questionnaire to determine whether they had suffered any birth interventions or distress. These results were compared with an age- and gender-matched control group.
Results On the basis of this relatively small study, significant risk of development delay syndrome(s) occurred with both foetal distress (p < 0.001) and Ventouse assisted delivery (p < 0.01).
Health visitors are now the health police - and the government's campaign to stop aggression against NHS staff is backfiring, says maternity pressure group
The witch hunt for potentially abusive parents is now dominating and distorting supportive services for parents, says maternity pressure group.
Health visitors, who used to take over where maternity care left off, are now visiting women if possible before the baby comes, and their first job is to question mothers to assess them to see how great a risk they may be to their babies. They are doing this secretly, without consent, and without telling mothers the real reason; they will say that it is to see if they will need extra help. What it usually meant is extra surveillance - and a risk-rating which will stay for ever on the child's and mother's record. They ask questions about past episodes of mental illness, how she got on with her own mother, domestic violence, and so on. This means that any subsequent accident or illness in the child may be seen as suspicious in mothers who get a high rating.
"This fits in with the whole pattern we are now seeing in child care" says Beverley Beech, Chair of AIMS, "Surveillance and suspecting parents - mostly mothers - has taken over from support which many first-time mothers need."
"The fact that health visitors have given in so easily to this, and are carrying out this secret surveillance makes us question what has happened to the ethics of the nursing profession."
Research has shown that the vast majority of parents labelled as high risk by this system will never abuse their children - and some parents labelled as low risk will.
There are parents who need more support, but all our evidence suggests that the real practical support isolated parents need is not there. Increasingly, health visitors simply report anyone with problems to social services - who also increasingly get care orders rather than providing real support. "And real support is what parents find supportive - not simply what a social worker thinks they should have. Increasingly we find what gets good marks from health visitors and social workers is passive compliance. But for someone coping as a single parent, or in difficult circumstances, a passive compliant parent may not be the best protection for children".
Parents are not obliged to use health visitors. They are entitled to refuse. But some parents who exercised their right to refuse were reported to social services as a potential risk to their children. "The whole of child care is becoming much more authoritarian in approach - and the sad result is that professionals are much less trusted." say Beverley Beech, and Jean Robinson, AIMS Hon. Research Officer.
Recent research has shown that mothers lie when they are asked questions about postnatal depression: they are afraid to tell the truth in case they are reported to social services and their babies are taken. So they are not getting help. (research details available from AIMS)