Taking a body-based approach to birth trauma support
Introduction
A body-based approach to birth trauma support is helpful and sometimes life-changing, but is not widely known about. Given that trauma does not happen independently from the body and the effects are frequently in evidence (e.g. tension, restless legs, racing heart, digestive problems, birth injuries, painful sex), it makes sense to include it in the healing journey. In this article, I want to explain how working directly with the body through trauma-informed yoga and somatic practices can provide an important route to wellness. I will also talk about supporting pregnancy and birth after trauma.
Invitation to be compassionate to yourself
For those who have experienced birth trauma or worked with people who have, some of the information in this article may be triggering. Please take a break whenever needed and think who you could talk to about difficult feelings. The article finishes with positive steps.
What is birth trauma?
The estimates for how many women experience birth trauma in the UK start from 30,000 a year (that is 4% of births) (Ref 1), but are likely to be much higher. During the pandemic, the prevalence of trauma has increased for a number of reasons, including partners not being there throughout labour for support and no or little access to the postnatal wards.(Ref 2) What is clear is that birth trauma is an issue affecting many women and their partners, and that it is increasing over time.
When many people think about trauma, they think about a life-changing event that has left a lasting effect on someone. Trauma with a capital ‘T’ if you like. Birth trauma includes traumatic events such as stillbirth or being frightened that the baby was going to die like the heartrate dipping leading to a caesarean birth. Or perhaps the mother or the baby sustaining an injury or having feelings of not being well cared for or even bullied.
Perinatal trauma
Perinatal trauma is a useful term because it includes the time from conception all the way through to the postnatal period. Sometimes it isn’t a one-off event that leads to trauma, but an on-going series of events through this period causing prolonged stress. For example, repeatedly not feeling listened to antenatally and the constant anxiety from that (not enough care) or going overdue and feeling pressurised multiple times into unwanted procedures (too much intervention). The important thing is how the individual experienced the situation as traumatic.
What makes birth trauma stand out is that the perinatal time is expected to be a joyful time and instead it has been overshadowed by negative feelings. Other people around the person may not understand this when the baby is healthy and expect the affected person to bounce back. Anniversaries of the trauma can be particularly difficult.
Post-traumatic stress disorder (PTSD)
Not all challenging perinatal experiences or difficult births will result in someone becoming traumatised. This might depend on factors such as whether timely support is given and previous mental health. If you have experienced previous depression or anxiety, you are at a higher risk of developing PTSD (Ref 3).
It is estimated that 25-30% of people who experience a traumatic event will go on to be diagnosed with PTSD (post-traumatic stress-disorder). Symptoms often develop quickly after the event, but sometimes there is a delay in the onset of symptoms or people suffer with considerable distress for a long time before seeking support. I have personally worked with people who only sought help for their birth trauma 10 years after it happened.
Can you get PTSD from a traumatic birth?
Yes. You’re more likely to develop PTSD if the trauma is unexpected, goes on for a long time, involved being (or feeling) trapped, is caused by people, involves a perceived threat to your life, causes mutilation to the body (which episiotomy may be experienced as) or involves children.
The PTSD could be caused by direct exposure to the stressor, witnessing the trauma (e.g. partners can sometimes be worse affected by birth trauma as they were fully aware of what was happening, without the effects of pain relief), or indirect exposure to trauma in the course of professional duties (also known as vicarious trauma e.g. midwives). Partner trauma is possible and can also lead to PTSD.
What are the signs of birth trauma PTSD?
Signs of PTSD include re-experiencing, avoidance, negative thoughts or feelings, and arousal and reactivity. An example of re-experiencing is that if the birth trauma occurred when the person was in a particular position (e.g. lying on the back with legs parted), flashbacks or upsetting memories may occur when in this position again (e.g. for sexual intimacy, cervical screening, movement classes). There may not be a conscious memory of being in this position, which can be very confusing when flashbacks, panic attacks or anxiety seem to appear out of nowhere.
Signs of avoidance may be not doing anything connected to the event, including talking or thinking about it. This may be include avoiding travelling to or past the hospital, so appointments for postnatal care or a future pregnancy would be problematic, as would having a Birth Reflections appointment there (yes it happens that appointments are in the same building!). One of the particular challenges of birth trauma is that the baby can be a continual reminder of the trauma.
Avoidance may be subconscious, and the person may have difficulties remembering the birth. Memories created during emotionally charged, traumatic experiences are stored in a part of the brain called the amygdala, which means that the emotions can resurface without context.(Ref 4) The hippocampus is normally involved in memory-making, helping us to know what happened when, but traumatic memories can be more fragmented, the order of things happening be confused and so cannot be recalled in the same way.
Can traumatic birth cause anxiety? Yes. Negative feelings can include anxiety, depression, and a belief of worthlessness with deep feelings of shame, guilt or failure. The symptoms of trauma may make relationships difficult and make it hard to connect with others. There may also be feelings that something terrible is going to happen to the baby and this makes it difficult to trust others to help care for the baby, or to leave home to attend baby groups and everyday activities.
Signs of arousal and reactivity is an indication that the sympathetic nervous system is high alert. Judith Herman, psychiatrist said ‘After a traumatic experience, the human system of self-preservation seems to go onto permanent alert, as if the danger might return at any moment’. This might look like irritability, insomnia, startling easily, startling awake, hypervigilance. All of this is very tiring to live with and effects the person’s immunity. One of the long-term side effects of trauma is an increased risk of autoimmune diseases due to increased inflammation from heightened stress. This is why it is important to seek support rather than putting up with the effects of trauma.
Treatment for birth trauma
Someone may not have received a diagnosis of PTSD or have enough of the symptoms to qualify but may still feel that something is wrong. Birth trauma counselling is available through the NHS but waiting times may vary depending on where you live. In some areas, people (including partners) can self-refer into the Talking Therapy service and are prioritised if recently postnatal. For PTSD in particular CBT (cognitive behavioural therapy) or EMDR (Eye Movement Desensitization and Reprocessing) therapy are recommended by the NHS. Private treatment is available also.
After a difficult birth or if someone is scared to give birth again in the UK, they might first book an appointment for a birth debrief. These services are run by senior midwives in the NHS and are free but may have long waiting lists. Locally, it is called the Birth Reflections service. It is an opportunity for the midwife to look at the hospital notes and explained what happened and in what order. This can be helpful, but it is an information-giving service rather than a therapeutic encounter. I have heard mixed experiences from people across the country, with some finding it cathartic to others feeling more traumatised because they felt that the health professional was defensive and didn’t aid reflection.
The emotional shock of birth trauma can be processed cognitively through talking therapies. However, we know that the ‘body keeps the score’ (the title of an excellent book by Van der Kolk) and the body plays a role in healing from trauma and returning to wellness.
How can you process birth trauma physically?
Van der Kolk has conducted a lot of research into PTSD and championed the use of yoga in trauma therapy. He said that ‘After trauma the world is experienced with a different nervous system. The survivor’s energy now becomes focused on suppressing inner chaos, at the expense of spontaneous involvement in their lives. These attempts to maintain control over unbearable physiological reactions can result in a whole range of physical symptoms, including chronic fatigue.’ (Ref 5)
Trauma-informed yoga is wonderful for working with the nervous system in a sensitive and collaborative way. Part of birth trauma resolution is rewiring the nervous system to not be on high alert all the time and to downregulate to a state of ‘alert relaxation’, which is where we want to spend most of our time. This happens through practicing being in the present moment through mindfulness and embodiment practice: noticing the physical sensations of simple movements and the breath. This facilitates emotional regulation too: Van der Kolk said, ‘It helps you to stop trying to ignore what is going on inside you… Trauma makes you feel as if you are stuck forever in a helpless state of horror. In yoga you learn that sensations rise to a peak and then fall’. (Ref 5)
How does yoga heal trauma?
Where Talking Therapies could be described as a top-down approach, yoga and somatic exercises are a bottom-up approach. Through different movements and practices, a feeling of safety (or at least soothing) is created in the body and this signals to the brain to switch from the sympathetic nervous system (SNS) (flight or fight) to the ventral vagal parasympathetic nervous system (PNS).
Sometimes I ask clients if there is a safe space in the body we can return to (often the feet) and they say, ‘No, there is no safe space’. The shutdown/ freeze response from trauma creates a stillness (to play dead) that can lead to dissociation. The inability to move and feeling disconnected from your own body can be very frightening and may lead to a feeling that the body is untrustworthy and unsafe, even if the freeze response resulted from the body trying to protect itself.
It is one thing to understand this cognitively and another to have an embodied experience of the contradiction. Simple yoga movements can support the experience of moving gently back and forth between the body as an uncomfortable place to be (maybe the norm for someone who has experienced trauma) and the body as an ok place to be.
In flight or fight?
The high surge of energy of the flight/fight mode and dampening of the higher cognitive faculties (resolution/ negotiation skills, analysis etc) can feel like being out of control and be equally frightening. Stephen Porges, in his Polyvagal Theory, talks about predictable pathways of response through these nervous system states. After trauma it may become the norm to cycle between the dorsal vagal PNS (freeze state) and the SNS. The state of alert relaxation in the ventral vagal PNS is where we want to spend most of our time as humans and we can achieve this through movement, self-touch, sound and breath that affect the vagal nerve.
Judith Herman said, ‘Recovery can take place only within the context of relationships; it cannot occur in isolation’. This is key in birth trauma and anxiety. The trauma has usually happened with other people around and with feelings of not being in control (or feeling trapped) or not being listened to. Healing takes place in a therapeutic relationship where a feeling of trust is created and the trauma informed teacher gives choices and decision-making to the client.
This is modelled throughout the session. For example, “Where would you like to be in the room?”, “We could start in this position or that position…”, “You could do smaller or bigger movements”, “You decide whether to have your eyes open or closed”, or “You don’t have to stay in the movement or position – you can move out of it at any time or tell me you’ve had enough or it doesn’t feel good/right/comfortable”. The sessions are collaborative because what may be helpful to one person with perinatal trauma may not be beneficial for another.
Why birth trauma matters
I remember at the end of a Mother and Baby Yoga class, a mum once shared with me that she had found both of her emergency caesareans traumatic, but that she was done having children and was going to put these experiences in a box. While this is one way of managing trauma, these experiences lodge in the body. It may be possible to carry on with life until other stressors are added, like work stress, caring for elderly parents or illness. From the clients I’ve worked with it seems that it takes less to push them into overwhelm if the birth trauma has not been resolved. Not forgotten, but resolved to a point that it doesn’t take its toll on the nervous system.
In the birth trauma sessions I offer, we practice something called Embodied Listening. Gene Gendlin who was a psychotherapist wondered why some of his clients would get better and others wouldn’t. (Ref 6) Through extensive research, he realised that those that used interoception – the ability to describe what they could feel in their bodies – were the ones that were successful in therapy. Interoception includes things like feeling butterflies in your tummy when you have a job interview, feeling that your heart is broken, your throat being in knots when you don’t know how to say something difficult.
Often, after trauma, people’s instincts are to not listen to or feel the sensations in the body. It’s a protective mechanism to prevent you becoming overwhelmed. However, when it’s safe to do so (and with someone to guide you if needed), listening can be the first step in healing. Being able to witness what’s there can be a big relief and enables compassion towards oneself. The simple, gentle yoga movements before listening help to soothe the rawness of emotions to be able to start the listening process.
Sometimes, consciously or subconsciously, people feel that the trauma was somehow their fault. When you start listening to the body you realise it wasn’t.
Birth trauma should be screened for as part of the 6-8 week check-up with the GP and 9 month health check with the health visitor. Often the trauma can be pushed to the side because of the demands of looking after a newborn baby, unless the symptoms are severe enough that the mum can’t function due to mental illness. By putting the mother’s experience of birthing centre place, I believe many more could get the support they need faster.
Pregnancy and birth after trauma
After a traumatic or challenging birth, the prospect of pregnancy and birth can be incredibly daunting. Ideally, people would have access to support before the next pregnancy and birth. However, I have supported many people during a subsequent pregnancy to have different tools they can use to manage their anxiety and other emotions.
Again, using an embodied approach can be hugely helpful. Using simple movements in Yoga for Trauma to soothe the nervous system can make the body a more comfortable place to be. For some people, visualisations can provide a different way to experience the body and manage the effects of previous trauma, such as the difficulty of milestones like the number of weeks when a baby was born prematurely or very sadly when a baby died.
Most parents in this situation would be on a special care pathway through their hospital, with additional appointments. Discussions about birth choices should be put into writing and added to their maternity notes so that anyone taking a part in their care do not have to ask for the story of the trauma to be repeated and can be sensitive to what would ease the journey with this pregnancy and birth.
Working with a hypnotherapist has helped some of my clients to overcome their fear of birthing and EMDR has supported others to process previous trauma. Reflexology with someone who specialises in pregnancy can provide mental and physical relief, and time to switch off. Often a multi-pronged approach provides the best support.
I recommend working with a trauma-informed yoga teacher like myself. However, any movement that you enjoy is so valuable in providing space away from all the thoughts, soothing the nervous system and releasing endorphins through exercising (there is lots of good quality research evidence on the effect of exercise on mental health – Ref 7). This might be walking, swimming, a yoga YouTube video, or gardening for example. If you find it difficult to find the motivation to move, buddy up with someone and make a regular time that you will go out for a walk with the buggy or sling.
Conclusion – Healing from birth trauma
The first step I think is to acknowledge an individual’s experience. After eight years of running a women’s circle and supporting those with perinatal trauma, I have seen again and again the power of fully listening to someone and witnessing what happened to them.
This is where Birth Reflection services can fall short of people’s expectations – parents might expect an opportunity to share their experience and reflect on it with someone understanding in a safe space, but if that person is a midwife, they are likely to be conflicted by their role as a representative of the hospital.
The second step is to develop a trusting relationship with someone who can keep listening and witnessing. Sometimes people who’ve experienced trauma feel that they can’t keep talking about it with friends or family. Sometimes others expect them to feel a certain way, like they should feel positive about another pregnancy when actually they feel conflicted, or that they should have put it behind them by now.
The third step, which is often neglected, is to involve the body in the healing process. Until we establish a feeling of safety in the body and finish the stress cycle started by the traumatic event(s), the effects are likely to keep showing up.
I am always incredibly honoured to be part of someone’s healing journey. Such courage is needed to take those first steps and keep going when there’s a setback, but it’s always worth it.
References
1. https://www.birthtraumaassociation.org.uk/
2. Amy Brown. 2021. Covid babies. How pandemic health measures undermined pregnancy, birth and early parenting. Pinter & Martin.
4. https://www.nicabm.com/trauma-how-trauma-can-impact-4-types-of-memory-infographic/
5. Bessel Van der Kolk. 2014. The body keeps the score. Brain, mind and body in the healing of trauma. Penguin books.