Trauma-Informed Birth Care #025

In birth care we have the opportunity to support someone through one of their most transformative life experiences. It is our responsibility to create trauma-informed spaces for everyone in our care. 

We are discussing how and when we became aware of trauma-informed practices, the different types of trauma we encounter, specific steps we take in our care practices to reduce trauma, and our goals moving forward to create a perinatal healthcare system where trauma experiences are rare, rather than present in 1/3 births.

Transcript

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Maggie, RNC-OB  0:05  
Welcome to Your BIRTH Partners, we're here to break down barriers and cultivate community as we discuss issues that impact pregnancy, birth and postpartum. We welcome you no matter what your background is, and are so excited to learn together. So today, we have the whole original podcast crew on to talk about something that's really important, trauma informed care. And this is so important, and so deep, that we certainly are not going to hit on all of the elements of it in this 30 minute podcast. However, we thought it was worthwhile, that we speak a little bit about how becoming trauma informed has impacted our practice, both in the you know, individual moments that we have with those in our care, how we approach certain situations, and also how it has changed our outlook on what has up till now dominated a typical birth care, especially in the hospital.  And so we really want to see a moving away from a standard of care that makes birth in some ways seem matter of fact, and something that has to just be rushed and pushed up along. And that we don't actually have time to address and care for the person who is in our care. And that is something that absolutely needs to change. So I welcome you into this conversation. On to the show! 

We are going to dive into another big topic here. And that is trauma informed care. And this really, as we were talking about, you know, different ideas for topics, these last few episodes of the season, Abby had mentioned how like this is, you know, we could spend hours talking about this. And I think one of the things that sometimes gets in our way is that, you know, perfection being the enemy of the good. So trauma informed care is it's big it is, you know, it's immense. And I think one of the things that I have realized is that when I was going through nursing school and learning more about birth care, I was kind of coming up as this idea that like some people are, you know, going to have trauma in their backgrounds, we need to be extra sensitive to that. But the impression that I was given or that I received was that this is like a small portion of the population that we need to be like more sensitive to. And I think what I have seen, and as I've, you know, gone through my practice is that, like, trauma affects almost everyone. And it lives in the body. And then as we are making our way through pregnancy and birth, and just this really intense period in our lives like it is going to come up and it's sometimes unexpectedly for everyone involved. And so I want us to just have a chance to kind of dig into when did you all pick up on the idea of really having like trauma informed care as part of what you do.

Ray, CPM  2:57  
I think one of the main reasons I chose to train as a CPM outside the hospital system was because of trauma I witnessed in the hospital setting. And I couldn't imagine becoming the midwife they wanted to be in, in that environment. Yeah, with training, kind of maybe without autonomy, or with a lot of norms that felt really uncomfortable to me, just assumptions about consent isn't a given in the hospital setting, and I was like  I needed to train outside of that system in order to be the kind of care provider I wanted. And I'd seen some really hard and scary things as a doula that made me feel like it would be impossible to be in a hospital setting. And I think when I was like, when I was doing my training, it was really, like, very difficult for me to realize that I was going to cause harm as a provider, you know, I was like, I'm going to do this big thing in the most perfect possible way, and then everyone's going to be safe and happy. And that's not true. You know, I like to kind of sometimes tell people like I have like a toolbox of like, really shitty skills, you know, that are like incredibly painful and life saving. And don't involve, like a ton of consent. Like, we're like, there's a consent in this relationship, like you've chosen to hire me to keep you safe. But like, does that mean you hired me to do a manual removal? Yes. But will it be awful in the moment like, yes.  And I think realizing the negative impact I could have on people and how powerless I was over that was really devastating to me. And, you know, I've been in practice now for like four years and have a lot more quoting than I did when I first started and feel less scared of that than when I first started.  But it's, it's challenging. I mean, I think like, I really like that within you know, home birth midwifery care, like consent, and like informed decision making is the foundation so there's a lot in the model that prevents harm, you know, in that, like I ask before I touch people every single time I do it. Informed consent for, like things that happen during birth, like in pregnancy. You know, there's, people really get very clear and like how I like learn and how I provide care before it comes to birth. So a lot of things are in Yeah, aren't surprised. And also, like when I talk about, like, how I manage complications and how I transfer, you know, so even if, like, they're not like, these are not necessary scenarios people expect, there's like a lot of trust in the relationship and how I'm keeping people safe. And I like to think that it's protective, but it's not always, you know, I think my partner...I feel like I'm going off topic, but I went to birth, you know, yesterday, and, you know, I got to my client's home, and like, I can't do this, this is awful. And I was like, "Ah, yes, looks good." And you know, had a baby two hours later. And my partner when I got home was just like, "how do you know when someone's saying that, and, like, it's okay," and I was just like, "it just sounds different." But, you know, that's like an assumption that, I make that like, I'm just like, "there's like normal labor sounds, and then there's like suffering and they sound different." But, you know, that doesn't mean that like, I'm gonna make assumptions about how, you know, like, what people want and how they're going to be cared for, and like, I'm going to get it wrong sometimes. And that can be really traumatic.

Pansay, Doula  6:15  
I do remember very well, at the early stages of my doula work, and being in the hospital setting. And at that time, really feeling that it really wasn't, you know, that this is the way it was going to be done. Right, you know, here. But once I was able to experience and participate in several, you know, home births, and look at it, you know, being untouched and, you know, respected and honored, celebrate all those things, it's very hard for me to hold back to the hospital, because that just became, it just felt barbaric, you know, to me, but it was at that time that I knew that I had to change, you know, and make make a difference in my practice, as far as informing the client of what happens, what really happens when you are there, and how to prepare and fight, you know, for their rights and protect themselves. So that was the shift I often really believed, like, all doulas should support just the one homebirth just, you know, just one, because it, it really connects what we hear about as far as the naturalness, you know, of birth, and how the client is really in control, really honored, really respected here, so that that's when the shift took place for me. 

Abby, MD  7:39  
In thinking about trauma and birth. You know, it's interesting there, it's a big category, there are a lot of different categories, you know, things that one thinks about my background, before medicine was as a rape and sexual assault counselor, like that's what I did first. And I feel like there's always been a subset of patients that are coming into birth, with actual traumatic experiences, or traumatic medical experiences that are really going to shape the way that they do when they when they have their baby. And then there are the traumatic births, which were the unexpected births. You know, we have the births, where things are supposed to be going right. And then suddenly, very quickly, they aren't.  I think the more nuanced thing is the whole middle spectrum of that. And it's been interesting being in a hospital setting my whole career and seeing in the past couple years, a real attention suddenly towards consent in birthing trauma informed birthing like these are these are terms that I feel like ob gyn hadn't heard a couple years ago. And it's funny because now I'm seeing on some of the OB GYN sort of like social media that I follow and the like people using these terms and thinking about this and thinking about consent and birthing. It's interesting, because I think what's spearheaded a lot of this, unfortunately, is this phenomenon where as a society, we've created this thing where people want perfect birth, and have expectations about their birth. And then when that isn't what happens, there's a lot of disappointment and people walk away from that really upset. For me, though, that can be problematic. But the movement of really making sure that nothing is done in a hospital setting without consent, and without sort of a partnered relationship between the provider and the patient and without sort of compassionate delivery of information. That that's the part of this that I think a we can be doing better, but we are starting to do better.

Angela, CNM  9:36  
I was reading an article just a few days ago, and it was talking about how we respect women, when we are providing care for them. And the one thing that stood out to me and actually I remember just learning this being told this when I was in nursing school, I was 19 years old and one of the instructors always said, :whenever you are, you know, greeting a patient, do not greet them for the first time undressed" and that always stayed with me. And I was like, "well, yeah, that makes sense." You know? Like, she doesn't know me, why would I make her be undress before she ever even gets to move me.  What a vulnerable and uncomfortable thing for her. And then, you know, a week ago, here's 20 years later, I'm reading this article about how we should assume trauma. As providers, as clinicians, we should assume trauma in every single patient. And it does not matter even now I see 30 patients in my outpatient clinic some days, not a single one of them is undress before I go into the room, not a single one of them, I do not like it, it's a very vulnerable thing to ask a woman that you've never met before, to sit on your exam table, covered in pieces of paper, while you talk to her, and try to get into her history and get to know her before the exam. And so I think that is me certainly is hard to move from that, you know, you know, my physician counterparts, they sometimes have 35 patients in their clinic, and they have 10 minute appointments, and it's double booked. And unfortunately, the business of women's health care of medicine in general, does not accommodate for us, always delivering trauma informed care, and assume and trauma in people it is around, getting the patients in now. generate those RV use, otherwise your pay is impacted. And it's unfortunate, but it's still we have to make it a priority. We have to make it a priority. To be consciously aware of those things and knowing that we do not know anyone's background. And I even go as far as always asking the women if they would like a chaperone in the space with me because I just I refuse to assume I refuse to assume that she's going to be 100% comfortable with it just being me and her because I don't know what her story is or her history,

Ray, CPM  12:28  
I guess in home birth that's really one of the benefits of being like outside the insurance system like a lot a lot of drawbacks, but because I'm not I don't have to meet the same numbers like slowing down is a given you know when, like yes to never meeting someone without clothes on. But also like if someone is due for a pap smear when I start caring for them, like I just defer until the second appointment, because four weeks or eight weeks with a pap smear is like not the end of the world and having more relationship before I'm like in someone genitals is a big deal. And I can like have a conversation about how have you dealt with speculum exams? Like, is there anything that makes them better? You know the last few IUIs I did, I'm like, "do you want to insert the speculum yourself or me?" People are perfectly capable of inserting a speculum themself. And it's just trying to, you know, there's like, even I think with things that have to go quicker. There's always ways to build in consent an agency, I think what I have to interact with larger health systems, I'm just always aware of just that it's like not a part of like, it's not central to training. So then it's like something that's often learned after the fact versus like, in community with midwifery care, like consent is really central. And it just assumes that trauma history. I think, for me, like trauma informed care is like really parallel to trans care. It's just not assuming people are doing okay in their body. And if that's the case, like how do you slow down to create safety, even, you know, like, I can't control if someone has a trauma history, and it comes up, but it can, you know, be consistently respectful. And that does make a big difference.

Abby, MD  14:01  
I think in addition to slowing down to make sure the consent process happens, and important part of this, to me too, is just creating a situation where the patient has a sense of control, because I think that as long as we're partners in whatever's about to happen next, and as long as the patient feels like they're in control, I think that changes the dynamic in a healthier, healthier way. I struggle with how to provide, you know, efficient care and also feel like I'm always you know, asking for consent, allowing a patient to feel in control, providing compassionate care. But I think there are just very little subtle tweaks that you can do that completely changed a patient's perception and experience and change the dynamic.

Maggie, RNC-OB  14:47  
I totally agree with you. I think it's sad. It's such an indictment of our healthcare system that you know, as Ray and Pansay were talking about this feeling that you need to be outside of the hospital environment to be able to get that like that is problem with the system in which we're operating that it is so hard to get enough time to, to actually ask someone for consent to let the person and care actually dictate what goes on. Right now, you know, the research shows that about one in three people feel like their birth was traumatic, which is devastating. And at the same time, I was having conversation with someone who is not in the birth field and has not given birth earlier this week and talking about this about how just kind of some of the stats around where our perinatal healthcare system is at. And they responded when I said, you know, one of three people think their birth is traumatic, and they just were like, "Well, of course, birth is traumatic, like you're having you're going through this like experience, and there's like a baby coming out of your body and you don't get to you don't get it, you don't know what's going to happen. Like you're totally out of control, like how would it not be traumatic for everyone?"  And I just thought, like, how, how sad that is that as a society, we have normalized, that idea that birth is that it is just going to be hard and traumatic. Think that, like we said, assuming trauma, assuming that everyone has a history, whether they have disclosed it or not, I think especially in my role, as you know, as labor delivery nurse, I often, you know, compared to you all, who luckily get to hopefully see people in clinic beforehand, you developed a relationship with them before it's time for birth, I'm usually meeting people for the first time unless I've seen them, you know, for a triage visit, like, "oh, you're here to have the baby, let's do it." So there's a very, very small window in which to really establish a rapport and to get to know understand people. And it is very hard, especially someone comes I'm in labor, to then go through this whole history with them and sort of dive into all of these issues. And so I really have found that for, for me, what has been helpful is just assuming, if it is not been disclosed to me in their chart, or by them, I am assuming that they have a history of trauma, I am assuming that they are not comfortable with random people, me just coming in and putting my hand inside of them like I am assuming that all of those are going to be really difficult feelings for them and then navigating it as such. And that's been something that I feel like change. I think when I first started out as a labor and delivery nurse, I was kind of taught the idea that like you just kind of you roll in and you say like, "Hey, this is what we're doing. Let's get to it, doot doot doot doot doot." And I look back on those. And I just realize like, Oh, my gosh, I am certain that I made people really uncomfortable. And that I did cause harm doing that, because I wasn't being aware enough.  You know, around cervical checks. I've really changed my practice around that. And I also think I've changed my mindset about how important that piece of information is to care that if it's not, you know, if it's not going smoothly, if there is discomfort or pain that there is always time to great, we're not going to do this right now.  Let's circle back around. Let's think if this does this really matter right now, like do we even really need this information? That that is one thing that like I had a light bulb moment about, but I'm wondering like, what are some of the things that you've realized I know, they're relatively easy steps that you've taken to kind of create space for trauma informed care?

Angela, CNM  18:15  
I will say some of the things and I don't know, I've always done this. But I'm even more conscientious of it now. I mean, I literally ask permission. Before I do everything, I go into space and my patient is clothed, I go through a history and i ask "is it okay? If we do a breast exam? Is it okay, if we do a pelvic exam? Your pap smear is due." like I ask permission before we do the exam and I talk about what those things means and what's going to happen and I, especially my young women who've never had a pelvic exam before we talk to those things. And it goes I mean, even though I've gone through that process when I come into the room, asking if it's okay for me to enter, I ask them or let them know "Hey, now I'm going to lower the drape. Now I'm going to touch you you feel my hand touch you now I'm gonna make room insert my speculum, please let me know if this is uncomfortable" and I am constantly making sure that they're okay. And if at any time, they are jumpy or uncomfortable, we just stopped the exam. I cover them up, we take a moment to breathe. Like it takes no additional time. Like you know, I'm talking through all the steps that I go through. But it's not like it prolongs my clinic appointments. You know, I'm still in and out of there as quickly as I need to be. And I never leave work past the time I'm supposed to I'm always added their own time. It's just taking the moment to just listen, listen and be conscious and be aware because we all know what it's like to meet a complete stranger and have to be naked. And, you know, God forbid, have to put our legs or feet in stirrups. No offense to anybody who uses stirrups, I just do not like them at all. It's a vulnerable thing. You're so insecure and self conscious. And so you just have to ask, even in a hospital setting, I was always Okay. Is it okay? If I do a cervical exam? Are you okay? If I do this, and I never ever, ever, like pull the sheets up, because I can't see in there anyway, it is just lift the sheets just enough so I can put my fingers where they need to go so that I can complete the exam. That is it.

Abby, MD  19:07  
I think all of those things are things I try to do in practice. I also I really like the question, "What are you expecting to happen today? Like what was you know, what was your expectation of what we were doing at today's visit?" And I also always, before I do an exam, I always say if you're uncomfortable, please let me know if you need me to adjust if you need me to stop if you need a moment. And then beyond that, I think the other really important thing is just watching somebody's body language and paying attention and watch my residents check somebody's cervix and not look at their face, you should always be looking and paying attention to body language and picking up on on the subtle cues that patients give if they're uncomfortable. And if you notice that, it's never the easy thing to do, especially if we are rushed, you need to stop and you need to address it and make sure that patients Okay.  None of these things that you just mentioned, or that I mentioned, take a lot of time.

Pansay, Doula  21:31  
Let me say, the first thing when I think about trauma, you know, especially with myself and a lot of my clients, black women, our trauma is so deep. And a lot of it is generational. When you think about how mothers are going to birth, the stories that we hear is not give us the easy transition when we start having our own children. So I consider every client, just like you all said that their traumas probably similar to mine, and seeing how OBs and midwife at home and hospital, yes, home birth, you do have more time, you know, with them. But it's a different setting to really be able to dig deep for them to uncover and you know, really get into the past trauma, and how they feel now about this sacred, beautiful experience that has been just covered with fear about what's going to happen. So with every client, I feel that it's my job to provide a safe, sacred space to help them kind of strip down the layers and look at what happened. how, you know, how can we help. And that opens a gateway for what's to come if we're in this, what's happening now. And I find that with every woman that if you deal with trauma, it makes them stronger, and help them be able to find their voice to speak up. You know, to watch what's going on now to be able to say I don't feel comfortable. Now, can we talk about this? Let me talk to my husband about it. But we would go into our pregnancies, feeling defeat questions, and we kind of just let things happen thinking that it has to be that with pregnancy. It's a it's a mind body and spiritual experience. So what it has to be dealt with as a whole going to the hospital as two separate things. So I've seen a complete shift that you know, dealing with clients, tending to the mind, spirit, I mean spending, sometimes it a consultation or a prenatal visit, supposed to be an hour and three hours have gone by where they are just talking and releasing; it happens so much my birth outcome has been significant. How we built their confidence, you know, to talk to the providers. "I don't feel comfortable, you know, with this, no, I don't want to do with you do this. Let me try. Let me find a waiver. Because this is not what I want to do." But it has to start, you know, taking taking care of the whole woman. It cannot be separated, dealing with the trauma of the past trauma from previous births, whether or not childhood, you know, trauma, trauma that's embedded in our DNA generationally. Right it has us feeling so defeated. With Sacred Butterfly Births, we deal with the whole woman, one woman at a time, and help her to release and heal from that trauma, which helps her to be stronger. And to walk into this pregnancy, I can't speak up and say that this is uncomfortable. This is not you know, what I want to happen, but really helping them find their voice. That that's my part. And because I feel like though I don't have too much, you know, control in a hospital setting about what what's waiting for us, right? So what what what I do have control and what what kind of what I can help with, is with the client and helping her find her voice and knowing that, yes, she has a choice. And yes, you have say so. And yes, you can decline anything and you should be respected. It's your right. And that you're not just the number that you will person. And this is a spiritual experience that should be honored and respected.

Ray, CPM  26:04  
I so agree with everything that everyone has said. And I think the thing that keeps coming to mind for me is like preventing birth trauma has also has to do with prenatal and postpartum care. You know, like prenatal care, for me is about helping people like teach people how to parent by teaching, like by through informed consent, you know, by actually, you know, like, let's say with something like group beta strep or GBS, like talking about what the risk of a GBS infection is on a baby, what how that would be dealt with the risk of death and a newborn, if you decline antibiotics. And then if someone chooses to decline, let's say screening or antibiotics, talking about like, this is how I'm going to manage things differently. These are all the ways I'm more likely to transfer your baby, are we on the same page that you still want to decline this, okay. And then just respecting that choice, and then carrying out different management, if I you know, can't rule out a GBS infection, or the water has been broken for a certain period of time, you know, all of that. So there's like a part of like, informed consent and refusal and respecting that. And then, you know, in the birth process, I think, you know, I've definitely, like, have been through a lot of intense situations with people that you know, and that could be traumatic, and a lot of ways and sometimes are, but there's a really big difference if you understand what's happening to your body, and like, feel a part of the decision making during it. So like, when I've had clients that, let's say, transferred for, like a baby that's in a stuck position, and, you know, labor's not progressing, and we go through a lot of interventions in the hospital, and they don't work. You know, before COVID, I would go with folks and like, could help with decision making and help under, like, you know, from a trusted source being like, this is what I'm thinking, like, this is why I think pitocin is your best shot, or like these other tools we have left, but we're running out of tools, you know, so even if like the opposite, you know, of the plan, like a C section happens, they're like, yeah, that made the most sense for this birth, even if I'm like sad or angry or disappointed, like knowing what's happening in your body and feeling like you have a care partnership, maybe makes a really big difference during the birth of love. The other part is the postpartum like having, you know, a very different experience than what you expect to happen in your body having like, big, you know, trauma stuff comes up during birth, because that stuff. And it could be simple as someone touching your leg, you know, it doesn't have to be like these invasive things that we also do. But having somebody like, you know, for me, it's like, you know, being able to process the birth and then having adequate support to like, get through a lot of the early postpartum transitions, which, you know, like having a baby is a little bit like getting hit by a truck. So, you know, like, if someone's like they're in like in your corner, both for processing and then to help you get out of pain and like get your body more healed and like help adjust to baby, then you're not like left with this raw experience with like, no support. And so, you know, like in the US are really failing for family postpartum care. And, you know, I wonder if these numbers would look different if like, we had like visiting nurses going to people's houses twice a week, the first like three or four weeks, you know, in Germany, a midwife comes to your house every day for the first month and I was once hired by someone who was working from Germany and they were like, what I need to cover a lot because they're insurance from Germany cover that I was like, I literally don't even know what it would do every day when someone's you know, house like how, like, but how well do they set people up for like success when they just having support and hearing someone to answer your questions and or troubleshoot your hemorrhoids is just a part of it.

Abby, MD  29:31  
I don't mean to change this up to I'm listening to this conversation and thinking about how as a hospital provider, who is part of this history of providers who have provided sometimes very unacceptable, dangerous dramatic care to patients, how can I be coming from that history? And how can I become a person that patients can trust You know, I'm grateful for the skills I have when birth really does become traumatic. And you know, I'm the one that ends up doing the C section when things are really wrong or dealing with a postpartum hemorrhage or dealing with these really quick emergent situations, how can I provide that care, but also distance myself from a history of physicians who have done harm to women? And get patients to trust me? I don't know that there's an easy answer. I feel like there are a lot of themes, what you were talking about with postpartum, you know, education and Pansay, what you were talking about with the education and empowering women during birth, that needs to happen. I feel like in a busy practice, we don't always have time to do that. So we need to use our resources, we need to use our, you know, support people, our doulas, our educators, and really come up with a system where we can all help really get patients to their best possible place, going into a birth with the best set of expectations about what that birth may or may not look like. And then help them walk away from that feeling like they were in control and cared for while and treated, you know, safely and compassionately.

Maggie, RNC-OB  31:16  
I mean, obviously this is my vision. And that's like, why I love having these conversations with all of you, and all the different roles and life experiences that we represent. Because I feel like that is that is what we need, like, our system needs a whole reboot, so that we can actually have people best supported in the way they need by the people who have spent their life learning how to give that care. Well, like we all can't do that, necessarily. We all care for people very differently. And that's great, because people need us all to be very different kinds of providers and different situations. And, you know, just like Pansay was saying about, you know, the intergenerational trauma that is part of our world here in the US because of systemic racism, that is something that I can be aware of in a more more academic level, or, you know, a more mental level, but it is not something that I have experienced as a white woman. And so I am going to connect with those people differently. And so I think with all of this is that moment, again, for us to balance out what are the systemic responsibilities, and the things we can change on that bigger level? And where do we find the personal responsibility for our individual actions and how we can change the tide, one person at a time. In particular, there are some wonderful birth professionals out there who offer trainings around trauma informed care. In particular, the Birth and Trauma Support Center run by Krysta Dancy has a wealth of information on this topic for how you can, you know, change your practice to be more in tune to the way trauma affects all of us. And as we've highlighted in this episode, in different ways, because it's not the same trauma for each person, it's not going to have the same, you know, impact on their birth and on their experience, but it's all things that we need to be more aware of. So I've taken some wonderful training through there that have really helped open my eyes. I particularly enjoyed trainings from Dr. Sayida Peprah, who is a psychologist and a doula and does a lot of work around intergenerational trauma in the Black community. I have really enjoyed trainings from Mandy Irby who speaks particularly to nurses and other birth pros about how to prevent trauma in hospital setting. I also had the pleasure of doing one recently with Eri GuajardaoJohnson, about trauma informed care for survivors of sexual assault, and that was very powerful, and I'll link all of these folks and their trainings in the show notes, so you can find them easily. But I do feel like this is our opportunity to, you know, reflect on our own practices and what we're doing now. And take a moment to see how we can model for everyone else in the system, ways to change the cycle of trauma being so prevalent in birth, and create a different future for it. So, thank you all so much for having this challenging conversation with me.  I appreciate you.

Thanks for tuning in. We love to talk birth and would love to talk with you. Please join the conversation by finding us on Facebook, Instagram, or Twitter, we're Your BIRTH Partners on all platforms. And we welcome you especially to join our new Facebook group, so there we are Your BIRTH Partners community. And there we have an opportunity to dig more deeply into these conversations we have on the podcast and learn more from each other as we apply these out there into the real world of birth care. So we look forward to seeing you there. You'll be able to find on our show notes, links to some of the trainings that I mentioned that have been really helpful for me growing as a trauma informed professional, and we look forward to hearing from you about what has helped you on this journey. Till next time!