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Birth Trauma – a subjective experience by the woman giving birth, her partner or anyone witnessing the birth and believing the event to be traumatic. In the UK there are up to 20,000 women that are affected by birth trauma.  
That is 30% of all birthing women found some aspect of their birth traumatic. 3-4% of all birthing women go on to develop Post traumatic Stress Disorder (PTSD) and can be as high as 15.7 % in high risk groups (Grekin & O’Hara, 2014).  
 
Birth trauma is very distinct from Postnatal depression and the signs and symptoms vary between the two conditions.  
 
However, due to the lack of awareness of Birth Trauma many postnatal women are being misdiagnosed. 
Why Birth Trauma happens?  
 
What is the basic neuroscience explanation for the condition, and what is the difference between Postnatal Depression and Birth Trauma? Evidence-based and new emerging treatments available will also be discussed in this article. 
Historically Birth Trauma was not acknowledged until 2014, when the NICE guidelines included Birth Trauma and PTSD and advised on the management of the conditions. Since then the awareness of Birth Trauma is growing and Healthcare professionals are educating and training other healthcare workers to acknowledge this distressing condition. 
 
 
Why does Birth Trauma Occur? 
 
Birth Trauma occurs when the experience during the antenatal period, the birth or even in the postnatal period seems fearful or traumatising. For example some birthing women report an overwhelming feeling of imminent death if they were left alone in the birthing room while the over worked midwife went to acquire medicines for the woman or ran out to an emergency on the Labour ward to help. It is crucial to recognise that the experience is completely subjective (Betterbirths - Svanberg & Moore 2019). “What is important is how the mother perceives her delivery, not how clinicians would view it” (Prof. Cheryl Beck – 2005) 
 
Risk factors for developing Birth trauma include previous birth trauma, sexual abuse, high risk pregnancy – such as preeclampsia, preterm birth, stillbirth or medical complications (Ayers et al 2016). 
 
 
Neuroscience Explanation of Birth Trauma 
 
The following basic neuroscience explanation on how we process memories can explain why we develop traumatic experiences and why they can become clinically distressing. The brain has certain areas which are involved with the storage of memory and these include the hippocampus and the neocortex. These higher areas of the brain store and add a rational context to a memory. However, if a woman at the time of the event, feels she is losing control of the situation or is fearful for her life or there is an emergency involving the baby, a hormone known as ‘cortisol’ is increased in the woman. 
 
The cortisol inhibits the higher brain areas -hippocampus and neocorte. The primitive areas in the brain area known as the ‘amygdala’ takes over the processing of the experience. The amygdala is known to be involved with the ‘flight/fight/freeze’ response in the human. Unfortunately the amygdala provides a crude narrative to a situation making the individual feel as if they will die. If the memory is stored in the amygdala and not processed by the hippocampus once the arousel levels decrease after the event, it means any memory attached to the event may be triggering for and cause the woman to relive the distressing event. 
 
Unfortunately for the 30 % of women who develop birth trauma the hyperarousal levels never come down within a month of delivery. This can be due to being sensitised by well meaning debriefing or being reminded of the event due to triggers. This leaves the mother anxious, hyperaroused, having nightmares, and not being able to enjoy the precious moments with the new baby and partner. It can lead to difficulty with breastfeeding and avoidance by not socialising with other mothers for fear of having to relive the event by telling them the pregnancy and birth journey. 3-4% of birthing women develop into PTSD. Women in their 70s have still been affected by a traumatic birth as reported by Sheila Kitzinger (Birth Crisis 2006). 
 
Postnatal Depression .vs. Birth Trauma\ PTSD 
Healthcare professionals and GPs unfortunately may misdiagnose Birth Trauma as Postnatal Depression (PND). It is important to distinguish between the two conditions as the treatment for PND and Birth Trauma /PTSD is different. Identifying BT/PTSD can be difficult as depression can also be a symptom. Thus education and awareness about how to distinguish between the conditions with training in individual Maternity Services is vital. 
 
BT and PTSD criteria (DSM-V) is defined as the person has been exposed to life threatening event or to others and the response involved fear or helplessness. The traumatic event is persistently re-experienced by intrusive thoughts, nightmares or flashbacks. There is hyperarousal due to insomnia, irritability and difficulty concentrating. 
 
 
Management / Treatments 
 
The NICE guidelines recommend that people with PTSD should be offered trauma-focused psychological interventions. These include: 
1) Cognitive Behavioural Therapy (CBT) : 6-8 sessions which last about 90 minutes. 
2) Eye Movement Densensitisation and reprocessing (EMDR): 8-12 sessions – each session lasting 90 minutes. 
 
CBT is quite a well known psychological intervention involving altering thinking patterns and cognitive behaviours. EMDR is a non-invasive intervention for psychological trauma. A recent randomised controlled trial (RCT) of EMDR therapy showed it could be used during pregnancy for treating previous traumatic experiences (Zolghadr et al 2019). 
 
A very recent intervention also known as Birth Trauma Resolution Therapy (BTR) is also being introduced to many trusts in England. It involves using non-disclosure therapy to avoid re-living the event, and using the REWIND technique. It involves using breathing techniques and visualisation to reduce arousal and emotion connected to the traumatic event. This process thus allows the traumatic event to be processed by the higher brain areas – hippocampus and neocortex. Thus allowing the memory to be stored as a rational normal event and prevent anymore kind of distressing effect. 
 
These sessions can last for 60-90minutes, there are no RCTs at the moment. 
It is important if you are experiencing Birth Trauma or more long term PTSD symptoms to inform your healthcare professionals or GP. A referral can then be made within 2 weeks to see the Perinatal Mental Health teams at your Maternity unit or your local Improving Access to Psychological Therapy (IAPTs) service. Please take action and ask for help. 
Below are also organisations with more resources and information on Birth Trauma and PTSD, and where help can be obtained. 
 
 
Dr Saima Sharif, MBBS, MSc, BSc, Specialist Registrar Obstetrics & Gynaecology 
 
 
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