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Treating Postpartum Depression
Postpartum Depression: Diagnosis and Treatment

Section 11
PTSD in Pregnancy and Childbirth

CEU Question 11 | CEU Test | Table of Contents | Depression
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

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In the last section, we discussed obsessive-compulsive disorder.  This included prenatal and postpartum OCD and preventing potential dangers of prenatal and postpartum OCD.

Do you have a client whose childbirth or pregnancy brings up traumatic memories for her? 

In this section, we will discuss Post-Traumatic Stress Disorder and Postpartum.  This will include PTSD and pregnancy and childbirth and PTSD.  If you are already familiar with PTSD and its symptoms, you might use this as a review.

If fear and embarrassment are two factors contributing to women’s reluctance to confide their symptoms of OCD to their doctors, the fear created from a third form of anxiety, post-traumatic stress disorder, or PTSD, can be even more isolating and distressing.  As you may know, PTSD is characterized by the intrusive re-experiencing of a past traumatic event, avoiding close connections with family and friends, emotional numbing, and finally, chronic hyper-arousal.

Intrusive symptoms generally involve terrible nightmares or sudden, painful flashbacks that are sometimes so vivid the person actually feels that he or she is going through the trauma again.  In order not to relive that pain, the person with PTSD may become emotionally numb, go about daily life in a dull, mechanical way, become more and more isolated, and generally try to avoid contact with people or situations that are reminders of the trauma. 

In addition, he or she is hyper-vigilant, with exaggerated startle responses and symptoms of extreme fear, including an inability to breathe normally, increased heart rate, nausea, sweating and feelings of panic, all of which mimic the fear created by the actual experience.

♦ PTSD and Pregnancy
First, let’s discuss PTSD and pregnancy.  Since, in women, PTSD is most often related to some kind of sexual violence or abuse, it stands to reason that when a woman is pregnant, the trauma is most likely to come back to haunt her.  This is a time when women undergo pelvic exams as well as examinations of other intimate parts of their body that may trigger flashbacks, nightmares, sleeplessness, hyper-vigilance, and panic attacks without their even being aware that they are unconsciously reliving a deeply buried unresolved issue from the past.

When Veronica, age 27, came to see me several years ago in just the second month of her pregnancy, she was requesting a psychiatric evaluation in order to have a cesarean section.  At the time, C-sections were performed only if necessary for medical or obstetrical reasons, and if a woman wanted to have one for purely psychological reasons, she was forced to go through rigorous and often embarrassing questioning.

Although I knew immediately that Veronica was struggling emotionally, I didn’t know the cause of her struggle at the time.  In compliance with hospital policy, I had to refer Veronica to the ethics committee, which ultimately denied her request.  Since she’d refused to provide any reason for her wanting a C-section, their decision didn’t come as much of a surprise to me. 

I continued to see Veronica during her pregnancy, and when she was in her third trimester, I received a frantic phone call from her husband, who told me that she had been up every night sweating and trembling, sleepwalking, talking to herself and sometimes even screaming or crying out.  He knew that whatever Veronica had been experiencing, it was deep-seated, intense, and well beyond his capacity to deal with. 

It took many sessions before Veronica trusted me enough to feel safe confiding her long-guarded secret.  What she then told me was that she’s been awakening in the night seeing the image of a man wearing green coveralls and a green cap that were similar to the scrubs doctors wear in the operating room.  As I continued to gently encourage Veronica to divulge, she further confessed that this green-clad figure was actually her uncle, who had molested her repeatedly when she was a child.

Years after these incidents but also many years before her pregnancy, when Veronica was having her first pelvic examination, she experienced her first flashback to the molestation, and ever since that time she’d avoided anyone touching her genitals or doing intrusive examinations, which was why she’d been so desperate to deliver her baby by cesarean section.  Veronica further confided that even sexual intimacy with her husband had been traumatic, although she’d never allowed him to know it.

Have you found, as I have, that women with a history of sexual abuse tend to prefer female health care providers, particularly when they undergo physical examinations?  

Phoebe, age 25, was unfortunately unable to find that degree of comfort with her physician.  Phoebe had been sexually abused by her stepfather for ten years and, as a result, was terrified of entering a relationship with a man.  Instead, she had chosen a female partner with whom she was very happy, and together they had decided to have a baby through artificial insemination. 

Once Phoebe had conceived, the couple decided to attend prenatal classes, and Phoebe went for routine examinations.  During one of these exams, conducted by a doctor who reminded her of her stepfather, she experienced her first flashback to the molestation.  From that point on, Phoebe began to have panic attacks and to avoid going to any more prenatal exams.  She was finally admitted to the hospital when her partner became alarmed because Phoebe had been experiencing severe chest pains and fainting spells.

♦ Childbirth and PTSD
Second, in addition to PTSD and pregnancy, let’s discuss childbirth and PTSD.  Although PTSD normally results from a trauma in the past, there is growing evidence that a difficult childbirth experience can, in and of itself, trigger the onset of this illness.  In my own practice, I have found that women who have experienced a traumatic birth and who become pregnant for a second time often ruminate about their earlier experience and become increasingly distressed as their pregnancy advances.  But PTSD can also occur immediately after the trauma, as it did for Delia.

Delia was carrying twins when in the third trimester of her pregnancy, she developed a serious complication that resulted in the death of one of the babies.  After that, Delia became acutely anxious and angry with her doctors.  During Delia’s first visit with me, it became clear that she blamed the health care system and believed that she hadn’t received proper treatment in the hospital. 

In fact, however, despite the doctors’ attempts to save the second twin, there was nothing more they could have done.  In effect, the death of one twin had been virtually inevitable if they were to save the other.  It took many months of therapy before Delia was finally able to accept the truth, which was that she had actually received appropriate and proper obstetrical intervention.

When a woman is so focused on her pregnancy going as planned, as Delia was on having twins, it can be difficult for her to come to terms with any deviation from that plan.  Angela, for example, had been determined to give birth at home and had hired a midwife to oversee the delivery. 

Unfortunately, however when the baby was found to be in fetal distress, Angela was immediately moved to the hospital.  Even then, Angela continued to resist all obstetrical intervention and remained absolutely determined to have a vaginal birth.  In light of her vehement feelings, the obstetricians waited as long as they could without endangering the baby, but ultimately they had to perform a cesarean section.  Angela, despite giving birth to a healthy eight-pound baby, felt, as she put it, "horrified" and almost immediately developed symptoms of acute PTSD.

PTSD may actually be associated with an increased risk of obstetrical complications.  As with any form of untreated depression or anxiety, the baby as well as the mother is at risk.  All the more reason, then, for clinicians to be vigilant in looking for symptoms of PTSD in their clients, looking for any history of molestation, abuse or violence, as well as any symptoms that the women may be experiencing or have experienced in the past.

Do you have a Veronica or a Delia who might benefit from hearing this section? 

In this section, we have discussed Post-Traumatic Stress Disorder and Postpartum.  This has included PTSD and pregnancy and childbirth and PTSD.

In the next section, we will discuss Eating Disorders and Postpartum.  This will include pregnancy and the course of the eating disorder and the eating disorder and the baby.

Peer-Reviewed Journal Article References:
Ayers, S., Radoš, S. N., & Balouch, S. (2015). Narratives of traumatic birth: Quality and changes over time. Psychological Trauma: Theory, Research, Practice, and Policy, 7(3), 234–242.

Dworkin, E. R., Zambrano-Vazquez, L., Cunningham, S. R., Pittenger, S. L., Schumacher, J. A., Stasiewicz, P. R., & Coffey, S. F. (2017). Treating PTSD in pregnant and postpartum rural women with substance use disorders. Journal of Rural Mental Health, 41(2), 136–151.

Handelzalts, J. E., Hairston, I. S., Muzik, M., Matatyahu Tahar, A., & Levy, S. (2019). A paradoxical role of childbirth-related posttraumatic stress disorder (PTSD) symptoms in the association between personality factors and mother–infant bonding: A cross-sectional study. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Jaffe, J. (2017). Reproductive trauma: Psychotherapy for pregnancy loss and infertility clients from a reproductive story perspective. Psychotherapy, 54(4), 380–385.

Lafarge, C., Usher, L., Mitchell, K., & Fox, P. (2020). The role of rumination in adjusting to termination of pregnancy for fetal abnormality: Rumination as a predictor and mediator of posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy, 12(1), 101–109.

Nakić Radoš, S., Matijaš, M., Kuhar, L., Anđelinović, M., & Ayers, S. (2020). Measuring and conceptualizing PTSD following childbirth: Validation of the City Birth Trauma Scale. Psychological Trauma: Theory, Research, Practice, and Policy, 12(2), 147–155.

Online Continuing Education QUESTION 11
How might a person with PTSD avoid reliving their trauma? To select and enter your answer go to CEU Test.

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Postpartum Depression: Diagnosis and Treatment

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