With astonishing insight, Netflix titled their 2020 film exploring profound birth loss, “Pieces of a Woman”. Insightful because at every level, birth trauma involves disconnection, a breaking into pieces marked by a sense of shame. Pieces of information about the mother and baby that were not joined enough to prevent what happened. The disconnection from anticipated joy, the disconnection from staff, baby, loved ones, and shockingly, the disconnection internally; muscles and tissues in the pelvis torn apart, sections of the brain shutting down and disconnecting from one another. The window of MRI into traumatised brains displays the silent void in areas responsible for recognising emotions and enabling them to be processed. We may feel horrified that birth trauma sufferers feel shame and make wildly illogical accusations of blame towards themselves, but this is how the traumatised brain operates in a bid to protect itself. As a pelvic health physiotherapist who wants to walk with women as they ‘knit together’ their pieces, I would love you to join me in ‘unshaming’ the experience of birth trauma and ‘unshaming’ the details of treatment.
The language around birth trauma cueing shame is profound. Disbelief over the seriousness of the diagnosis or disgust at a choice of Caesarean birth are common crimes of the past. As far back as the Latin roots of the words for genitalia and their nerves, comes our union between shame and the pelvic structures. The etymological dictionary records that “vulva” comes from the Latin word pudenda “thing to be ashamed of”. The pudendal nerve supplies feeling and function to pelvic floor muscles, labia and vaginal tissue. The male equivalent was later translated in Old English as scamlin “shame limb”. Little surprise then, that on top of the shame reaction common to all trauma sufferers, birth trauma sufferers can experience extreme shame, self-loathing or disconnection from their pelvic area or whole self. Common phrases spoken by women in my clinic are; “I’m too afraid to look down there”, “numbness is better than pain” or “it’s disgusting”. Not “my vagina”, but “it”.
Our larger cultural story is one of denying trauma exists or masking any language about it at all! Known as shell shock in WW1, all reference to this term was banned by official military decree in the UK at the time, and it’s presence was attempted to be ‘electric shocked’ away in luckless German soldiers. No small achievement then, that research with returned veterans in the 70’s labelled “psychotic” finally led to an official diagnosis of Post Traumatic Stress Disorder in 1980. In 1990 the revised definition for PTSD made provision for birth trauma by including “ ‘witnessed or confronted’ with serious threat or injury”.
Literally, it is of monumental significance that organisations like the Australasian Birth Trauma Association exist. Their online presence clarifies what birth trauma is and how to get help. It covers the physical trauma to pelvic joints, organs, pelvic floor muscles or large tears of the perineum, (perineal tears can end up involving more than the skin and the muscles near the vagina but can extend inside the vagina or to the anus and rectum). Importantly ABTA also explain the psychological trauma from experiencing or witnessing threatened or actual injury to the mother or baby during birth. Dads and partners can have birth trauma too, and it’s not measured by the degree of damage to anyone’s pelvic floor. Links to support services can launch a healing journey, mapping the breadth of professionals often needed; perinatal psychologists, colorectal surgeons, maternal mental health nurses and pelvic health physiotherapists to name a few.
Part of ‘unshaming’ the experience of birth trauma, is all of us facing up to the spectrum of severity. It may be several months of exhaustion and challenging thoughts that seem to relate clearly to a larger perineal tear. It may be years of triggered episodes of frozen panic with a legion of immune and mental health consequences when the physical injury seems comparatively small.
The engine pulsing behind trauma is our constant evaluation of what an event or sensation means. If I injure my knee, it doesn’t mean much for who I am as a person, unless I earn money or sanity from running. Tear my pelvic floor muscles from the bone during an unexpected forceps delivery and it means many staggering things. My organs tied to dignity are under threat because I can’t stop my bladder leaking when I cough, my sexual identity is at sea because my perineum has been cut so I no longer relate to what I see and feel down there or feel disgust when I should feel arousal.
Yet at the same time, birth trauma doesn’t mean enough to us as a culture. There’s no clear social currency. That subtle agreement from ‘everyone’ that our expectations of someone shifts because of what they’re going through. In the words of my courageously honest friend, cancer has good social currency; ‘it’s the cancer card Liz, no one expects you to do [inane meetings] when you are dealing with chemo and cancer’. When our loved one is in a fight against death, we rightly do not burden them with anything but what is most critical to health in their most important relationships.
But for birth trauma the difficulties with child bonding or emotions is not anticipated or ‘covered’ by others. Maybe because it feels private or embarrassing. A torn pelvic floor means that settling a baby or navigating the hardness of a poo is a nightmare that sucks any energy for menu planning or small talk to connect with other mums. Birth trauma means an immune system behaving like it’s backed in a viral corner, a mind disconnected from confidence, a body that may have lost it’s ability to control wee, poo, sit painlessly, enjoy sex or ‘feel like itself’.
‘Unshaming’ the experience of birth trauma may mean saying things like; ‘Let me bring you a meal, I know it’s been months, that’s normal’, ‘feel free to accept or ignore this invitation for a mums’ group catch-up, I will pop in when you feel ready’. Most of all, if someone is brave enough to share some of their struggle avoid the holy trinity of making someone feel worse:
Silver lining it
Defending the perpetrators
In case you missed Bréne Brown’s fantastic talk on empathy ‘silver lining’ a problem is trying to point out the positive angle or outcome from the horror. It usually starts with ‘well at least…’ Well at least you and the baby survived. Well at least you still have some pelvic floor muscle. Followed by a good dose of inspirational poster worthy ‘the only way is up’.
What about ‘denial and defence of the perpetrator’ responses? We know it happens in other forms of trauma. Victims’ own families can’t face the reality of an abuse and tell the child that it didn’t happen, they are naughty for saying such things, or even worse, regale the child with the virtues of the perpetrator. The language of ‘perpetrator’ is enormously loaded, and unfair given the good intentions and complex load for obstetricians and midwives. However, trying to impress the virtues of the birthing staff upon victims of birth trauma when they venture to share their suffering, sends a powerful message of the worthiness of staff in comparison to the person who right now is feeling unworthy of love and care.
‘Unshaming’ responses include “I don’t have the right words, thanks for telling me” “Has there been any helpful information I could read to know how to be a better support to you?” or for those for whom honesty is a simpler poetry; “that is totally s@8**y”.
In chintzy loungerooms in 1980’s Australian suburbs, older women began to meet regularly in the hope of processing their births many decades on. All had physical injuries related to their birth that could have been lessened by good treatment at the time. They spoke of accidental leakage of urine (incontinence) and prolapses (organs like the bladder, uterus or rectum coming down in the vagina or protruding out the vagina). They sang a familiar anthem ‘I wish there had been education about pelvic floor muscles then’.
Treatment options for emotional and physical birth trauma need to be as comfortably public as Kim Kardashian’s insured cheeks. Let’s ‘unshame’ some details of birth trauma treatment.
From day one there needs to be awareness and support. Perineal swelling and stitches will need compression from thick pads or a support garment, gentle ‘pulsing’ pelvic floor exercises (if any), ice limited to ten minutes or less and good furniture and bolsters to support excellent posture and breathing patterns. Extra manual support will need to be applied (though a pad or hand pressed to the perineum or sitting on something firm) while pooing, coughing or sneezing. Small, soothing movements are great, standing still for long periods isn’t. Support might be asking the midwife to read your birth transcript with you and answer some questions, or calling the maternity social worker to listen to some of your alarming thoughts.
As the weeks progress, the support team will need to continue and expand. Emotional therapies need to be trauma informed. Ask ‘how’ the psychologist is trauma informed. A variety of approaches, including equine therapy, sensorimotor integration and rapid eye movement techniques may be used. Prepare to try more than one; ‘finding the right psychologist is like buying a good pair of jeans. Even if they look awesome online you need to try a few on before you get a good fit’.
Physical therapies whether from a GP, urogyneacologist or pelvic physiotherapist should present the range of treatment options and put the client in control of choosing the type and pace of treatment. There will be muscles that are both tight and weak. Ligaments and muscles may be torn or stretched. Sometimes it will be enough to use devices like pessaries (silicone ‘splints’ in the vagina) alongside muscle relaxation and strengthening. Sometimes a careful dietary and supplemental recipe is needed for a poo that is not too hard or loose to avoid leakage or straining. Sometimes electronic feedback or balloons will be used to retrain pooing (defecation if you want to feel fancy). Sometimes a sex toy will be used to limit the depth of a partner’s penetration, or to help relax muscles. Sometimes medications will be used for nerves that are really angry and sensitised by the injury and stress hormones. Sometimes surgery will be needed. Always, feeling safe and respected during treatment is needed.
There will be harder months. Recent research showed a slump in mental health scores six months after significant perineal tears – more so for the women with medium tears. At ten months, women struggling to manage a prolapse will be faced with a much heavier baby going through separation anxiety, wanting to be held with no concern whatsoever for destroying mum’s recently improved sensation of bulging in her pelvic floor. Yet perhaps most challenging is considering pregnancy or birth again.
So let’s ‘un-shame’ the holy trinity of giving birth trauma sufferers some helpful control:
Firstly, choosing the mode of delivery with all the needed information. Last month our Australian Commission into Safety and Quality in Health Care published new guidelines to reduce the risk of large perineal tears and provide better treatment should they arise. These guidelines are based on an intervention bundle that has been followed by teaching hospitals since 2017 and has shown encouraging results. It includes risk factors that indicate when a Caesarean section would be a safer birth choice due to the risk to the perineum or pelvic floor muscles.
Secondly, being allowed to ask as many questions, from as many professionals as are needed. Fears need to be addressed until they no longer dictate thoughts and emotions about birth. Asking questions needs to be welcomed and normalised. Even if it’s expressed in an anxious way, it’s a step towards health, and provision needs to be made for the extra time these questions take.
Thirdly, and most importantly, choosing pregnancy and birth carers. We have the privilege of being in a country where public health includes the right to a second opinion. Rather than being made to feel difficult, someone who seeks a second opinion is practicing the very sense of control needed for reconnecting the pieces of their mind and body. Could we dare to say ‘good on you’ to a birth trauma sufferer who says ‘I would like a second opinion’.
Kind honest words, support and extra time for sufferers of birth trauma. Please? Un-shame.
Liz Lush is a Senior Women’s Health Physiotherapy Clinician, Childbirth Educator, Lead Clinical Educator at All Women's Health in Brisbane
Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma.
Beaumont T and Phillips K, Showcasing a model of care for women who sustain an obstetric anal sphincter injury at an Australian tertiary hospital, A & NZ Continence journal, 2021, Vol 27, no 2.