P4P Birth Trauma Webinar
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[00:00:00] Dr. Alicia Power: All right. Good morning everybody. I'm so excited. I'm Dr. Alicia Power. I'm a family doctor in the Victoria bc and this is our very first webinar for our Pregnancy for Professionals platform that we started, which is all about interdisciplinary collaborative learning for providers of care to pregnant, newly parenting people and newborns.
[00:00:23] So today we are doing a webinar on Birth Trauma. And really, this is such an incredibly important topic. We, I just wanna recognize that I am currently not in my home area, but I am currently on the ensued territories of the Comox First Nations. I am on Hornby Island, which is an island off, an island off of Vancouver Island.
[00:00:45] Quite close by the crow flies to Dr. Pip Houghton but not as the ferry boats. As we are going through this webinar, I think it would be really incredible to think about our First Nations communities and how birth has changed so [00:01:00] dramatically for them in the last few hundred years, and how perhaps I invite everybody to think about how we might be able.
[00:01:07] Support them in a different way. Learning what we learned in this webinar today. I'm going to introduce our two incredible speakers. These two professionals provide care to our vulnerable populations, our postpartum parents and pregnant parents, I'm sure as well. And they really support them along their journey from a mental health point of view.
[00:01:28] So Teela Tomassetti is a registered provisional psychologist and doctoral candidate in Alberta, Canada. So we're not only interdisciplinary inter provincial here people and she specializes in the area of birth trauma. Prior to this, Teela has been a therapist for two decades, supporting survivors of a domestic violence, sexual assault, childhood sexual abuse, and tragic losses.
[00:01:49] After suffering her own birth trauma by the way of midwifery, violence, and an excessive hemorrhage almost taking her life, Teela decided to start the fast-growing Instagram account at the T on birth trauma, where she [00:02:00] breaks the silence and supports thousands of survivors in finding their voices. Her doctoral research will focus on the fond trauma response in birth trauma survivors, the intersectionality of race, gender, and systemic oppression, and how providers can begin to dismantle it.
[00:02:15] Thank you Teela for joining us today. Dr. Pip is a family doctor and mama to three boys. She has recently moved to the Comox Valley on Vancouver Island where she's committed to spending as much time outdoors as possible. Pip is passionate about perinatal mental health and normalizing the common but challenging emotions that come with transition to new parenthood.
[00:02:34] You can find Dr. Pip at Making Mama Well on social media and if you have any interest or your patients have any interests, both Teela and Pip have done a couple of podcasts with us on our patient focused platform at she found Motherhood and the she Found Motherhood podcast. So, if either of them are inspiring to you, you can certainly listen to those or send your patients to listen to them.
[00:02:58] So today we're gonna be talking about birth [00:03:00] trauma. We're gonna be covering, kind of recognizing who is at risk of it occurring to the rules that care providers and health professionals along the entire journey of pregnancy and postpartum, not only intrapartum Have in recognizing its occurrence and how we can support people who've already been affected by it, both after pregnancy, but also in subsequent pregnancies.
[00:03:20] So without further ado, I'm gonna pass it on to these two incredibly intelligent and wonderful people.
[00:03:28] Teela Tomassetti: Good morning, so are we starting off, I guess, Pip with just a definition around birth trauma I think would be helpful. Hey.
[00:03:36] Dr. Pip Houghton: Yeah, and So I think we're, it, this is a fun conversation because we're coming at this from different perspectives and training.
[00:03:44] So we were talking about what we wanted to share in terms of defining birth trauma. And so for me as a physician, we always go back to our diagnostic criteria. To to clarify what is going on for our patient. And so that, for us, that's leaning on [00:04:00] the, the DSM and looking through the diagnostic criteria there.
Clinical Criteria
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[00:04:03] Dr. Pip Houghton: And so under that sort of trauma and stressors related disorder, we're gonna be looking for clinical criteria that matches what our patients experience is. And it's very verbose. I'm not gonna go into all the details that are, are listed there. I would encourage anyone who's interested to go have a, a read through, but we're sort of looking at those eight clusters of criterion and making a diagnosis of, a trauma or stressor related disorder.
[00:04:29] And, to clarify, there isn't a diagnosis of perinatal trauma in the DSM, so we're just, we're looking at that trauma and stressors related disorder and the stress or trauma exposure or the event would be that perinatal event that occurred. That the patient has either come to see you for or you're maybe working through with them. So the eight criterion that we'd be looking at, and again, there's more details within there that you can have a look through yourself, but an exposure to some sort of stressor. And importantly here that where I think we need to be mindful of [00:05:00] is this can be an actual stressor or a threatened stressor.
[00:05:04] And when we're dealing with our perinatal patients that threatened stressor may be more threatening for them as the perinatal patient, then we perceive it as a care provider. So, do, is there, is there a threat or a perceived threat that they may lose their baby or that they're in harm's way or that they're in danger?
[00:05:23] So, that's a required piece there, that stressor or threatened stressor. And that may be through direct exposure, or it may even be through witnessing trauma. So we wanna keep in mind what's happening with our partners and support people as well during a birth that may not go the way we expect or may have an event that the patient and their, their partner was not expecting to occur.
[00:05:42] And this can even happen indirectly through learning that a relative or a close friend was exposed to trauma. So even someone who wasn't even in the birthing room may hear that the person that they cared deeply about was exposed to some sort of traumatic event, and they may experience trauma as a result. [00:06:00] Criterion B, we're looking for intrusion symptoms and there needs to be one of those required for a diagnosis of PTSD in particular. So for intrusion symptoms, we're really looking at those unwanted, upsetting memories, nightmares, flashbacks, those sort of what I think a lot of us would perceive as classic symptoms of PTSD.
[00:06:18] Criterion C would be avoidance. So either avoiding feelings of trauma or things that trigger feelings of trauma, or actually avoiding the specific scenario that triggered the trauma. So for some of these patients that may look like. Avoiding care. So avoiding follow up with their team, avoiding hospitals or avoiding anything that was part of their traumatic experience. Negative alterations in cognition and mood. So this can come into play where you know, obviously a negative shift in mood, but also the cognitive effects like exaggerated blame of self or exaggerated blame of others just changes in how they're perceiving the details of their experience that have a negative impact on them.
[00:06:55] And then changes to arousal and reactivity. So this is where we may see more [00:07:00] irritability, hypervigilance, a heightened startle reaction, change in concentration, change in sleep. And then for a PTDS diagnosis, particularly, we're looking at a duration of over one month. If we're looking at something more like an acute stress response, it's somewhere in that two days to one month period. A change in function, an impact on their day-to-day function. And that we're not able to blame these symptoms on anything else. So there's no underlying medical disorder or medication that could be contributing to what they're feeling. And then within that sort of trauma and stressors component of the DSM we're also looking at things like acute stress response adjustment disorder, and a few other stress related stress and trauma related conditions that could be occurring that isn't necessarily PTSD. So that's sort of the kind of medical bits and pieces. But I know that Teela has other aspects of defining trauma in particular birth trauma. That's is sort of adjacent to the details of the DSM, which aren't necessarily specific to a birthing person.
[00:07:59] Teela Tomassetti: Yeah, [00:08:00] absolutely. So I'm coming at it from that psychological perspective and in working full-time with survivors. These are some of the things that I'm noticing.
Studying Survivors
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[00:08:06] Teela Tomassetti: So one of the things that we talk about within the community is the subjectivity that's involved in birth trauma. So that really speaks to how unique and diverse the experience of birth trauma is for each person. So when we say the subjectivity we're not speaking to it necessarily being a choice that was made by the person deciding, okay, I, I'm deciding that my birth was traumatic, but instead it's anything that exceeds the nervous system's ability to cope before, during, or even after birth.
[00:08:36] So essentially it is the nervous system slipping into that fight, flight, freeze, and a lesser known, newer trauma response. That as Alicia spoke to Fawn, which is what my doctoral project will be speaking to. So this, the causes, when you kind of end up breaking them down. Down and, and start talking to survivors about this can feel endless. There are a multitude, like a cascade of different causes. And [00:09:00] so I think we immediately think of the emergency situations that come to mind, like cesarean sections or the baby being rushed to the NICU, but what comes up most often for survivors is actually around the way they were treated and made to feel in that experience.
[00:09:18] And so that is actually what I hear most often. And at this time, there isn't a perfect scale that's used to diagnose or look for specific criteria. So as Pip explained is that there is nothing in the DSM around this. So we are looking to PTSD, but there are a few different questionnaires that are currently used around that, such as the traumatic event scale and perinatal PTSD questionnaire.
[00:09:45] And the only one that I've been able to find in my research that I think does a really excellent job of looking at specific birth trauma symptoms is what's called the City Birth Trauma Scale. And that was introduced in 2018 and it has really good reliability and some [00:10:00] indication of validity. So it's a promising measure of birth related PTSD for research and also clinical.
[00:10:07] Dr. Pip Houghton: So I think we were going to move on to talk about people at higher risk of birth trauma, which I think Teela you were going to...
[00:10:16] Teela Tomassetti: Yeah, I'd love to talk. Yeah. Yeah. So when I explore who's at higher risk, one of the things I am always quick to explain to providers is at the forefront of our mind, we need to consider that this isn't, this isn't an absolute, that just because these are indicators does not mean that it's going to lead to the person being impacted by birth trauma.
[00:10:37] And it's also something that I explained to my clients too. So if they have some of these precursors, I'm not saying, okay this is absolutely going to take place to you, but instead, this could be a potential, and these are the reasons why. So I, I think having that full conversation is so essential.
[00:10:53] So the main risk factors for postpartum PTSD are depression and pregnancy, fear of [00:11:00] child. Negative birth experiences, complications of pregnancy or birth, lack of support and dissociation during birth. And however, like one of the things that I've noticed with this is that there's also it's largely unrecognized in maternity services.
[00:11:19] And so unlike PPD, it's not routinely screened for, and what I'm seeing in my therapy room is that at first these survivors will speak to that they were misdiagnosed with PPD and that in fact these are trauma symptoms that are taking place for them. So you'll also hear that those who are at a higher risk are people who have experienced sexual assault in their history.
[00:11:43] Now, the reason why they're at higher risk there is because that, you know, during child's birth, there can really feel like a loss of sense of control around the body, around decisions that are being made. And this can really mimic what took place during a sexual assault. So if there is a [00:12:00] lack of consent is if there is unconsented cervical checks, or they just don't feel like again, their body is their own, you may see the trigger of that old sexual assault, that residue stepping forward into the childbirth experience and triggering them as well as women of color.
[00:12:17] So women of color are three to four times more likely to die from maternal mortality and. Higher risk of birth trauma due to issues of neglect, abuse, and racism within those experiences. So I was very grateful for Alicia to speak to at the beginning the importance of the indigenous communities that we work with and really being able to acknowledge the intergenerational trauma that exists there and within these spaces to ensure that they feel empowered, that their voices are heard, and that opportunity and options are given as much as we can.
[00:12:51] So if we know these things beforehand, then they can be used as an opportunity to talk about how the loss of control can come up in birth. And I [00:13:00] just, I really wanna stress the word can, because we shouldn't assume that it's gonna be a given, that they'll feel that loss of control, but that it, if it does come up, you know, these are the ways that you can work with your provider to feel more empowered around those discussions.
[00:13:14] Dr. Pip Houghton: Yeah, and I think, from the primary care perspective, a lot of what you're speaking to is really knowing our patient's stories, knowing their journey and where they've come from and trying to identify those pieces while not coloring everything in their experience with those pieces.
[00:13:31] And, and the reality is in our care models is that's not always possible. We would love to know every single patient from the second they come in with a positive pregnancy test until they go home with their baby and undo all of their postpartum care. But that's not how the system works.
[00:13:46] So, as, as much as we can create care circles where we try and know our patients as best we can, we, we should make an effort for that. And, and those specialists who are here, who walk in at the very end of a labor and [00:14:00] delivery, maybe not going the way, the patient wanted. This is particularly challenging for you guys, so you know, you don't know anything about this patient aside from what you got overnight in a 2:00 AM phone call and potentially very urgent situation. So, I, I completely recognize that this, this is tough to do to approach birth from a trauma informed perspective. But as much as we can know our patient's stories and even if we don't know their stories, just take that time to form some sort of connection so that the patient feels like we're making an effort to know their story.
[00:14:31] Those little moments are so impactful and can be really protective for the patient's experience postpartum. And Teela mentioned the importance of empowerment for our patients going into labor and delivery and making sure that they have, an appropriate amount of information, awareness as to what's going on during birth so that they do have a sense of control over birth choices and that they do, know what to expect a little bit without scaring them.
[00:14:55] And this is always a hard line, and Teela and I discussed this the other day, is how do you, how do you prepare our, [00:15:00] your patient so that they're empowered and have that sense of control without scaring them? And I don't know that there's a right answer and it's probably patient specific. But, making sure we provide patients with their resources to arm themselves and empower themselves as much as feels appropriate to them, given their background.
[00:15:16] And when we're in that labor and delivery. You know, time and, and things maybe don't go the way our patient is hoping, or maybe things aren't heading in an urgent situation. Again, taking as much time as we feasibly can, given the circumstances to talk to the patient and their partner about it as human beings who have no idea what's going on. For us progressing from, a failed vacuum to c-section might seem obvious, but to the patient, that's not obvious. And when things go quickly and they haven't had that, gentle interaction with their care provider, that can feel very traumatic. So just making an effort to catch those moments as much as we can.
[00:15:54] Teela Tomassetti: Yeah. If I can even share a personal example. So I, I wear many hats while [00:16:00] I sit here, and as Alicia explained, I'm a birth trauma survivor myself. And on the note of what you just said my birth went from a home water birth to me being in the hospital to all of the sudden decisions were being made around a possible emergency C-section or forceps and an episiotomy. And I'm bringing this up because the way that my doctor, or the doctor who entered the room to give me that information, the way in which he delivered that is what saved me from feeling traumatized in that moment. He was so calm and unbiased in his approach, and he just delivered all of the information in the same way.
[00:16:37] So I could tell that he had no agenda there, that he was saying, these are the options. This is the route, the different routes that we can take. And so, it does make a world of a difference. I can speak to that as a survivor myself the tone that is being used, how you're approaching the conversation, giving them a second to breathe and digest the information before they move forward to make those choices. And just [00:17:00] the bit of warmth that he had behind his voice too. He knew that it was going to be a difficult decision for me to make. So it, it does make a difference, a big one.
[00:17:09] Dr. Pip Houghton: Yeah. Those little things they teach us in med school. Sit down beside the patient if you can, if they're not actively hemorrhaging and we're trying to prevent loss of life, if you have a second to pull up a chair and sit down next to the patient and talk them through what's about to happen, that sitting down piece is, is hugely impactful. It feels like you have time to connect. And it's, it doesn't make a big difference to us as care providers. So Teela, I think next on our list is you had some key words that patients often bring into the experience with you or, or sort of statements that maybe as care providers we might catch our patients saying in a different setting. So this may even apply to, the physios in the room or the other care providers who talk to patients postpartum. So what are, what are the words that we were kind of talking through the other day?
Key Words from Survivors
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[00:17:55] Teela Tomassetti: Yeah, so I'm gonna pull up my list here. I'll try not to go through all of them [00:18:00] cause they're, they're a long list. And I'll take it slow because I, these come from survivors themselves, so these are directly from there.
[00:18:07] So you're again going to see freeze and fawn showing up afterwards. So those are the most, the two most typical responses that you'll see. So you'll hear a great sense of failure. That comes up for so many who go through birth trauma because the societal messages that we have around this is that your body was made for this. And so when it doesn't go as planned then the first, kind of pointing of the finger that happens is towards themselves. There is a great deal of guilt that takes place there, sense of blame and shame as well. An embarrassment that they weren't able to fulfill, the dreams and hopes that they too had about their birthing experience. You'll also see shock at at some points. The survivors that I meet with, they explained that the first few days and sometimes even leading up to the first few weeks, they had no idea the severity of what happened because their system is still very much in that state of shock from what happened.
[00:18:59] And so it does [00:19:00] take some time for them to be able to process and give a voice to, to their experience. So this is the, some of the things you would hear. So, I don't really remember much. This is really hard to talk about. I'm having a hard time moving past this. I just don't feel right. Is this something I did wrong? Could I have done something better? Is there something wrong with me or the baby? Is everything okay? It all felt like it went wrong. At least. And then you'll hear like the, the flip side of that, where you'll hear statements of at least the baby's healthy. Like at least we're okay now. So even dismissing their own experience at first because that is often what's taking place around them. So they're picking up those messages from other people. Then you'll also hear another flip side to that of being like, is it possible to have my tubes tied right now? Can you talk to me about birth control? So like an immediate fear of having another pregnancy take place right after that. This wasn't why I imagined this was all really scary to me. Then you'll also hear another side to this around like laughing [00:20:00] or joking about it or smiling, saying things like, oh, I didn't, didn't see that coming. So, the, the trauma responses that I spoke to earlier, the traditional ones that we know around, like the fight, flight freeze, and now fawn, you're also hearing other F's come out. So there's like flooding that happens, there's flopping, and then there's even funny where people will joke about it and laugh because they have no idea how to process the fear that's taking place inside of them. So those are just some of the examples that you might hear and come across.
[00:20:28] Dr. Pip Houghton: Yeah, and I've noticed too, I've heard a lot in chatting with patients postpartum. The, well, I was so prepared for this, so what did I, what did I miss? I, I, I exercised throughout my whole pregnancy. I did hypnobirthing, and I did X, Y, Z. So just a lot of that reflecting back on, what did I miss? Which speaks to that, that guilt and shame piece for sure.
[00:20:48] Teela Tomassetti: Mm-hmm. Yeah. Yeah.
[00:20:51] Dr. Pip Houghton: So we had talked through, after birth, the patient has, identified that they're struggling with, with coping. And so we talked about [00:21:00] how can providers support a patient after birth not going the way they had expected. And so I think this is where from a primary care perspective or maternity care perspective. And, and I will say I, I don't do maternity care myself. I don't deliver babies. I, I don't do all of that stuff. I see patients and I have seen patients. I'm just returning from maternity leave myself in a one-to-one setting for mental health support. So usually I'm seeing them, eight weeks, three months, six months postpartum. And we often talk through how their care providers supported them and helped them identify that they weren't coping and weren't feeling themselves. So from a care provider perspective, if you're following up on a postpartum patient regardless of how you perceived their birth going, or even if you weren't there, so maybe you're doing the postpartum follow up on a delivery that you didn't actually do, which happens a lot. Always take the time to address the birthing person and their partner and ask how their birth went. Don't assume that because the discharge summary makes the birth sound like fairly straightforward that that was the patient's experience. [00:22:00] So when you're setting up your office, if you're, if your clinic allows for this every time you book in that well baby visit those postpartum baby visit checks, book one for the parent as well, so that you're giving yourself that space in your day to check. You know, How was your birth? If you perceived that the birth was hard, it sounds like you had a harder birth than what you were expecting. How, how are you coping? How are you recovering from that? And take those moments to check in with them every time. And, and from a GP perspective, if you're able to make sure that every time you book a baby, you always book in the parent so that you've got that little spot of time to check in, whether it's about their birth, maybe they're fine from their birth baby, there's no hard feelings, you can fill that spot.
[00:22:40] Talking about other things that are relevant to postpartum, whether it's infant feeding, postpartum bleeding, birth control. There's lots of stuff you can talk about in that space. But if you don't give yourself the space, you're gonna focus your visit on baby and you won't see the parents. And this is the thing that new parents speak to so [00:23:00] frequently, is that after baby arrives, they don't feel seen and they don't feel heard. And, and I know this is. Coming from patients all over the place who have excellent care providers who love what they do, they love their patients, they want their patients to feel seen. And still this happens. So give your patient that space in your day if your scheduling allows for it. But, but make sure you see them. And for those of you who aren't in medicine, physio, acupuncture, chiro, take the time to see the parent as, as a human being, not as someone who just birthed the baby. And just as a birther, see them for who they are and how they're fitting into their new context as parent, but also how they're recovering from birth.
[00:23:44] And, physios are often the ones who pick up on birth trauma because they're spending so much time with patients postpartum doing pelvic floor physio. So you guys have a world of opportunity to use supportive language for patients in these contexts and encourage them [00:24:00] to check in with their doctor if they're, if they're struggling, or a counselor if they're struggling.
[00:24:05] Teela Tomassetti: Mm-hmm.
[00:24:07] Dr. Alicia Power: Can I ask a, I'm gonna break the rules and ask a question here. Yeah. So I think, oh, I'm gonna make a statement and ask a question as well. I think there's a lot of misunderstanding perhaps around kind of what goes on in the birth from, or lack of kind of that immediate debriefing. Kind of talk about, you kind of have this experience and then take the opportunity to almost immediately debrief. And I'm not sure if you guys are gonna go over that, but also farther out. I think it's really important to for everybody to understand, and I speak for myself, but I think all of my colleagues and certainly all of the care providers in our community, midwifery, obstetrics, pediatrics, anesthesia, and family doctors would be more than happy to follow up with anybody who seems confused about what happened at their birth, who we think might have some birth trauma, and might actually have a good conversation and debrief with the patient, with the provider who is actually there helping to make the decisions, I [00:25:00] think is a really important thing. Now, sometimes they may not feel safe with that provider and then finding somebody else to do that with, but I, I just want to so here's kind of my question in terms of people recognizing this who weren't in that clinical situation with the patient, with the client how can they support them without making assumptions of what actually happened in that scenario? Does that make.
[00:25:24] Dr. Pip Houghton: Yeah, and I mean, to use myself as an example, so I I, my first born, my birth experience was not what I had hoped for. I didn't actually feel unsafe or traumatized as a result. I felt very well cared for, but it wasn't what I had imagined for myself. And I had a doula there with me and my husband and my physician is a colleague and a friend. So I had so many opportunities to review what took place, both in a clinical setting, but also, when my doula came to my home, she was able to, to talk through [00:26:00] what happened and you know, how meaningful that is to have people fill in the gaps of stuff you may not remember because labor is so long and you're exhausted and so many things take place.
[00:26:10] So, having those reoccurring opportunities to debrief can be so helpful. Cuz a lot of the time the uncertainty around what happens to you can be a big triggering piece at the anxiety and fear that we continue to carry. So I think when you're approaching a patient who you feel may benefit from some specific debriefing, I think we, we want to be mindful that, as you said, that person may be triggered by the people who are present during their birth experience.
[00:26:41] So can we, can we just, say it sounds like you might benefit from some clarity around what happened in your birth. Does that sound helpful to you? Or unhelpful? If they feel it would be helpful. Would you, do you want me to find out a bit more information? Can I connect you with who was in the room? What feels like the safest fit for [00:27:00] you, but really follow the patient's lead there. I don't think it, we can assume what would be good or bad for the patient in that experience.
[00:27:08] Teela Tomassetti: Mm-hmm. Yeah, I would agree with that too. I remember back when Sarah and I met to do the She Found Motherhood podcast, we talked about what seems like an ordinary day to a provider is something so different for the survivor. And so I think generating conversations Pip like you just shared and using language, like sometimes naming it and saying has your birth left you confused or really upset about specific parts of it that you need to talk about? Cuz that is what you'll hear often is the confusion around it. Like when I asked for responses the other day for what providers might hear on my page, that was the biggest thing that came up is what happened? What happened? Why did this happen? How did it happen? And so that confusion and that sense of clarity can offer a peace and really help for those trauma responses not to consolidate [00:28:00] into that long-term memory where you are seeing them long-term. So yeah, I think clarity is key.
[00:28:06] Dr. Pip Houghton: Yeah. And I think I mean, Teela, I know this is one of the modalities you use when working with your patients and you're gonna speak to that more, but that whole narrative therapy is so healing. And certainly you're much better to speak to this than I, but one of the things I always encourage patients to do is if, if they feel safe doing so, is to actually write their birth experience.
[00:28:24] And if they feel comfortable, share it with their partner, whoever was there, because we, we need to tell our stories. Mm-hmm. . And we need to learn from our stories.
[00:28:34] Teela Tomassetti: Mm-hmm. One of the, one of the hopes that I have in the future is to do what I'm calling outsider witnessing circles with providers. And so these are providers that say, don't even necessarily know the survivor, but that they've got, a doctor in front of them or a midwife or a nurse even that is really listening to their story afterwards and witnessing that and the power of that is incredible just to have a provider listen that is in the same role and validate their [00:29:00] experience and share I understand like why that was so upsetting for you. And so that's one of my goals as a psychologist, is to start to introduce these circles to providers so that we can get some healing starting like right after. So that our different systems aren't being flooded with birth trauma survivors.
[00:29:17] Dr. Alicia Power: It's interesting, I had somebody reach out on our, She Found Motherhood Instagram the other day about having a fourth degree tear and the physician kind of, pushing their, putting their hands up in my vagina and had this, pulled my baby on fourth degree tear on what happened. And, and so I don't, I wasn't there. I can make an assumption that there was a shoulder dystocia and that's what happened. And I kind of explained that just in a very neutral way. This is my assumption. It sounds like this is perhaps what happened. And she, she was like, thank you. Nobody had talked to me. I'm sure somebody had talked to her, but she doesn't remember in the midst of the experience having been explained that. And so now she kind of has this understanding of, again, perhaps I [00:30:00] suggested she go talk to her care provider or her family doctor who would have the summary to go over it. But she, she'd been holding this in for years about this confusion that happened at her birth and just a very simple kind of explanation gave her that a little bit more power, a little bit more understanding over what happened.
[00:30:18] Teela Tomassetti: Yeah. You just helped to resolve a lot of those trauma symptoms for her, Alicia, by doing that. So it's powerful stuff.
[00:30:25] Dr. Alicia Power: So I think we as providers hold a lot of feelings when, when we hear that one of our patients or one of our clients might be experiencing trauma, and I think we internalize that a little bit more. Do you mind, could you guys mind touching on that a little bit?
The Provider Experience
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[00:30:40] Dr. Pip Houghton: Yeah. I think we, no one goes into medicine without caring deeply about our patients and so we, we so badly want them to have a good experience and at the same time, I think most of us want to be viewed as good. We don't want to be viewed as bad. And so when [00:31:00] when a birth doesn't go the way we had hoped for our patient it can be really hard to sit down and acknowledge that with the patient. And I think in some cases we may deflect or avoid that if we feel that the patient might blame us for that experience or, or maybe we're worried that we're gonna trigger the patient by bringing it up. So I think it, it's important to connect with our patients. Based on their experience and not our own as providers. And, you know, except that it's okay to feel that way. It's okay to feel anxious about how our patients are gonna perceive us. It's okay to feel worried that they won't like us anymore. They've gone through a big event and we were there. It may not be your fault as a provider, but you were there in the room when it happened and so there's a lot going on psychologically for that person that happens to be tied to a time and space that you were at. That doesn't mean they think poorly of you or poorly of your care.
[00:31:54] So try and separate yourself from your emotions in that perspective and come at it from the, the patient's point of [00:32:00] view. The other important thing is here, sometimes some, sometimes birth is traumatizing for the providers as well. And so we, we need to make sure we're being mindful of our own trauma because you may have witnessed something.
[00:32:12] Horrific yourselves while also caring for the patient. And, and it, it may be that addressing the patient in the moment isn't good for either of you, and that's also okay. You can set aside a time later when it feels best for you as a provider who also needs to be safe in your emotions and recovery from what you've witnessed and care for the patient.
[00:32:34] Teela Tomassetti: I'm really glad you brought that up, Pip, around the vicarious trauma that providers, we, I, I think about how, like the trickle down effect so often and that if we're not taking care of our providers, that's where it starts, right? Is ensuring that they are heard and seen and that their experiences too are validated.
[00:32:52] And if we can do that and take good care of the provider, it's gonna have that effect of the birth trauma survivor, or like the, [00:33:00] the patient, I should say, the birther experiencing better outcomes when it comes to the treatment from providers. So, yeah. So important.
[00:33:08] Dr. Alicia Power: Can I ask another question around kind of checking in with patients. Now we have an incredibly, incredible group and incredibly diverse group of people who are on this. So we've got some labor delivery nurses, right? And they're not all, we've seen the people, the patients six weeks later, but I know in our in our hospital, oftentimes they'll go see them the next day and check in and say hi to their baby cuz they, they've bonded with this patient.
[00:33:29] We also have, pelvic physiotherapists who may have seen the patient before delivery and then following up afterwards. So I'm just wondering from a, from a, is checking in too much an issue? Or how can you do that in a way that's kind of safe and and, should, should we, should all members who are involved in the team be checking in? Or is that the responsibility of one person? Or is that kind of everybody's responsibility?
[00:33:52] Teela Tomassetti: I think anybody, anybody checking in. And so, I, I love to shout out Dr. Billy Wong from the Lois [00:34:00] Hole Hospital because he wasn't originally my provider. He stepped in in that moment and took really great care of me, which involved good informed consent like I spoke to earlier. But then what it ended up resulting was in excessive hemorrhage and blood transfusions and all that stuff. But a couple days later, he came to check in on me. And I will never forget that moment. Like I will never. And my partner Ryan had run home for something and I was just lying there with my daughter and he just knocked on the door gently and he walked in and he said, I don't, I don't know if you remember me. And I said, I remember you. Yes, I know who you are. And he said, I just wanted to see how you're doing. He said, that must have been really scary. And he even named it. And I was like, that was very scary. And I remember just sitting there like quietly crying. Well, he said do you have questions for me? Do you wanna know why that ended up happening? And just saying what do you need now? Like, how are things going in this space? And it was just a few minutes, and it was a moment I'll never forget. And so I think it just, anybody, anybody [00:35:00] walking into that space to acknowledge that what you may have just went through was tough.
[00:35:04] I see you as a human being in front of me, and I just want you to know that I saw that too, and that you're not alone in that experience. So yeah, whether it's the nurse, whether it's yeah, the doctor themselves walking into to say something. Just a couple minutes.
[00:35:21] Dr. Alicia Power: Thank you, thank you for sharing your story. I think, so we've kind of chatted a little bit about that narrative therapy, and I know til you've got a lot of skillsets in some other kind of evidence-based therapies in Pip as well. So I was hoping that you guys could kind of, when we've recognized that somebody has experienced birth trauma what are the options for supporting that person, both like postpartum, but also kind of if they are hoping to have more children in preparing for a future pregnancy as well?
[00:35:49] Teela Tomassetti: Pip, do you wanna speak to this first and then I can dive in with EMDR
[00:35:53] Dr. Pip Houghton: Yeah, so I mean, from the, from the primary care perspective, I think the key is really identifying and then lining the [00:36:00] person up with the appropriate resources. Because certainly, as, as a GP I have, some skills, but not, not Teela's breadth of knowledge and supporting, I'm counseling for trauma. So, so really from the. Postpartum support is, is identifying that the person needs support and then, and then finding the right place for them to go. And then, if there's features of anxiety that is really impacting function, having that conversation around, what do we need to do to treat your anxiety? Are, are you scoring so high on your screening tools that we need to talk about medication so that you're able to actually, functionally involve yourself in the, in the therapies and the other, the other non-medication options. And, and I think again, just to kind of backtrack to checking in remembering to check in later on down the road too, not just immediately.
[00:36:48] Post-birth because a lot of these, cases of postpartum anxiety and postpartum depression, which are very intimately linked with birth trauma, don't truly reveal themselves until six or eight months postpartum, or [00:37:00] sometimes not even really until the subsequent pregnancy starts to become a question.
[00:37:03] So just making sure we're checking in with people regularly if we know that they did have a hard birth. And then, and then from, my perspective, I would certainly be referring them onto a counselor with specialty training in an area that's most suitable to their circumstances.
[00:37:19] Teela Tomassetti: Yeah, I'm thinking of my own GP and the conversations that we've had cuz now I'm 21 months postpartum. And so, she's on that leave now herself. But up until that point she was checking every time I saw her. It was, how are you doing with that? Do you need anything? Do you have any more questions? Can I get you any other referrals? So yeah, that ongoing process really helped my, my healing. So I, yeah, I wanted to talk about EMDR.
EMDR
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[00:37:43] Teela Tomassetti: I'm gonna try my hardest not to get too excited when I talk about this, just because I love it so much because I have seen the changes that it can make and not only the changes, but like the fast changes. And so this is something that I'm going to be advocating, just exists in hospitals, so this can be highly [00:38:00] preventative too.
[00:38:00] And research is starting to come out around this. There's only one research study that I've been able to find so that spoke to EMDR being done immediately after a birth, and it was 79 percent of 0.8% of the trauma symptoms dissolved as a result of just doing two sessions of EMDR. So you don't mean much. It's time effective. Cost effective. And so for those who are newer to EMDR it is a therapy that's founded on the basis of our emotional wellbeing, interwoven with our physical or somatic state. You'll also hear, we always say somatic in the, in this world. So therefore, EMDR employs a body-based technique called bilateral stimulation, which is when a therapist will guide a client through eye movements. You've got tones or taps. I even you know, I made sure to bring mine with me today. So this is what they look like. They're called tappers. Buzzies. This is the most traditional form of EMDR, that you're gonna see if you walk into a clinician's office. And I always joke with my clients, this is not [00:39:00] electric shock therapy, cuz they're like, what are you handing me, I'm like, it just gently vibrates back and forth. That's the bilateral stimulation in their hands. And so during trauma, brain processes and stores memories incorrectly and that incorrect storage can lead to memories, feeling very present for them, which we end up all seeing as the trauma symptoms that present. So it ends up making the survivor feel like the past is, is the present that they're currently living in it. And so EMDR interrupts that. And so I wanted to offer you, I'm just gonna scroll here, a little elevator pitch to explain this to your clients. And I read it to my husband last night. I said, Hey, you don't know much about EMDR. Does this make sense? And he kinda looked at me, he's yes. So I got the green light from somebody who's not in this world at all. So hopefully it is, it is. Okay. So when we have been through a traumatic event, It ends up getting stored in our bodies, in our long-term memory, which causes the trauma symptoms that you're experiencing.
[00:39:58] So, and those trauma [00:40:00] symptoms end up creating those flash flashbacks, nightmares, intrusive thoughts, crying. So what EMDR does is it pulls the memory from our long-term memory into our working memory and uses bilateral stimulation in the form of the eye movement or the tappers, and interrupts the emotional charge so that you can process that memory quickly.
[00:40:21] And that when you look back on that memory, you don't have that emotional charge anymore. It still isn't great that it took place and it still, might bring you sadness when you think about it, but you won't have that physical response to it. So that's what it interrupts. And this is why I'm really gonna start advocating for this to exist within hospitals is because if we can get to this immediately, then it doesn't have a chance to go into that long-term memory place and create the PTSD symptoms.
[00:40:47] Dr. Pip Houghton: That breakdown is so helpful because I have found, I've really struggled to explain what EMDR is to patients, and I worry that I'm not doing it justice. So thank you for that. And, and maybe you [00:41:00] should share the link of the little video you sent me too, so that people can share that with their patients too.
[00:41:04] Teela Tomassetti: Yeah, it's a two minute video, literally two minutes. It's a little cartoon that explains EMDR and afterwards, my clients are always nodding their head like, oh, I get it. That makes sense to me. So I'll definitely share that.
[00:41:16] Dr. Alicia Power: Are there any other tools or recommendations around kind of that supporting people who've experienced birth trauma while Teela's searching for that video? And there's actually a question in the chat around kind of medication Pip, I don't know if you wanna address this one.
[00:41:29] If medications are indicated as part of the support for postpartum person who experienced birth trauma, is there any evidence yet for using more PTSD focused medications for nightmares, flashbacks, et cetera?
[00:41:40] Dr. Pip Houghton: You know what, I haven't actually l looked at the evidence for that specifically as it relates to birth trauma. My assumption would be that if, if there's evidence for it in other forms of trauma, then it could be applied to birth trauma whilst, being aware of medication safety and breastfeeding.
[00:41:56] Dr. Alicia Power: Thank you. Alright. Anything else that you guys wanted [00:42:00] to touch from before we get, we've got a couple of great questions in the chat. Any other things that you guys wanted to touch on or any kind of final points before we get to some of those question?
[00:42:10] Dr. Pip Houghton: I think my final point is to just always make sure we're, we're creating an opportunity to see the new parent, the new mom, see them as a, as a human, not just someone who just gave birth. Mm-hmm. So those, well baby visits, making sure we're, we're seeing the parent at those visits as well.
[00:42:25] Teela Tomassetti: Yeah. And on that note, don't forget about the partner. Yes. Uh, I think my, my GP has done a phenomenal job with me and I had to share with her a few months in " Hey, my partner's really struggling too." So he would be at those appointments with me, but she wouldn't ask him questions or anything and he witnessed all of that. I didn't see the hemorrhage taking place to me. He did. And so please don't forget about the partners. Cuz it really is a domino effect.
[00:42:52] Dr. Alicia Power: I think that's so important. And I know in our system where we practice, we are the pregnant person, postpartum persons, care provider, and the [00:43:00] newborn, but often not the partners, but at least recognizing, validating and recommending a way that they can get support, I think is a, is a huge piece of the puzzle. Okay. That was incredible. Thank you both. We've got a couple of questions if you gain so patients expectations of labor and delivery are often far from reality. How do you recommend we prepare them antenatally.
[00:43:20] Dr. Pip Houghton: I, I like to, rather than focus on a birth plan, kind of frame it as birth wishes and try and come at that conversation from the perspective of we, we will try to honor these wishes as much as we can. But a lot of what happens in labor and birth is you. It just happens the way it happens. And so we, we will try to do our best to honor these wishes as much as we can.
[00:43:49] But let's think about, if labor's not progressing well, what would your wish be then? And, and I know that sometimes this conversation can be hard because some people actually don't even want to [00:44:00] address the possibility of things going outside of their plan. So it can be hard to even engage them in that conversation. And particularly for first time parents who haven't gone through labor and birth before, this can be particularly tricky. But I think regularly having that conversation around, we're here to support you and honor your wishes as much as we can. But truly, sometimes things don't go the way we really wish. And so if that happens, how can we support you and manage things going differently than you expected in a way that feels right and safe for you?
[00:44:32] Teela Tomassetti: Yeah, I like that. And framing it in such a way that like, this is, this is one of the ways that you're demonstrating as a provider that you care about. The person sitting across from you and even naming it that way, that I really wanna ensure that we're covering all of our bases here. And yeah, I understand these are your hopes and your dreams and your wishes, and in case that doesn't happen, why not? Let's just have a plan B together. I just wanna make sure that in that moment that you feel heard, you feel safe, you feel seen [00:45:00] using language like that, they're gonna go, oh, okay, they're saying this because they really care, not because they're trying to scare me or or things like.
[00:45:08] Dr. Pip Houghton: Yeah, and we had even kind of talked about this around epidurals. So requesting epidural and labor and making sure that the patients understand that even if an epidural is not part of their birth wishes, should that change epidurals don't happen the second you ask for them. So kind of normalizing the process for your center.
[00:45:25] And in some centers you may not have an anesthetist even in-house, so that may be request epidural and it happens an hour or two later, depending on what the one anesthetist on call is, is dealing with. So making sure that the patients really understand the logistics of your particular center and what goes on, should they have a change in their birth wishes or even if they're sort of on the fence about what their birth wishes are.
[00:45:46] Just letting them know what to expect if they choose plan A or plan B.
[00:45:50] Dr. Alicia Power: There's another question, Teela for you. Can a family physician get trained to provide - is it EMDR or EMDR?
[00:45:57] Teela Tomassetti: EMDR. So eye [00:46:00] movement. So just think of that when you Yeah, I know it's a mouthfull: Eye Movement Desensitization and Reprocessing. Yeah.
[00:46:07] Dr. Alicia Power: So is there training opportunities out there for people if they're interested in learning more?
[00:46:11] Teela Tomassetti: Yeah. I'm trying to think, Kate, when I have gone to EMDR and the advanced EMDR training, which is where you'd get the recent protocol event from, which is when you would do it immediately after a birth took place. I feel like right now the requirements are that you have to be at a master's level of education. And so I'm just trying to think back to my trainings. If I've ever run into any doctors, I, I don't think I have or nurses. So, but let me get in touch cuz I work closely with Dr. Judy who used to run EMDR Canada and I'll see if what can be done there or if there's specific programming that can exist. Maybe we can launch something like that. So I will pass that information back to you, Alicia, when I get in touch with Dr. Judy.
[00:46:55] Dr. Alicia Power: Thank you so much. And one final question. And this is kind of for people [00:47:00] who are having, so for anybody, so from a, if a physio or a doula or a family doctor or a midwife or somebody doing a consult in for somebody who's pregnant, notices that people have a, a significant kind of fear around birth, is there resources that you can send them to? Is there tools you can provide them? We kind of talked about that reframing the birth plan to birth wishes or birth preferences is the term we like to use, but same idea, so we kind of talked a little bit about that. Are there any other kind of your favorite tools or, or resources? Obviously probably counseling would not be a bad, never a bad idea. But what do you guys suggest to people afterwards?
[00:47:40] Teela Tomassetti: You're saying before when they're pregnant?
[00:47:43] Dr. Alicia Power: So I think regardless of it, that they have ex, even if it's their first trauma, so oftentimes we have people with a lot of fear around birth. Maybe they just don't understand it or they understand it too much, whatever that is. But how can we support them in the pregnancy? Around that fear of that upcoming situation.
[00:47:59] Teela Tomassetti: Yeah, I, I'm [00:48:00] a little biased, but yes. Therapy. And so there's there's a protocol in EMDR called the Future Events Protocol. And so you can actually help somebody to process the birth before it's happened.
[00:48:09] And so one of the, it's not just survivors that I work with Pip was talking about too at the beginning, is just, it's also people who are pregnant or planning or miscarriages or things of that nature. And so anything in the perinatal world, and I find that to be really effective. So I have a lot of pregnant people coming to see me and saying I am, I am nervous for this. I've got really high anxiety. I'm scared something bad is going to happen. And I find that EMDR is the quickest way to cut through that and just to give them a plan emotionally and mentally walking into that space. And so after that, and that can just, literally a session is all they would need for that. I, I watch them walk out with their shoulders higher and just more confident to be like, okay, I've got this.
[00:48:52] Dr. Pip Houghton: Yeah.
[00:48:52] Teela Tomassetti: And I think how it plays out too, that regardless of how it plays out, they've got this.
[00:48:57] Dr. Pip Houghton: I think the other thing [00:49:00] that is relevant for us in primary care is not all of our patients can access counseling. For some patients that can be, financially very distressing, which is unfortunate that we don't have better coverage. But I think in the office, if this is identified is sometimes we can just help our patients understand that fear is sort. Overestimating the situation while underestimating our ability to cope.
[00:49:22] So they may be underestimating their ability to cope with pain or whatever it is that they're fearful of. So if we're not in a position to get our patient into the appropriate counseling to work through this, can you in the office kind of walk through some of these fears that they have? So is is their fear, their ability to manage pain?
[00:49:38] So what situations in the past have they been able to draw on resilience to manage pain and cope with pain? And how did they, you know, how did they do with that experience? So just, some, some tricks that we can use in the office if our patients aren't able to get into counseling, which certainly I would advocate for if they could get there, but, but the reality is not all of our patients can.
[00:49:58] Teela Tomassetti: Mm-hmm. [00:50:00] Absolutely.
[00:50:01] Dr. Alicia Power: I would just like to say a huge thank you to both of you for joining us today. It's been an amazing conversation. I know that I have a few takeaways that I'm gonna start implementing in my practice and I suspect others as well. I've put up the post webinar survey just in the chat. If people could take one minute to kind of fill that out and any other suggestions that you have would be greatly appreciated. But thank you both for your time. I think this is such an important topic and something that all of us, all interdisciplinary providers, regardless of when we see people whether they're two years out from birth, whether they're preparing for it, whether they're postpartum, physio, appointment, whatever that is, whether they're at the lactation consultant with their newborn, we all have an opportunity to really support this population and kind of hopefully decrease, decrease that birth trauma or support people in a way that they can move forward with it more effectively in their lives.
[00:50:47] So thank you both and really thank you all of you who came and joined us today. Cause I think the more people who see this, the better it is. We are gonna post the replay of this up on our website. So if your colleague wasn't here and [00:51:00] you think they'd enjoy them, just tell them to check out in about a week or so and we'll send an email out with those links, the couple things that Teela had sent us so that you guys have access to that too.
[00:51:11] Teela Tomassetti: Thank you.
[00:51:12] Dr. Pip Houghton: Thank you.
