On the day Amina became a mother, she experienced a true sense of victory. She had suffered several major stressful events during her lifetime and, as her due date approached, her pregnancy, which had been filled with fear and anxiety, felt unbearably long. Becoming a mother was a significant accomplishment and, by all means, not an easy one.
Amina first showed up at the high-risk pregnancy clinic during her second trimester. She had been receiving psychiatric care for the prior five years, ever since she was raped a few years previously. Her psychiatrist referred her to high-risk pregnancy care due to the influence the rape had on her personality and her life. The objective was to plan her upcoming birth in such a way that would prevent any further emotional harm to her and her newborn baby.
In many ways she had recovered from the rape: She left her parents’ home, learned a profession, met Tarek—the man she married—and became pregnant. Yet during the pregnancy she felt high levels of stress and anxiety and, as the birth got closer, her symptoms became more severe. She experienced more flashbacks of the rape and more dissociative events.
The physical changes associated with pregnancy and the lack of control during birth are known to be catalysts for trauma from past abuse to resurface (LoGiudice 2017; Padoa 2018).
On the one hand, it’s an amazing experience to create life and to feel your heart open to a new human. On the other, many of the sensations are centered in the “scene of the crime,” which makes them a trigger to a survivor (Beaulieu 2017).
I met Amina and Tarek on her second visit to the clinic. She was open and honest about what had happened to her and about the scars that had been left in her soul. She was set on having an elective caesarean and the physician who spoke with her was convinced that this would be appropriate for her. She also had been involved in a road accident as a child and suffered an injury to her pelvis.
My mission, as a midwife, is to create an empowering birth environment and to offer women postpartum support to enable them to care for their new babies. Since I knew that the birth environment for Amina would be in the operating room, I contacted Deena, the operating room nurse in charge of elective caesareans. We held a meeting and created “a roadmap of stations” that patients go through, from admitting to the end of the operation and the post-op (Figure 1). In recent years more knowledge about the correlation between sexual trauma and health issues has been accumulating, mainly regarding women’s health issues (Padoa 2018). It is obvious that health care providers have a great influence over women’s experiences and the care they receive.
Figure 1: Map of Potential “Junctions” before Cesarean for Pregnant Patient Who Survived Sexual Abuse
Recommendations for Nursing StaffWoman arrives to the OR with her chosen companion
- Woman wearing underwear, covered, accompanied by the support figure of her choice. Patient must give consent regarding all procedures.
- Nurse will explain clearly and patiently.
- Nurse will ask relevant questions in a supportive, empathic way.
- Nurse will prepare patient, as needed, in a manner that insures her privacy (for example, put ECG stickers behind a curtain).
- All information and teaching, including validating the details, will be done sitting, maintaining eye contact, allowing questions and answers.
- Accompanied by a nurse, and
- Maintaining privacy and a personal attitude.
- Staff might include more men than women. Maintain privacy, cover patient.
- Female nurse stays with patient, explains about preparation for regional anesthesia. (Lying with back to the anesthesiologist can cause flashbacks for women who were assaulted from behind.)
- Female nurse will support through this stage and keep eye contact with patient to reassure and support.
- Nurse will not tie hands and will follow patient’s requests.
- While waiting for scrub, keep patient covered until doctors are ready to start.
- Nurse stays close to the woman’s head during scrubbing, explains all procedures, and keeps patient notified of sensations and feelings that might arise.
- Gets consent for procedures.
- Uses terms and explanations to reduce flashbacks, reminds the patient of grounding objects or uses terms that help her keep grounded.
- Nurse stays close to the woman’s head and explains all procedures.
- Nurse keeps in touch with the patient and companion person to reassure and keep them updated, makes sure patient is not dissociating.
- If dissociating, helps patient return by speaking quietly and using clear short explanations about what is happening.
In women’s reproductive health care, this clinical competency demands attentiveness to multiple organic systems and complex factors affecting the overall well-being of women, especially expectant mothers and their babies. Obstetricians/gynecologists, midwives, and labor and delivery nurses engage patients in a joint mission to encourage wellness in all aspects of reproductive health care (Florian 2018).
Therefore, we looked for the stations with the inherent potential to activate trauma in a victim of sexual violence, situations in which she might feel embarrassment, loss of control, or any other feeling that could create an escalation of symptoms (Padoa 2018; Reeves and Humphreys 2018). We took into account every little thing that might matter and considered how potential hazards could be avoided, for instance: how the patient is dressed on her way to the OR, who meets her there, how the meeting is held, when the husband should enter, when and how she will receive the baby, and so on.
With our roadmap in hand, we held a four-way meeting with the couple. Deena explained all about the preparations that would be performed before the operation and all the procedures that would occur during and after the operation. She answered their questions and took them to see the OR, pointing out the route and the different areas. Amina asked if she could bring her teddy bear, and Deena legitimized her request by agreeing to allow it, stating that this could empower the patient’s sense of control over her reality in the OR. Amina was very pleased; she expressed that seeing the place and getting approval for her personal needs had reduced her anxiety.
In addition, Sera, a social worker experienced in caring for women with PTSD, was also involved and became a part of the team. She and Amina met alone and with Tarek several times. The main objective of these meetings was to establish trust in order to enable healing. Slowly Amina started to trust the team members. During the preparations, Amina’s privacy was maintained, together with good communications among the team members. Every decision about the planned caesarean was known to all the team members.
The conversations with Amina enabled her requests to become more precise and allowed us to understand what else was needed. She understood that she would feel better in a mostly feminine environment during the operation, which included doctors, nurses, anesthesiologist, and neonatologist—they all needed to be women. We asked the director of obstetrics for his cooperation in this matter. In addition to minimizing the presence of students during the operation, Amina requested that she not be addressed from her right side. She had been attacked from the right side, and it was important for her to be approached from the front or the left side. This information was crucial in order to optimize the care she would receive, both in general and in the OR in particular.
Amina also met with Dr. Levine, the head of the anesthesiology department. She became anxious when she realized that the preparation and anesthesia might cause her to experience loss of control, because the operation was to be done under spinal anesthesia. She told the team that she had been raped after being given date rape drugs. These drugs are used to make a person vulnerable to sexual assault and easier to attack (Cafasso 2017). Therefore, she needed to feel as much control as possible over what was going on. In this meeting, Amina had the opportunity to be influential and, as a result, Dr. Levine suggested that Sera, the social worker, be present during preparations for the operation. She could help Amina maintain her sense of control in the OR by using stress reduction techniques such as relaxation and guided imagery. Multi-disciplinary support and cooperation was critical for the success of our mission: to enable an empowering birth experience for Amina.
A couple of weeks before the planned date, everything was ready. Each of us knew our part in the plan. We knew that an unplanned operation would not be ideal, so we tried to minimize the difference between the original plan and what might happen if Amina were to show up with contractions or arrive after her membranes had ruptured (or any other situation that would require an immediate decision not in accordance with the plan).
In order to enable as much of the plan to occur in all possible circumstances, we recruited assistance from the highest level of personnel via the nursing supervisor of all the operating rooms in the hospital. Amina’s chart was also updated in a manner that enabled anyone who saw it to clearly see the plan and to know who to turn to in order to make it happen.
Just a week before the planned operation, Amina showed up with diarrhea and contractions. The doctors decided to operate sooner, perhaps the next morning. I understood I had two missions: 1) Because we were working on a tight schedule, I needed to make sure that all the designated people would be able to be present at the operation as planned, and 2) I had to make sure that the contractions wouldn’t warrant a vaginal examination. In all the time we had known her (since 24 weeks’ gestation) she had not been examined once.
It was obvious to anyone who met Amina that she couldn’t endure a vaginal examination. On the other hand, I knew that waiting for a planned caesarean, with contractions, could cause the personnel some stress. So, when the idea to hospitalize Amina in the high-risk ward came up, it seemed like a good idea. Anyone who goes into active labor is transferred from the high-risk ward to the delivery room when the contractions get strong. As long as she could cope with the contractions, as far as staff would be concerned, it would mean that she was not yet in labor and no one would examine her.
Sure enough, the next morning, the original plan started to come to life. Amina walked with Tarek and Sera into the OR to meet with Deena. Shortly after, preparations for the caesarean began. Both the anesthesiologist and Deena kept Amina informed as the obstetricians proceeded with the operation. When the baby was born, Amina felt how her belly emptied. Soon the baby’s cries filled the room and Amina’s tears of joy were running down her cheeks and Tarek, next to her, was crying as well. The midwife caring for the newborn spoke to the couple, explaining how she and the neonatologist were caring for the new baby. She approached Amina and, as had been decided upon ahead of time, placed the wrapped baby on Amina’s chest, facing her with his big, dark eyes looking toward his mother. Amina put her left hand on her baby and smiled contentedly. The room was thick with emotions as the couple held their new baby. After a few minutes, the midwife, the baby, and the father continued on to the newborn ward, where nurses cared for the baby.
Sera stayed with Amina while the operation continued. It was then that Amina first experienced dissociation, but the experienced social worker who was right next to her spoke quietly to her, reminding her that she was in the OR and that she had just had her baby and would soon meet with him again. Amina slowly “returned.” Parratt (1994) interviewed sexual abuse survivors about their experience of childbirth. She found that flashbacks were triggered by the childbearing experience and that the responses to the flashbacks were individual for each survivor.
Privacy, touch, and control were identified as important issues for abuse survivors during childbirth. Survivors largely lacked control during childbirth. Being touched, especially in areas of the body related to incest or rape caused some women to recall the past abuse. During the immediate postpartum period, touching their babies (i.e., wanting or not wanting to touch them) was an important issue. Women must have individualized care during childbirth (LoGiudice 2017; Byrne, Smart, and Watson 2017).
After a couple of hours in recovery, Amina was back in the ward, where she met again with her baby. The feelings of excitement and happiness that filled her were beyond words. With the baby next to her, knowing that the pregnancy had ended safely for both of them, she felt a wave of deep contentment.
In the coming days, we paid attention to the breastfeeding issue. Amina wanted to try and, with a lot of support from a breastfeeding consultant, she succeeded. We were also looking to see how both parents were starting to engage with their new role in life.
The last issue that was dealt with was a care plan for her support at home. Because the family could not be with her when her husband was out of the house at work, we were worried that Amina might experience too much stress caring for baby alone. Therefore, the husband was instructed about the importance of his support and availability and the social worker found a volunteer who would be available for her during the daytime.
After less than a week, Amina and husband left the hospital with their baby and with hopes for a good future for all of them.
*This program was made possible by the help of my colleagues as mentioned in the article. I thank them and Ms. Mindy Levi, who helped write and edit the article, from the bottom of my heart!References:
- Beaulieu, S. “A Sexual Assault Survivor’s Reflections on Birth.” Life. Huffpost. December 6, 2017. huffingtonpost.com/sarah-beaulieu/a-sexual-assault-survivors-reflections-on-birth_b_4831780.html.
- Byrne, J, C Smart, and G Watson. 2017. “I Felt Like I Was Being Abused All Over Again: How Survivors of Child Sexual Abuse Make Sense of the Perinatal Period Through Their Narratives.” J Child Sex Abus 26(4): 465–86.
- Cafasso, J. 2017. “Symptoms and Effects of Date Rape Drugs.” healthline.com. Accessed March 9, 2019. healthline.com/health/date-rape-drugs.
- Florian, PM. 2018. “The Unwelcome Guest. Working with Childhood Sexual Abuse Survivors in Reproductive Health Care.” Obstet Gyn Clinics 45(3): 549–62.
- LoGiudice, JA. 2017. “A Systematic Literature Review of the Childbearing Cycle as Experienced by Survivors of Sexual Abuse.” Nurs Womens Health 20(6): 582–94.
- Parratt, J. 1994. “The experience of childbirth for survivors of incest. Midwifery 10(1): 26–39.
- Padoa, A. “Medical Issues Regarding Sexual Abuse Survivors.” Class lecture in the course: Issues regarding sexual assaults. Tel Aviv University. February 27, 2018.
- Reeves, EA, and JC Humphreys. 2018. “Describing the healthcare experiences and strategies of women survivors of violence.” J Clin Nurs 27(5–6): 1170–82.