Hard labour: difficult births

“There’s something on my face.”

That was Vicki Delinger’s first conscious thought when she awoke. It was followed by overwhelming confusion and fear. She tried to talk and couldn’t; she couldn’t move either. Then Delinger took a deep breath and started gagging and coughing.

The “thing” on her face was a mask attached to an endotracheal tube going down her throat. When you are intubated, a machine is breathing for you. If you draw a deep breath, it makes you gag.

At this point, nurses and her husband, Scott, weren’t able to tell Delinger exactly what had gone wrong. But she had suffered a very rare obstetrical emergency called an amniotic fluid embolism. While she was giving birth, amniotic fluid or fetal debris of some kind had entered her bloodstream, causing an anaphylactic-like shock and the collapse of her cardio-respiratory system. It’s fatal 80 percent of the time.

The nurses tried to soothe Delinger’s panicky tears. “It’s OK. Your baby’s going to be fine. She’s beautiful,” they said. “That made me cry even harder,” the Edmonton mother of one recalls.

The next day, Delinger finally got to hold little Katie for the first time. The baby would have to spend a week in the neonatal intensive care unit. Mom had to spend four days in the ICU herself. Finally, nine days after the birth, they were all home together.

At home, Katie was OK and Mom was on the mend…physically. But things weren’t normal. Delinger did her best to put the incident behind her, but it became harder and harder to cope with the demands of motherhood. “Sometimes I just had to put Katie down so I could go outside and cool down.” Delinger had memory problems and trouble sleeping; she couldn’t get her near-death experience out of her head. Then the flashbacks started. “I was in the shower one day when I suddenly got this feeling like I was intubated again.”

Shelley Stacey knows how Delinger feels. Her flashback takes her to the moment the obstetrical resident climbed on top of her and started pushing down hard on her belly. Her daughter, whose shoulder had become stuck in the birth canal, had gone into distress. They had to get her out fast, hence the abrupt actions of the resident. After the dramatic and somewhat violent birth, Stacey could hear them talking. The baby was floppy. Floppy? That doesn’t sound good.… “What’s going on?” she cried in panic. “Everything will be fine,” the doctor said. Stacey didn’t believe it. This was nothing like her first birth, not at all.

Eleven weeks later, baby Piper is fine. But Stacey is not. She’s still in pain from a separated pelvis, and the panic and anxiety remain with her. A few weeks ago, she felt pain in her chest. She called her husband at work, thinking it was a heart attack. It proved to be a panic attack.

Two moms. Two tough initiations into motherhood.

Delinger was eventually diagnosed with post-traumatic stress disorder (PTSD), a cluster of psychological symptoms brought on by a traumatic event, serious physical or psychological harm, or the threat of harm or death. The symptoms include insomnia, nightmares and feelings of extreme stress when exposed to reminders of the incident.

PTSD is usually seen in soldiers or victims of crime, violence or disaster. But in the last 10 to 15 years, researchers have recognized that women who have difficult birth experiences can exhibit some or all of the criteria for PTSD.

It’s hard to say how common birth-related PTSD is. Some cases may look like postpartum depression to family doctors. (Stacey is currently taking antidepressants, which she says have helped.) Two studies in which women were assessed during and after pregnancy found that three percent met all the criteria for PTSD; however, 20 to 30 percent met some criteria. So, clearly, mental distress after a difficult birth affects a lot of women.

Researchers have identified numerous factors that increase a mother’s risk. Some are obvious: stillbirth, giving birth to a child with a significant health problem, extreme pain. But others have to do with how the woman felt about the way she was cared for: high levels of medical intervention, uncaring treatment, feelings of powerlessness, not being given enough information and having procedures done without consent.

People who have never given birth might wonder how well a mother can take in information or make informed decisions in the midst of a labour crisis, but it’s striking how clearly certain things stick in some mothers’ minds. Stacey, for all she went through, still wants to know why the resident who jumped on top of her didn’t take a few seconds to explain what she was going to do and why, and why no one explained it to her afterwards.

Susan Martensen is not surprised. She has been a doula (a trained birth and/or postpartum support person) and childbirth educator in Ottawa for 16 years. “Some of these birth memories don’t go away,” she says. “Women will remember parts of it when they are 90. I always ask my clients about their birth experience, and all of them want to talk.” Martensen believes that debriefing, as she calls it — talking about the birth, sorting out a woman’s recollections, feelings and questions — can be helpful for any mother. It can be particularly important after a difficult birth.

For one thing, although time heals many wounds, negative feelings about the birth tend not to go away quickly — and some mothers focus on them. These feelings can combine with the stresses of postpartum life and other factors to impair a woman’s functioning early in motherhood, including her relationship with her baby. Delinger still carries some guilt about the way she related to her daughter during those first months. “At first it was all I could do just to look after her basic needs. It was only after about a year that I started to enjoy her. That’s not the way it’s supposed to be with a mother and baby. I often wish that I could go back and do that first year over.”

Several factors ganged up on Francine Roussy Layton when she became a mother. Her delivery and early motherhood took place in Switzerland, far from home and family. She gave birth just six weeks after her father’s death from a sudden illness. The labour was long, discouraging, exhausting — and scary at times. “I had no energy for weeks,” says the mother of two, who now lives in Ottawa. Throw in a high-need baby, who cried a lot and slept relatively little, and it’s not hard to see why early motherhood became such a struggle. “When Francis was two months old, I realized I wasn’t coping,” she recalls. “I said to [my] John, ‘You need to take your paternity leave right now. I’m not doing very well.’” Luckily, he’s a federal employee (with a foreign posting at the time) and was able to take three months off.

That really helped. In particular, it gave Roussy Layton space and time to just be with her son and start feeling good about being his mother. “I’d had little desire to hold him up to that point. But seeing John enjoying being with the baby helped me to start enjoying it too.”

Still, Roussy Layton was haunted by the pain of her delivery — its intensity and duration, her disappointment that she couldn’t handle it, and how it seemed to take over. “At one point I felt like I had to detach myself from my body to deal with it,” she says. “I’m a psychologist. I know that’s the sort of feeling victims of extreme abuse experience. It’s not a good sign.”

Roussy Layton spent six days in hospital after the birth of her son. She needed that time to rest, but she also did a lot of writing when Francis was asleep or being cared for by nurses. She wrote about her utter despair when she learned that, despite the pain she couldn’t cope with, she was not even one centimetre dilated. She wrote about how the epidural didn’t take away the pain as she had expected, and how the nurse assigned to her care was more focused on the monitors than on Roussy Layton’s pain concerns. She recorded the fear she felt when the baby’s heart rate started to decelerate during the pushing stage, and how beaten and battered she felt by the end, when they had to use a vacuum extractor to get the baby out.

Writing helped her to process the experience, as Roussy Layton puts it. “It doesn’t make it all better, but it helps you to put it on the back burner,” she says. “I had to figure out what was in my control and what wasn’t. I had to ask myself, Why did I wait until the pain was off the scale to ask for pain relief? I told myself that next time I will not wait until the pain is at 10 on the scale before asking for an epidural.”

Martensen says this is a tremendous accomplishment. “This kind of realization helps a woman build a frame of reference about her past experience and what she might do differently preparing for her next birth,” she says. It’s also important because it’s positive. One of the things Martensen tries to do, when she works with a client to reconstruct her journey, is help her see the positive aspects of the experience she has gone through. “I’m not going to tell her she had a great time, but I try to plant realistic seeds of accomplishment, so she’s not focusing only on negative ideas,” Martensen says.

Another factor that can exacerbate postpartum trauma is anxiety about the unknown. Vicki Delinger learned this through writing her experience down in a journal, something her psychologist recommended. “I learned that a lot of my anxiety and stress was due to the fact that I didn’t fully understand everything that happened,” she says. Once she had a chance to identify, discuss and process some of the unknowns, Delinger spent less time imagining the worst.

One problem facing mothers who want to talk about their experience is that most friends and relatives aren’t eager to hear about a traumatic delivery. “Everyone gives you the feeling that you’re supposed to be happy,” Delinger says. “So when you aren’t, you feel guilty. You don’t want to admit it. I’d tell people I was happy even though I wasn’t.”

Even well-meaning visitors often make comments, such as “You’re OK and you have a healthy baby — that’s all that matters,” in hopes that it will help a woman move on with her life. But Martensen thinks that keeping these sorts of things inside makes mothers more likely to focus on the negative. “When you talk or write about your experience, then it’s out there. It becomes normalized,” she says. “You’re not going to uncover anything bad or worse than what you already know. In my experience, if it doesn’t come out, it doesn’t go away as quickly.”

Francine Roussy Layton tried to be honest when people asked how she was doing. “When I’d tell them I wasn’t doing OK, I could tell it made them uncomfortable,” she says. “But afterwards, I usually got more support from those people. I had one friend who made an effort to drop by and say hi more often after I told her how I was really doing.”

Delinger says social support, in the form of a new mothers’ group, helped her immensely. “It saved me,” she says. A couple of moms, perhaps sensing that she was struggling, would sometimes call the day before a get-together and ask if she was coming. “In some cases, I probably wouldn’t have gone if they hadn’t called, but I was always really glad that I did,” she says.

Martensen says these little shows of social support are very important. “The small kindnesses and support from husband, friends and family can help with the healing process more than people realize because they give the mother little positive things to focus on and feel hopeful about.”

The passage of time plays a role in healing as well. One study showed that the number of women showing traumatic symptoms at six months postpartum was half what it had been at six weeks. “Time does help,” Martensen says. “But time works a lot better when women also have a chance to process their experience and get the social and practical support they need.”