Are we trigger happy?

** Trigger warning: this post has no trigger warning. **Trigger Happy

Most of us have heard a newsreader warn about content which “may be distressing for some viewers.” However, as we increasingly turn to online networking sites for ‘news’, the responsibility for such content regulation now befalls users themselves.

As online birth communities have grown and developed, we too found the need for a content warning approach to facilitate the respectful exchange of information; this has manifested in recent times as ‘trigger warnings’ (TWs).

TWs and the online birth community

TWs began creeping into the online community around 2012[i]. In the virtual world of maternity consumers, TWs are often found in special interest groups relating to Vaginal Birth After Caesarean (VBAC); in these spaces, because the experience of unexpected and/or traumatic birth is common, the choice to attach ‘trigger warnings’ to graphic content is a direct reflection of an assumption of shared birth trauma. This TW culture attempts to both acknowledge and validate birth trauma, whilst also protecting individuals from the possible re-triggering of trauma responses.

At first, TWs were rare, attached only to content relating to pregnancy- or birth-related mortality or severe morbidity. However, as this culture has continued to develop, we now see an ever-increasing number of TWs for myriad permutations of birth: elective Caesareans, unplanned repeat Caesareans, assisted vaginal deliveries, long labours, bullying by medical professionals, scalp monitoring, induction, obstetric instruments, manipulative behaviour by medicos, gloved hands… And the list continues.

The problem with this ever-growing list is that, if not kept in check, it slowly censors birth. Whether one moderates a facebook group, writes a blog or regularly shares links to birth videos with friends, if we wish to hold a space in which women can freely exchange information and experiences, it is time for us to think about whether trigger warnings create more harm than they seek to avoid.

Trauma response or strong emotion?

Different to a non-pathological strong emotion which may feel uncomfortable, but is otherwise normal, a post-traumatic response may include flashbacks, disorientation and detachment or hyperarousal[ii]; users who experience such pathological symptoms during online interactions and/or feel the need to debrief their birth experience in any way, should seek the services of trained professional.[iii]

It is important for women who have been ‘triggered’ to know that “although [psychological trauma symptoms] can be distressing, they will settle quickly in most people. They are part of the natural healing process of adjusting to a very powerful event, making some sense out of what happened, and putting it into perspective. With understanding and support from family, friends and colleagues the stress symptoms usually resolve more rapidly.”[iv]

If women need support for psychological trauma symptoms, the online space can prove an invaluable source of community connection – fellow consumers might share information about local professional services and experiences of healing trauma. For this reason alone, it is important to ensure that we don’t, in our desire to protect women from their obstetric history, allow TWs to rob us of the opportunity to have open and honest discussions about trauma responses.

Isn’t it just safer to put warnings on everything?

In a word, no. This trivialises the topic of trauma by perpetuating an assumption that post-traumatic responses and ‘strong but normal’ emotions are synonymous. Not only is this unfair for trauma sufferers (because it downplays their suffering), but it also normalises the idea of traumatic response (which does not promote positive change). This blending of ‘strong but normal’ emotions and pathological trauma responses could, for example, even be dangerous for women with undiagnosed PTSD if they do not realise that their symptoms are pathological.

The overuse of TWs also runs the risk of lost effect. If TWs continue to appear with increasing frequency, when do we stop reading them?

Should we even try to predict what others’ triggers are?

If, as an individual woman, I am in the depths of exploring and healing my own triggers, I am likely already overwhelmed and reading lists of ‘suggested’ triggers is not likely to move me towards healing. In fact, this might do the opposite by: a) creating the idea that there is an insurmountable mountain of triggers to overcome, b) encouraging me to adopt new triggers, or c) making me wonder if there is something wrong with me if I am not ‘triggered’ by the same things as my peers.

It is also a dangerous assumption, particularly in VBAC groups, that because women share a history of traumatic Caesarean birth, they have carbon copy triggers. The trauma response is an intensely personal reaction which might even surprise the affected woman herself – it is folly to expect someone else to accurately predict the nuances of a triggered trauma response.

What happens if we don’t let women identify their own triggers?

Three years ago, Rachel Reed identified that “we have created a culture (and birth culture) that seeks to avoid and minimise extreme emotion and pain, and encourages being in control.”[v] This existing culture now has an online manifestation in the overuse of TWs, and this deliberate numbing of the full spectrum of emotion potentially prevents women from discovering complete healing and full empowerment.

For those with birth-related PTSD, exposure to triggers (with support and coping strategies in hand) is productive and leads to healing. Avoiding triggers ultimately maintains collective trauma symptoms in the long-run and is an unproductive behaviour – this is identified by the National Center for Health as a “maladaptive control strategy… resulting in maintenance of perceived current threat. Prolonged exposure to safe but anxiety-provoking trauma-related stimuli is considered a treatment of choice for PTSD”.[vi]

When does the expectation of a trigger warning inadvertently shame women?

In the case of online VBAC groups, women who share their birth stories encourage each other to be mindful of other members who might still have unhealed trauma; this means that women who plan VBACs and end up with repeat Caesareans invariably (and almost apologetically) precede their stories with TWs. The issue with this approach is that, as the collective increasingly expect TWs from each other, women are taught to err on the side of caution to avoid upsetting others (and any resulting backlash).

What we potentially have here is a new version of our obsessive need to feed mother guilt and shaming. An unmoderated TW culture unfortunately results in (and I have seen this happen) the censorship or removal of birth videos and stories which contain too many group-norm triggers. In this dynamic, calls from the membership for TWs will always be louder than an individual’s right to fully express her birth story. It is conceivable that we will reach a point at which even women who have fabulous, empowered VBACs will eventually feel the need to place TWs on their stories out of the need to respect others less fortunate.

What does an empowering online birth community look like?

There is an irony present when the very women who preach empowered birth to each other also encourage an outsourcing of responsibility for one’s own internet browsing. We cannot expect to question medical professionals and take increased responsibility for our birth choices if we cannot likewise take a similar approach to our own online interactions every day.

What supports empowerment, however, is an online birth community which assumes:

1) We are strong enough to survive reading a confronting blog post or watching a gritty, raw birth video;

2) We are smart enough to scroll past or click away if we notice we are not able to cope with this kind of ‘internetting’ today; and

3) We need to feel all of the strong or confronting emotions inside of us if we are to better understand ourselves and what needs to come next for healing.

At the end of the day, it is better for women to support each other towards healing and resilience – this takes away the need to fear triggers and demand warnings. This is a much more productive and powerful collective goal for the birth community to set.

Conclusion

From a macro perspective, seeking to sanitise or dull strong emotional responses to injustice, the medicalisation of birth and/or the stories of others is not in the long-term best interests of the birth community. Yes, we do need to be mindful of others’ pain and trauma, but robust, uncensored conversation about birth is precisely what is needed in order to fully discuss, validate and troubleshoot the problems of modern-day birth – it is only once consumers and care providers can be honest about the full gravity of the situation in which we find ourselves that we will begin to find solutions.

References:

[i] http://www.stirjournal.com/2014/09/15/trigger-what-why-trigger-warnings-dont-work/

[ii] https://www.psychology.org.au/publications/tip_sheets/trauma/

[iii] http://psychology.org.au/

[iv] https://www.psychology.org.au/publications/tip_sheets/trauma/

 

[v] https://midwifethinking.com/2013/03/27/feel-the-fear-and-birth-anyway/

 

[vi] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925813/

 

Planning an Empowered Caesarean Birth

This article was first published as ‘What If I Must Have A Caesarian Birth? Making It As Woman-Centred and Empowering As Possible’ on www.birthgoddess.com.au.

My Experience of Caesarean Birthmodern woman's guide_image

As a first-time mum preparing for a natural birth, I did pre-natal yoga, I memorised birth affirmations, hired a TENS machine and prayed for the best. One thing I did not do, however, is read the ‘Caesarean Section’ of the birth books on my bedside table. When the midwives set up a faux Caesarean birth as an antenatal education activity, I daydreamed about better things – my active labour, my drug-free experience of pain and my baby coming out of my vagina.

It therefore comes as no surprise that, when my normal, low-risk pregnancy ended in an ‘emergency’ Caesarean, I was totally unprepared, shocked and – ultimately – traumatised. While time, hindsight and more robust knowledge has shown me that my surgical birth was at best a statistic and, at worst, a medically unnecessary event [1], our first-born’s arrival Earthside changed the course of my life, and for this I am thankful.

Courtesy of that experience of birth (which was a crash course in being a savvy health services consumer!), I found a new calling connecting with mothers who are planning their ‘next birth after Caesarean’. In the five years since this birth, I have supported many women who have sought to make sense of their Caesarean births and assess the birth options available to them next time. I am always struck by the similarities of our stories: it is the shared nature of our experiences which allows me to share the following ideas for making the birth experience as positive, empowering and woman-centred as possible. Whether you are planning a Caesarean out of necessity or unexpectedly, you’ll see that there are lots of things you can proactively do to ensure the experience is the best possible one for you and your baby.

N.B. Please discuss the following with your partner, birth team and doctor – as always, make sure you seek medical advice from trained professionals and, if in doubt, seek a second or third opinion.

PLANNING FOR A POSITIVE, EMPOWERED CAESAREAN

Make the environment as comfortable as possible

–          Have your partner present. Ask the hospital ahead of time if you can have extra support people (such as doulas) present in theatre.

–          Take music to listen to as they prep you for surgery.

–          Ask for lights to be dimmed or directed away from your face. Alternatively, consider closing your eyes and visiting your meditation place.

–          Ask for conversation to be kept minimal and quiet or, if preferred, indicate your desire for a light-hearted, jovial atmosphere.

–          Ask your hospital if you can provide the receiving blanket for your baby.

Connect with your body and baby during birth

–          Request that the sheet is lowered so that you can see more of what is happening – this may make you feel more involved and less passive.

–          Ask the surgeon to give you a verbal commentary on what is happening to your body.

–          Ask a theatre nurse to raise your upper half slightly so that you feel more ‘active’.

–          Visualise your whole body during surgery – scan your awareness from your head to your toes and back again, filling every corner of your body with white light. Even though you will not be able to feel your lower half, mentally reminding yourself of your wholeness may help you to overcome any feelings of physical disconnection.

–          Research ‘maternally assisted Caesarean’ – this option may be available with some providers and may appeal to some.

–          Discover the sex of your own baby.

A physically mindful experience

–          If your Caesarean is elective, waiting until spontaneous labour begins before being admitted for the birth is one way to offer your baby some of the benefits of natural labour.

–          Ensure your surgeon performs a ‘lower segment Caesarean section’ (LSCS) – the lower segment is the strongest part of the uterus which means LSCS scars are less likely to rupture in subsequent pregnancies and births. (The upper segment is usually only cut in ‘classical’ Caesareans which are quite rare in Australia.)

–          Some surgeons flip the uterus outside of a woman’s body in order to complete the stitching of the incision – avoiding this method of closure can help minimise the feeling of internal bruising post-Caesarean.

–          Ask for stitches instead of staples, and discuss the advantages of a double layer closure for healing and future VBAC chances.

–          Request a Caesarean lotus birth – this is one way to ensure delayed cord clamping and these are possible.

Bonding with your baby

–          In the absence of foetal distress, many post-birth assessments can be performed on your chest (or later!). Ask those present to assist you to hold your baby so that you can enjoy skin-to-skin contact as soon as possible after birth.

–          Some hospitals routinely separate mother from baby, taking Baby to nursery while Mum is in Recovery. Ask ahead of time whether this is standard procedure at your hospital, and negotiate to have Baby stay with you instead.

–          Begin breastfeeding in Recovery. If this is not possible, arrange to express colostrum and have this fed to your baby.

A gentle babymoon

–          Whilst a Caesarean is a birth, it is also major abdominal surgery. In the excitement of birth, your recent experience of surgery can be quickly forgotten. If you had gone in for uterine surgery under different circumstances, you would take time out from home duties, accept offers of help and give your body time to heal. Caesarean birth is no different!

–          Give people things to do when they come to visit – folded washing, a mopped floor and a meal for the freezer are great ways for people to support your babymoon.

–          Invest in some SRC shorts, TubiGrip or shapewear – these can help to offer abdominal support when your incision site feels vulnerable. The Bengkung method of belly binding may also be beneficial once the initial tenderness of your wound has settled.

–          Rest, rest, rest. Plan to do nothing but breastfeed your baby and rest. (The rest can wait!)

–          Take your placenta home with you so that you can return it to the earth, giving thanks for its role in nourishing your baby.

–          Plan a ‘birth sealing’ ceremony to symbolically close your body after birth – this is a particularly useful exercise if your Caesarean has left you feeling open, vulnerable and/or disconnected physically from your body.

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[1] Whilst my ‘unnecesarean’ birth is a symptom of a system of maternity services which sections approximately one third of Australian women giving birth each year, there will always be a proportion of women and babies for whom a Caesarean delivery is genuinely the safest option – the World Health Organization has historically cited a 15% Caesarean section rate as the upper limit for a system which is providing Caesareans to women and babies who need them*.

*“… when caesarean section rates rise above 15%, risks of adverse health outcomes begin to outweigh the benefits.” –  Einarsdóttir K, Kemp A, Haggar FA, Moorin RE, Gunnell AS, et al. (2012) Increase in Caesarean Deliveries after the Australian Private Health Insurance Incentive Policy Reforms.