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.

******

[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.

Maternal-Assisted Caesareans: a cut above?

photo by Alan Light [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
photo by Alan Light [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
If you follow ‘birth interest’ pages in social media, you could be forgiven for thinking that there is a sudden epidemic of ‘Maternal-Assisted Caesareans’ (MACs) in Australia. As an Aussie with connections to birthing women, let me firstly assure you that this is not the case.

So, now that we know there’s no reason to fear of an army of Sigourney Weaveresque Aussie mothers taking over the birthing world (yet), let’s take a long, hard look at the MAC and what it does and doesn’t do to improve birth.

What is the Maternal-Assisted Caesarean?
Unlike some of the headlines which misrepresent this birth as a ‘DIY Caesarean’, the MAC is essentially like any other Caesarean until the baby’s head and shoulders emerge from the womb. At this point, instead of the baby being pulled out entirely by the OB, and then handed to other theatre staff, the baby’s own mother completes the delivery process by lifting the baby from her open incision up onto her chest.

There are some other practical differences between a MAC and a standard Caesarean. The mother must be scrubbed and gloved before the procedure begins, the drape between the mother and the operating space (which usually represents the boundary of the operating space) is lowered, and the mother may be shifted or inclined from the usual supine position in order to more easily reach her baby. Beyond all of this, and most importantly: the mother has to have the full support of her OB and his/her theatre staff to be able to proceed with a MAC.

Bargain Power
Before I go any further with this discussion, I want to briefly take a tangent (which will become relevant later, I promise!). As many Australians looove going bargain hunting in places like Bali, I’m going to use this kind of as my backdrop for an analogy.

Let’s say we hit the markets and find a rad stall selling t-shirts. In this marketplace it is accepted and expected that customers will haggle over prices with stall holders. The t-shirts are advertised at $10 each. In your mind, you think $5 is a reasonable price. So, setting that as your goal, you offer the stallholder $2 apiece. He scoffs at your offer, and suggests $8 instead. You raise your offer to $3; he brings his down to $6 – a generous gesture. But, you know you can do better. You express dissatisfaction, and even threaten to walk away and find a new supplier. He then suggests $5 a t-shirt, and even throws in a small key-ring for free. Winner, winner – chicken dinner.

(We’ll come back to more on this marketplace exchange later…)

For whom is the MAC likely to be most appealing?
Remembering that my experience (or bias!) is dealing predominantly with women who have birthed by Caesarean and had a negative or traumatic experience, what women usually report feeling during such a birth goes like this:

– I was scared for my life, scared for my baby’s life.
– I was forgotten, insignificant, like a ‘vessel’.
– I was powerless, voiceless and passive.
– I was disconnected from the experience.

Given that ‘previous Caesarean’ is the leading reason for all Caesareans performed in South Australia (that’s elective and unplanned combined), it is my belief that the MAC will be a birth choice predominantly considered and made by women having subsequent Caesareans. Of course, it is possible that a woman birthing by Caesarean for the first time may have a particularly strong stomach (pun intended, I think) and opt for a MAC, but I feel that, statistically at least, it is likelier that MACers will be mothers having second or third Caesareans.

So, if a mother opting for a MAC is the same mother who had a previous Caesarean in which she felt all of the above things, it is no wonder a MAC might appeal.

How a MAC is different to a Standard Caesarean from the woman’s POV
Returning to my experiences of working with women who have had less than desirable Caesarean births, let’s consider why a woman with this kind of birth history might choose a MAC.

Instead of the woman being an object of surgery, easily forgotten and disconnected from the experience, the MAC places the spotlight on the mother from the moment she starts scrubbing up till the moment she pulls her baby from her body. It gives her a role in Caesarean birth where currently there is none. It forces the care providers around her to engage the mother in the process of the birth. And, for mother and baby, the MAC reduces the separation time after birth and sets up skin-to-skin straightaway. In this sense, the MAC is a revolution for Caesarean mothers – what we are currently witnessing is a groundswell which may change Caesarean birth forever.

But, is it really going to change Caesarean Birth?
There are still some facts about Caesarean birth which remain, regardless of who lifts the baby from the mother’s womb:
– Caesarean birth is major abdominal surgery which comes with all the risks inherent to any major surgery.
– Caesarean birth increases risks to future pregnancies and births, including complications like uterine rupture and placenta accreta.
– Caesarean birth fails to ‘seed’ the baby’s gut flora like a vaginal delivery does.
– Caesareans which are performed in unplanned circumstances, by care providers unknown to the woman and/or in true emergencies are unlikely to be able to accommodate a MAC.

By Dbmayur (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
By Dbmayur (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Let’s go briefly back to Bali…
To be honest, I have no experience of haggling at a market in Bali (perhaps you already suspected this!). However, I do know that it is *possible* to haggle at these markets, I know that generally you have to ask for a greater discount than you are expecting to receive, and I know that I need someone experienced in marketplace haggling to show me the ropes.

Birth is no different.

The most exciting and realistic change the MAC represents for a woman is increased bargaining power, particularly if she knows in advance that she will be birthing by Caesarean. Let’s assume here that the $10 t-shirt you want to buy is your decision to birth by Caesarean, and your $5 goal price is your desire for an empowered birth.

Asking for a MAC might be like asking the stallholder to give you that t-shirt for $2. Sometimes, you might be lucky and get a generous stallholder (or OB, to explicitly make the parallel) who agrees to this from the outset – if this is your experience, awesome! Probably, and more realistically, however, it is likely that your initial request will be denied. The trick here is to anticipate this response and thus use it to your advantage. If you were secretly prepared to pay $5 all along, your $2 request is a means to an end which brings you closer to your $5 goal, particularly if you don’t really mind about missing out on the $2 deal.

In birth, this currently exists as women requesting a lotus birth at hospital when what they actually want is delayed cord clamping. By requesting the lotus birth, it forces care providers to consider not cutting the cord at all and – if they do cut it – might ensure true delayed cord clamping if not the lotus birth (i.e. no cord clamping). The MAC might work for women in a similar fashion, giving them a boundary to work back from as they fight for the Caesarean birth they deserve.

What Qualities Do You Want a Caesarean Birth to Have?

If you choose to birth by Caesarean and you want this experience to offer you a chance to:

– Have as active a role as possible;
– Connect with the ‘actions’ of the birth;
– Be the first person to hold your baby;
– Discover the sex of your baby for yourself;
– Have immediate skin-to-skin facilitated;
– Avoid the routine cleaning and swaddling of your child;
– Remain connected with your body and baby during your Caesarean;

… then talking to your OB about a MAC is a fantastic way to get this ball rolling. You might be denied the opportunity to truly assist in your Caesarean delivery, but you may instead end up getting the drapes lowered and being able to observe more of the birth (if this is what you want). It may be that, instead of witnessing the birth ‘first hand’ with a MAC, you negotiate for a photographer to be in theatre in order to document the birth so that you can look at the photos later if you choose. Perhaps, and most importantly, the MAC discussion may prompt you to clearly explain the importance of feeling involved during the birth and thus lead to your care provider to simply adopting a more empathetic tack during the procedure. These are the things which can make the difference between a negative or traumatic experience and a more empowered one. It just depends on what your goal point is.

So, what is the point everyone is missing?
There is a lot of good that the MAC can do, especially for women who genuinely have no choice but to birth by Caesarean and for women who have a desire to roll up their sleeves and be this actively involved in a surgical delivery.

But, in the hype surrounding the MAC, there is an important question we’ve failed to ask:

Why do women need to pull their babies out of their own stomachs in order to feel better about Caesarean birth?

I suspect the long answer to this question will reveal much about our birth culture, our social values, long-ingrained power structures and how we routinely view women and their bodies as a society… But, the shorter answer is that it is about the desperate desire for women to ‘take birth back’.

With a third of all women now birthing (and potentially only ever birthing) by Caesarean, this is a response to the systematic denial of an active birth experience for our generation. We need to very carefully think about what women are really asking for when they request a MAC – when the answer includes words like ‘respect’, ‘connection’, ‘trust’ and ‘I did it!’, we know that the situation is not as simple as, “Throw the woman a MAC bone, STAT!” and that the real solution can likely be applied to all births for common good.

Where does the Big MAC Debate leave us?

Lastly, let’s return to my marketplace haggling idea one last time. If we allow ourselves to be too quickly swept up in the ‘superior’ qualities of the MAC and what makes it better than a ‘crap’ birth, we run the risk of forgetting the true value of the ‘t-shirt’ we’re bargaining for – birth shouldn’t be disempowering by default, and we must accept (and demand!) this as a truth so that we know the high value we place upon it is reasonable. In fact… *whispers*… If I may be quite frank with you, I’m not even sure a good birth is something for which we should have to ‘bargain’ in the first place.

(Also… *slides in closer and whispers again*… There is the question of whether choosing a MAC over a normal vaginal delivery in order to feel empowered is a medical veto wrapped up in the illusion of empowerment – the MAC is intrinsically tied up with care provider permissions in a way that normal vaginal delivery is not… But, I think that’s another blog post for another day.)

In my opinion, the MAC is the current manifestation of a birth culture needing attention, and, because Caesarean birth is so prevalent, it makes sense that this kind of birth has become a platform for change. Like the $2 offer in the t-shirt exchange, the MAC can be a means to an end for the birth movement – it won’t stop women having unnecessary Caesareans (and, let’s face it – the MAC might even make Caesarean birth more appealing for some), but it does, at least, begin the more general discussion about ‘how can we make birth better for women and babies?’ and ‘what do women want?’… And, hey – if, while we’re working out the meaning of the MAC for our generation, this approach to Caesarean birth spares individuals from disempowering experiences in the meantime, well, I guess that’s the key-ring thrown in for free. 🙂