The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
A Free Film - A wide range of view points ~ A simple message Normalize Birth - watch the trailer then Donate! if you can |
When Survivors Give Birth:
Understanding and Healing the Effects of Early Sexual Abuse on Childbearing
Women (2004)
By Penny Simkin, PT, and Phyllis Klaus, CSW, MFT
"The only book of its kind, When Survivors Give Birth provides survivors
and their maternity caregivers with extensive information on the prevalence
and short- and long-term effects of childhood sexual abuse, emphasizing
its possible impact on childbearing women."
Notes from a talk about the book "When Survivors
Give Birth"
Abuse Self-Assessment Tool - offers a realistic assessment of severity of abuse.
Shekinah
Birthing offers EFT for Survivors of Abuse/Sexual Abuse: Preparing
To Give Birth - 1/14/08
For women with a history of sexual abuse, the challenges of pregnancy and childbirth can be overwhelming so that they may shut down or not resist further victimization. Sometimes it's easier to work on healing sexuality as a first step in preparing for an empowering birth experience.
There's a great DVD, 'Healing
Sex: The Complete Guide to Sexual Wholeness,' by Staci Haines, that
is very powerful. The approach to
healing is somatic in nature. It is a straight-forward and gentle
and compassionate approach to exploring how to heal fully (body, mind and
spirit). I consider this an extremely helpful resource and hope you find
it helpful as well. There is also a wonderful diversity among the
couples and singles represented in the DVD.
Staci authored a related book, The
Survivor's Guide to Sex: How to Have an Empowered Sex Life After Child
Sexual Abuse which is also a
very helpful resource.
A Safe Passage: Supporting
Women Survivors of Abuse, Through the Childbearing Year, Advanced Practitioner
Training - This site is dedicated to childbearing women survivors of abuse,
their family and friends impacted by the abuse, and care-providers looking
for information and training so that they may better meet the needs of
pregnant women in their care who have experienced childhood sexual abuse,
woman abuse, sexual violence or trauma from a previous pregnancy.
Surviving Child
Abuse - Recovery & Research, Exposure Disclosure (SCARRED).
Catharsis Foundation is a non-profit incorporated in Calgary Alberta in
2004 for survivors of ALL forms of child abuse — internationally.
MEDLINE
Abstracts - Sexual Abuse [Medscape registration is free]
Sexual
History Taking from The Association of Reproductive Health Professionals
(ARHP)
'Parratt, J. (1994). The experience of childbirth for survivors of incest. Midwifery, 10(1), 26-39', it is a bit old now but should still be a little helpful and it has quite a few references.
Rhodes, N., & Hutchinson, S. (1994). Labor Experiences of Childhood Sexual Abuse Survivors. Birth, 21(4), 213-220.
Roussillon, J. A. (1998). Adult survivors of childhood sexual abuse: suggestions for perinatal caregivers. Clinical Excellence for Nurse Practitioners, 2(6), 329-337.
Smith, M. (1998). Childbirth in women with a history of sexual abuse (II): a case history approach. Practising Midwife, 1(6), 23-27.
Smith, M. (1998). Childbirth in women with a history of sexual abuse (I). Practising Midwife, 1(5), 20-23.
Buist, A., & Janson, H. (2001). Childhood sexual abuse, parenting and postpartum depression - a 3-year follow-up study. Child Abuse and Neglect, 25, 909-921.
Buist has done a lot of work in the area but it is more focused on postpartum than the birth experience.
The RCOG Press published a book called Violence Against Women which contains four chapters on models of specialist and gynaecological practice in relation to abuse, rape etc.....Edited by Bewley, S., Friend, J. and Mezey, G. (1997):
25 Domestic violence and reproductive health care in Glasgow
26 Rape - including examination and history
27 Sensitive vaginal examination
28 Models of specialist and gynaecological practice - discussion
There are also some research papers which discuss the implications of caring for pregnant women with child/adult experiences of sexual abuse which have some recommendations, highlight concerns of women etc..... hope both of you find it helps.
Lent, B., Morris, P. & Rechner, S. (2000) Understanding the effect of domestic violence on pregnancy, labour, and delivery. Canadian Family Physician, 46: 505-7.
Bohn, D.K. & Holz, K.A. (1996) Sequelae of abuse. Health effects of childhood sexual abuse, domestic battering and rape. Journal of Nurse-midwifery, 41(6): 442-56.
Seng,J.S.; Sparbel,K.J.H.; Low,L.K.; Killion,C. (2002) Abuse-related posttraumatic stress and desired maternity care practices: women's perspectives. Journal of Midwifery & Women's Health, 47(5): 360-370.
Seng,J.S.; Low,L.K.; Sparbel,K.J.H.; Killion,C. (2004) Abuse-related post-traumatic stress during the childbearing year. Issues and Innovations in Nursing Practice, 46(6): 604-613.
This brief article on Deep
Tissue Vaginal Massage has some really good information for women experiencing
physical or emotional pain in their genitals after birth; it's also very
valuable for a pregnant woman who wants to reclaim genital sensation so
that her birth experience doesn't become a re-victimization. [currently
unavailable]
Announcement Concerning
the "Survivor Moms Speak Out" Book Project [currently unavailable]
Let the Truth Ring
Out! - (The Survivors WebRing)
I am reading a book titled "Rebounding from Childbirth Toward Emotional
Recovery" by Lynn Madsen. In chapter four there is a section about
sexual abuse and it includes a birth story.
Childhood Sexual
Abuse and the Potential Impact on Maternity by Andrya Prescott from
the Radical Midwives in the UK
Birth
Resources with Gayle Peterson
BirthWorks
Reading List - books to help women overcome the negative effects a
difficult past can have on pregnancy and birth [currently unavailable]
Midwifery
Today Conference audio tapes - search for the section on "Sexual Abuse
and Violence "
A Burden To Share
A Personal Account of the Effect Of Childhood Sexual Abuse on Birth
by Christine
Childhood Sexual Abuse and Its Effects On
Childbirth
Many Teen Pregnancies Caused By Rape
Notes from Sheila Kitzinger Talk - "Crisis in
the Perinatal Period".
With my 2nd pregnancy (probably my last), i discovered a fantastic book
called, Creating A Joyful Birth Experience, written by Lucia Capacchione
and Sandra Bardsley (ISBN 0-671-87027-0) $13.00 US Funds. They use a variety
of imagery and visualization exercises.
I too have this book and have found its exercises an absolutely /wonderful/
addition to pregnancy! It is great for any woman but especially good for
those in recovery and others who have extra emotional needs aside from
those "normally" (what's normal anyway?) encountered during pregnancy.
Another really good one that does some of the same things, and that I really
enjoyed with my last pregnancy is /Nurturing the Unborn Child/ by Thomas
Verny and Pamela Weintraub. While I don't actually know how much we can
truly communicate with and nurture our unborn children, the exercises in
this book certainly made me feel closer to my baby.
You might also try Spirit-Led
Birth and Parenting Supplies
Birth@Sierratel.com
209-683-2678 for questions
888-683-2678 for orders
They have an Appletree Ministries position paper written by Helen Wessel,
a
Christian writer and author of The Joy of Natural Childbirth, called
Inner
Healing, or Healing of Memories. They also have Oil and Wine
for the Wounded
by Bruce and Jan Wilson. It's a resource to help women recover from
past
abuse, especially sexual abuse and its possible negative effect on
childbearing. It is a Bible study workbook that can be used by lay
people or
professionals for one-on-one counseling or group support.
Pregnant Feelings by Baldwin and Richardson is a workbook for pregnant
women
and their partners to help release their emotions about pregnancy and
birth to
give them confidence and power.
Birthing from Within
addresses birth as an emotional and spiritual process.
An abuse survivor writes about her labor: "I had severe back labor unexplained by the position of my baby. Years later, I realized this was because I had "pelvic muscle spasm" syndrome (A syndrome fairly well recognized in the medical literature). This was causing my sacrum/coccyx to be clamped down by chronic muscle spasms and narrowing the birth canal. (This also explained why I have had a "flat butt" since childhood)."
"It is a static, chronic spasm, so the treatment seems to be "all or nothing". I have been able to release it once after days of releasing the many "knots" on both sides of the area and even working intravaginally and using magnets (and could for the first time feel my butt cheeks as two separate cheeks when I walked), but this only lasted for a few days. One other time a guided mediation on the first chakra focusing on the perineum amazingly released it, but for only a few hours. I still have it - I'm now 57. I hope to deal with it someday when my life is more calmed down.
"In hindsight, I think it would have helped if I not been in the traditional "on my back" position when I was in labor. It seems like anyone who is having 'back labor' should be helped to be either on hands and knees or squatting.
"I hope this helps others. Thank you for your web site."
Helping Survivors of Sexual Abuse Through Labor
Notes from Penny Simkin's Video
Notes from Abuse Workshop with Penny Simkin
Some of my clients have expressed that it felt traumatic to have suffered
memory loss during labor; for these women, it may be really helpful to
have a videocamera set up in the labor room just to record the general
happenings. Then they can go back and look what was going on, even
if they experienced memory loss from the labor hormones.
When I'm working with a laboring woman who may have an abuse history,
I start to say things differently during labor like...you are safe...no
one is going to harm you...your baby is coming out there is nothing going
in. Now this may sound crazy but I can't tell you how many women
have calmed down and pulled it together.
Many pregnant women find that intensive work is just not feasible during
pregnancy, so short-term problem-solving may be in order. I try to help
my clients identify things that scare them, physically and emotionally.
Sounds, smells, people, places, touches, you name it and it may trigger
a physical or emotional stress response. Then we try to come up with
ways to avoid the stressors and methods for dealing with unavoidable
triggers. Standards like visualization, relaxation, aromatherapy,
herbs, acupressure, may be adapted to help mom cope.
One of the shortcomings of hypnotherapy in general is that it tends to be a short-term fix, but I think that makes it almost ideal as a "solution" for labor and birth, which is a short-term situation.
Gayle Peterson
is the only person I know who combines hypnosis with abuse work.
She's got several books out.
For a handout for a training program, Penny suggests the articles published
in "Birth" 19:4 December 1992, beginning with "Effects of Childhood Sexual
Abuse on Childbirth: One Woman's Story" by Anna Rose and ending with Penny's
response article "Overcoming the Legacy of Childhood Sexual Abuse: The
Role of Caregivers and Childbirth Educators." You would need to check with
"Birth" about permission to reproduce the articles.
I work as a social worker with women who have been abused. The numbers (at least in the States) are staggering and unrecognized. The birth process is highly traumatic for many of these women. Some points to consider:
I think how you ask the initial question will affect how/whether a woman chooses to respond. I've seen some forms which just flat out ask "Do you have a history of sexual abuse/incest?" And not all women will chose to answer this... I generally try bring up the subject by asking something like.... "Birth is such a personal, and very private thing, some women are very modest and uncomfortable about it--- especially if they were abused sexually or have painful or unhappy memories. Is there anything you would like us to do, or not do in your labor or birth? Do you have any special needs we might help with or is there anything you think we should know about you"?
Putting it similarly, explains just why you are asking the question. Another thing: This doesn't necessarily need to be asked at the very first prenatal, or when the woman's husband/boyfriend is present, and (I think) should be asked by a woman --not a man; if you want honest answers anyway. (Some will refuse to respond to that question under those circumstances --- though maybe it wouldn't bother others). Also, I think it's important to ask if a woman "wants" to be touched in labor/birth --- a back rub may be heaven to some women but just make another more tense. -- Always ask first!
In one of my own births, I was EXTREMELY UPSET that someone kept lifting my gown to stare at my bottom while I was pushing -- I kept pulling it back down and telling them I'd let them know when there was something to see! But it kept happening... and I eventually l went into the bathroom with the door closed for privacy -- ended up delivering in there ( I did let others come in[Grin]). Don't bug a woman who has been "messed with" before! Let her labor at her own pace and don't rush, stare at, direct her -- any "bossing about" may be quite resented... ask her, advise her, but don't tell her what to do! Give her privacy and as much dignity as you can -- let HER do the choosing!
I follow this advice with those clients who (have let me know) they
were abused...... I've seen better labors, less stalling out, better second
stages since.
I have done much research on past abuse and birth and have interviewed many survivors. You should ask directly, but in the context of, "I need to ask some things so that I know more of how to help you. If some things come up in birth, I need to know where they are coming from." Then ask, do you have any health problems? Do you have any history of drug or alcohol problems- previous addicts might want to avoid narcotics in labor, have you ever been forced to have sex without consent, been hit by another person, etc. This is a little less threatening. If you, yourself, are a survivor, you may possibly want to reveal this if you have some clients that you suspect, but are not opening up to you. You might also say, that birth has been known to bring up things from the past that may not be expected.
Not all survivors are at a place where they can accept and reveal. Do
watch for triggers- do they freak when a culture is taken, pelvic
exam is done, etc? Also, watch your language- don't call women honey, sweetie,
watch whispering or approaching unsuspected from the back.
Many of you have reservations about asking. My personal, and professional experience is, that asking is the thing to do. Often, survivors can't wait to tell someone. They often throw out signals, hoping someone will bite. If they tell you, no, they weren't abused, then maybe they have not acknowledged it, and you let it go. Just be careful during the births. Do not whisper in their ears, or call them sweetie/honey. Always bring them back to focus on why they are there-- you are giving birth to a beautiful baby, call her by name, remind her this is not forever, and, if she has confided in you but feels she is "over it"- remind her that this is not the abuse- that this is a beautiful time in her life. The body fluids are her own- responding to her birth, not anything sexual, ugly or abusive. It is a very fine line to walk- the best thing is to follow your instincts.
One more thing- they may not confide if they think you will be sharing
this with others or putting it on her chart. Be sure to tell her and keep
her confidence. If the doctor/midwife is performing something traumatic,
or is about to- say something like, "Dr. so and so, there are some issues
that "Kim" is dealing with. It would probably be best if we could do without
____."
If a woman indicates on a history questionnaire that she has a history of abuse, it definitely should be followed up. I'd suggest a different approach than asking her if she thinks her abuse history will be a problem in birth. Closed (yes or no) questions tend to stop discussion. The caregiver might tell her she's glad she indicated the abuse on the form. Then explain why the question is on the form ("sometimes a history of abuse can come up unexpectedly during birth, but by discussing it beforehand, the abuse effects can often be minimized.") Then ask if she would like to discuss her own abuse or explore it further. If she says no, you respect her wishes, with the statement that if she'd like to talk about her abuse history or any other concerns at any time, you'd be glad to do so. If she says yes, then be prepared.
When your client discloses her abuse history, what do you say?
Non-helpful responses:
Many of you are wrestling with the decision of whether to discuss abuse issues in childbirth class or whether to ask a client (or "patient") if she has ever been abused. I have several thoughts on this:
First, I would advise you NOT to discuss it unless you have helpful services/referrals or reading materials to offer AND unless you can react appropriately when she discloses her abuse. If you do have helpful referrals and can react appropriately, then consider how to bring it up.
Someone on the list wonders "if it is really appropriate to 'stir up this can of worms' when she is pregnant, fearful." Sometimes the "can of worms" is already "stirred up" and if you raise the subject appropriately it will be a relief to the woman. In a childbirth class, it is better to bring up the subject to the entire group than to single out a particular woman. People then can decide whether to speak with you privately. If it is not safe for them to come to you, they won't. If you single out someone whom you think may be an abuse survivor, she may be devastated or ashamed that her abuse is so apparent, or she may be angry with you that you would make such an assumption. I usually bring up the subject in childbirth class when discussing the second stage and "holding back." After normalizing the tendency to hold back, I say that, "for some women, those who have been sexually abused, holding back may be due to body memories of the abuse. The actual birth and many other features of childbirth can be problematic for sexual abuse survivors. If anyone has such a history, I'd like very much to get together one on one, because there is a lot you can do to deal with abuse issues before labor." Then they can decide if they want to pursue it. Readiness to confront these issues varies and I believe it cannot be rushed.
I believe all doctors and midwives should become comfortable enough with these issues that they are able to ask individual clients about abuse as one of the many family/social history questions, to respond in an empathic way, and to offer helpful resources because there are important clinical and emotional implications.
What about the doula? Should she ask? I do not ask my doula clients about sexual abuse specifically, partly because our relationship has a different basis than counselor or clinician. I ask generally about her concerns, fears, or worries, telling her it is helpful for both of us if I know of these things. Then I trust her to reveal to me those things she feels ready to discuss. I would rather work with her at a level where she feels safe. We can work on her fears without her revealing the reasons.
Lastly, what if a woman has several of the characteristic issues associated
with a history of sexual abuse, but she does not disclose it (either because
she has not been abused or she has no memory of being abused or she chooses
not to disclose it)? In such a case it may help you to understand her and
provide better care if you ask yourself, "Would everything I see and hear
from her make more sense or seem more understandable if she were in fact
a victim of childhood sexual abuse?" If the answer is yes, then, whether
you are right or wrong, the possibility that she has experienced such trauma
may lead you to listen more empathically, to take some otherwise "unreasonable"
requests more seriously, and to avoid reacting defensively. If she questions
your authority or is hesitant to trust you, you will understand. In fact,
recognizing possible abuse should lead us to give our clients the kind
of respect and individualized care that everyone deserves. Later, I'll
try to write about how to react when someone tells you she's been abused.
Remember that she may not know, she may be completely blocking. Don't
push too hard...it's obvious by now that she's not ready to talk!
YES! Someone finally said what was in my head as I read this thread! Thank you.
As an incest/rape survivor and my experiences with women such as myself, I really encourage you to stop asking for information she probably has no recollection of. (oh, and I know it is said gently and with love... but I promise she is seeing it as pressing... and you risk losing her if it continues.)
I would explain (and have) that all women (I know, most) have pelvic exams during pregnancy and birth. I let them know when and how many standard vag exams women have and then explain that many women, however, choose to have two... one for the PAP and one when the membranes rupture. I let her decide how many she wants, but that two is the minimum. I also explain that someone will be with her, holding her hands (a Doula, perhaps?), that she can let me know when to move forward and when to stop, but that it has to be done to protect the health of both she and baby. (I am assuming no cultures have been done, either? We all know that if she is sexually active she must be tested... does she consent to bloodwork?)
If there is the remotest possibility for the pediatric speculum to be effective, I use it (although it might be difficult on a multip). As we all do, show her an identical speculum, let her touch it, hold it, even open it for her so she knows the noises... all very, very slowly.
For some, the lying back is a trigger... and you might see how raised she could be (with pillows) and still allow you to do what you need to do. In the same vein... I would offer her a gown, allow her to keep her shirt on, whatever feels safest for her. You might ask her to bring her own music, if that would help. I would ask her if she wants you to talk to her through the exam, or do the exam in silence. Offering her a mirror to watch, asking her if she would be more comfortable sitting in a chair, reminding her there is no rush, but it will be done today... speaking in a gentle manner, but not condescending.
I have used some or all of these ideas on women. I learned that offering as many choices to control the situation as possible helps the most frightened women.
Even though I share some heavy things here... I would encourage making the exam kind of a non-issue... matter-of-fact even, if that is possible. The rest of the visits upbeat and friendly, focusing on how it will be to have two children in the home, teaching life skills, stress reduction, etc.
During the 3rd Tri, reminding her again about the vaginal exam when her membranes rupture (or if she chooses, when she arrives, when membranes rupture, urge to push, etc.). If she looks like she is going to leave your care due to stress... a gentle reminder now and then that most people will not care what she wants and might even tie her down... (and it isn't an exaggeration, as we know) and how glad you are to have her with you so you can respect her rights and desires, etc.
One last thing... be prepared for another cesarean. If a woman does
not want a baby vaginally, we all have seen how they create it so they
don't. She doesn't sound ready to birth vaginally... but she will (I pray),
someday, recognize how incredibly lucky she is to have such loving and
caring midwives surrounding her during this most painful period in her
life.
Initially a mom I was working with would tense up so tightly and become
so fearful that she would scream out in pain. Working with her, ahead
of time if possible, on relaxing and breathing in the typical pelvic exam
position, fully clothed, could help. Helping her understand that
she is safe now during the exam and helping her understand that relaxation
will dramatically decrease the discomfort can make a difference.
This mom could not believe the difference it made for her and was so proud
of her ability to change this for herself. During the labor exams
she would chant out loud, "Relax, relax, relax".
I hope you get lucky and get a terrific nurse - I've sometimes had good luck asking for a nurse with particular sympathies for a special client.
However, in general, hospital nurses are clueless about external signs because they're not used to watching the labor progress. They arrive and leave at random points in the labor, and they only know how to assess dilation by checking the cervix.
When I'm labor coaching at a hospital birth, where cervical exams are generally off limits to me as the labor coach, I look first at the contraction pattern, then dilation bleeding, then early decels to reflect coming up against the resistance from the pelvic floor, then movement of the location of the heart (having a mechanical fetoscope is best for this) to reflect descent/rotation, and then expect an urge to push.
I'll be very pleasantly surprised if any of the L&D nurses have any interest in going along with any of this because it's something they can't really chart. And, if you can't chart it, it didn't happen.
I would be prepared to study up on the alternative techniques and then bluff your way like crazy that you really can assess dilation that way, start your estimate on the low side, make regular progress, and do everything you can to make sure she gets to the "urge to push" phase before they get too curious.
And remind the client that she can always say no. Ideally, she
will have discussed this with her care provider and it will be charted
that no vaginal exams are to be done for the first twelve hours, or something
like that. Get clear guidelines from your client, and remind them
that touching her without her consent is criminal assault.
1. I'd recommend Birthing From Within classes for preparation, to address things more wholistically if she is at all inclined that way.
2. My client with vaginismus worked with an Epi-No (the inflatable balloon-like device for stretching the perineum to prepare for birth and for re-strengthening the muscles after birth) and had great success. She used it for a while before becoming pregnant, in order TO become pregnant, and continued during the pregnancy. She pushed for 2.5 hours, but did not experience any unusual pain (she had no pain medications) nor did the midwife feel there was an extraordinary resistance in the tissues one might expect for a woman with vaginismus. She did have a moderate perineal tear. Considering her history, she considered it all a major triumph and had her second baby just less than 2 years later.
I would highly recommend the Epi-No, because she can control it herself (like perineal massage, but not so hard to reach around the belly and gives more quantitative feedback for those who want that, and gradually work her way up to increased stretching and most importantly, *increased confidence* along the way that it will NOT be a problem or interfere with her birthing vaginally.
Incidentally, vaginismus CAN BE, but is, of course, not always, an indicator of past sexual abuse, either in childhood or later. If this is the case for her, it may help her enough to work with the Epi-No, or she might also benefit from thinking and talking about what things about her history might also come up emotionally in birth, in addition to the physical.
A client I had who had such a history was able to talk with me about
it so we could plan on what things I could do during the labor to avoid
the triggers of her past experience...things like always looking at her
face, so she'd know people were paying attention to her and she wasn't
powerless to communicate her needs or requests, always letting her know
when something was about to happen (even more than usual) or before anyone
would touch her, reminding her that all of the sensations were produced
BY her body, FOR her benefit, and weren't things being done TO her....this
one applies to any woman with vaginismus, with or without a history of
abuse.
I was interested to see the message about the Survivor of childhood abuse expecting a first baby. I too am a Survivor, and I'm expecting my third baby. My older two are twenty and eighteen, and came before i really had come through my healing. It's very different now! It feels like starting something completely new. My two older children are thrilled about the baby, and so am I and my new partner. i have had to be very up front with the medics though about my history, so that they don't unwittingly cause me the kind of distress that can happen with insensitivity in intimate situations.
| About the Midwife Archives / Midwife Archives Disclaimer |