The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 1

The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester
Elizabeth A Simmons

CNS 721: Research and Statistical Analysis in Counseling

Wake Forest University

The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 2

Abstract

Women can experience Post Traumatic Stress Disorder (PTSD) related to the events surrounding

childbirth. Having pre-existing conditions puts a woman more at risk. Untreated PTSD could

have a long term negative impact on the entire family unit. More research on the prevention and

treatment of PTSD in the perinatal period needs to be done.

The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 3
Introduction

Post Traumatic Stress Disorder is when a person has an experience that faces them with

the possibility of death, injury, or sexual violence (American Psychiatric Association, 2013).

They will have intrusive thoughts, memories, or dreams about the event that causes them

distress. The distress can cause the person to self isolate and have negative beliefs about themself

or others. The person could begin to have loss of concentration, sleep disturbances, or engage in

self harming behaviors. This literature review focuses on pre-existing conditions that put a

woman at risk for experiencing Post Traumatic Stress Disorder, the events during childbirth as a

cause of PTSD, the possible results if left untreated, and the studies pointing to the best methods

of treatment.

The 4th Trimester is the 3 months following the birth of a child. During this time many

changes occur with mother and baby (Spelke & Werner, 2018). Because of the rapid physical

and emotional changes, women need specialized follow up care with their obstetricians along

with increased family and community support.

When a woman gives birth, it is an extremely vulnerable time. Some literature has

suggested that 21.4-34% of women experience trauma related to birth (Beck & Watson, 2008)

with 3.17- 5.9% resulting in PTSD (Ayers et al., 2016). Pre-existing risk factors, lack of

education about birth, and poor birthing practices impact the prevalence of PTSD. Lack of

quality postpartum care for women that experience PTSD as a result of birth can lead to a drastic

decrease in the quality of life during the 4th trimester.

Method

Parameters and Assessments

The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 4
For this literature review text books, DSM-5, peer reviewed articles, and other literature

reviews were accepted. The articles must have been published between 2007 and 2021. All

materials were written in English. All of the references were obtained electronically from the Z.

Smith Reynolds Library. The following databases were used: ERIC, ProQuest, PubMed, and

PyscInfo. Keywords that were searched include: birth trauma, PTDS, post traumatic stress

disorder birth, 4th trimester, postpartum PTSD, perinatal PTSD. Additional materials were

located by using the references and the “cited by'' listed in the search results. The materials

reviewed needed to contain information about perinatal mood disorders, specifically PTSD. The

information included documented and inferred prevalence of birth related PTSD, pre-existing

maternal conditions, socio-economic impact, health disparities among marginalized

communities, postpartum support, steps to prevent birth trauma, and care/treatment options for

birth related PTSD.

Results

Risk factors

First time mothers or mothers with a history of previous traumatic birth are more likely to

experience PTSD related to birth (Ayers et al., 2016). Women with a fear of birth, that have an

operative birth, or that experience complications surrounding birth with themself or the infant are

at risk for PTSD (Ayers et al., 2016). Having an episiotomy, vaginal tear, or forceps being used

during delivery could cause emotional and physical trauma (Alcorn et al., 2010). Having a

preterm birth (Cook et al., 2018), a low birth weight infant (Cook et al., 2018), an infant that is

admitted to the Neonatal Intensive Care Unit (Harrison et al., 2021), or a fetal or neonatal death

(Cirino & Knapp, 2019) can all be the cause of PTSD. Women that have a history of sexual
 The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 5
abuse or that have experienced intamate partner violence may report trauma related to birth

(Ayers et al., 2016). It has been suggested that attachment style can play a role in the prevalence

of PTSD. When a person does not bond with their caregivers as a child they mature into adults

that are anxious, disorganized, or fearful leading to poor relationships throughout the life span

(Ayers et al., 2014). Socio-economic status has also been associated with poor birth outcomes

(Ayers et al., 2016). The lower the education level and the closer to poverty a family is, the more

likely they are to have a negative birth outcome.

Causes

Feeling abandoned, ignored, or unsupported during the birth process by their partners or

the health care team can lead to PTSD (Çapik & Durmaz, 2018). Women that feel they lost

control of the situation or their body during the labor and delivery could be the cause of PTSD

related to birth (Ayers et al., 2016).

Consequences/Impact:

Women that have PTSD could have been given the diagnosis of postpartum depression

and/or postpartum anxiety leading to ineffective treatments and never truly addressing the root of

the problem (Ayers et al., 2016). They could have poor coping skills and report higher than

normal stress (Ayers et al., 2016). They may be unable to cope with aspects of life unrelated to

motherhood (Speier, 2018). All of these feelings can lead to poor bonding with their baby and

impact initiation along with the duration of breastfeeding (Beck & Watson, 2008). Several

themes emerge when looking at breastfeeding treads of mothers with traumatic births. Some of

the themes support breastfeeding initiation and duration. Mothers report the time they spend

nursing their baby was like a timeout from the trauma. It is a time to get their mind off the
 The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 6
negative emotions or a way to escape (Beck & Watson, 2008). Some mothers focus on

breastfeeding as a way to make up for the traumatic birth. If the woman blames herself, the act of

nursing can be her payment back to the baby (Beck & Watson, 2008). These groups of women

feel like they or their bodies failed at birth but are determined to be successful with breastfeeding

to prove they are worthy of being a mother (Beck & Watson, 2008). There are also notable

negative themes. Women become detached from their baby (Beck & Watson, 2008). They are so

overwhelmed by depression and/or anxiety that they just can not make room to bond with their

child. Some mothers may have flashbacks to the trauma inducing event when they hold, look at,

or breastfeed their baby (Beck & Watson, 2008). Research has shown that stress can lower a

woman’s milk supply. The stress from the trauma caused at birth becomes the factor that causes

a decrease in milk supply causing the mother to physically not have the ability to meet her

baby’s nutritional needs (Beck & Watson, 2008). Depending on the type of event, such as an

operative delivery or vaginal tear, a mother may be in too much pain to comfortably position

herself or the baby at the breast (Beck & Watson, 2008). To some women breastfeeding feels

like another violation of the body, another thing they are “forced” to do (Beck & Watson, 2008).

To back control of themself, they choose not to nurse.

Having PTSD can have a negative impact on the relationship the birth mother has with

her partner, extended family, and her health care providers (Alcorn et al., 2010). One study

showed that parents, either mother or father, with PTSD are more likely to abuse or neglect the

baby (Fredman 2019). The Fredman (2019) study touched on results showing that fathers, the

support person, or members of the health care team could also experience PTSD related to a

traumatic birth.
The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 7
Findings

Research has shown the further from the birth the mother is, the less severe the symptoms

of PTSD become (Ayers et al., 2014). Married or cohabiting families had less severe symptoms

than single mothers (Ayers et al., 2014). One study showed that the exaggerated stress situation

caused by hormones as birth approaches could be a reason the symptoms seem to improve with

time even when the mother does not partake in a treatment option (Cirino & Knapp, 2019). All

of the studies reviewed for this paper stated more research needs to be done on identifying

women with PTSD following birth and finding treatment options.

Treatments

One study had women being screened from 8-20 weeks of pregnancy for risk factors of

developing PTSD related to birth. Those that had positive screening took part in Eye Movement

Desensitization and Reprocessing Therapy (EMDR). They underwent a max of 3 sessions each

90 minutes in duration. The results of the effectiveness of EMDR are pending (Bass et al., 2017).

Another study showed that trauma based individual psychotherapy and trauma based debriefing

have had positive outcomes (Cirino & Knapp, 2019). Cognitive behavioral therapy is currently

the most researched and used method of psychotherapy with persons that have trauma, this

method is not limited to birth trauma (De Bruijn et al., 2019). Some providers have started to use

prolonged exposure therapy combined with cognitive behavior therapy and are showing

promising results (Reina, Freund, & Ironson, 2019). One study looked at the effectiveness of

cognitive behavior therapy via the internet (Nieminen, 2016).

The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 8
Discussion

A common theme in all of the literature reviewed was more research needs to be done on

all fronts. As a proactive measure, women who have a history of mental health problems should

be counseled during their child bearing years before becoming pregnant about possible outcomes

related to the perinatal time. It has been suggested that women with a history of a bipolar

diagnosis are at an increased risk of experiencing PTSD. Women should be screened during

pregnancy for risk factors of PTSD. After birth women should be screened again. Any women

with symptoms should be given local resources for treatment options. More treatment options for

women with PTSD or other mental health conditions surrounding birth should be available in all

communities. This would include inpatient care, outpatient care, psychotherapy variations, and

chemical treatment options. These resources need to be accessible by all, eliminating the cost,

transportation, and time barriers to receiving care. More research on what kind of treatment

options work the best in reduction or remission of symptoms should be done.

Community support should be offered to women in violent relationships and children that

have been abused. Support across the lifespan for survivors of abuse should be available. More

efforts should be in place to prevent these kinds of violations to vulnerable groups.

Health care providers should make every effort to listen to the pregnant woman’s

concerns. Discussions about possible complications at birth should take place with families

during the prenatal period. Women with a history of pregnancy related or preexisting health

conditions such as miscarage, previous preterm birth, gestational diabetes, or gestational/chronic

hypertension should be counseled that these factors can have an impact on labor and delivery.

Birth facilities should implement training for all staff in direct patient care roles to assist mothers
 The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 9
that were identified as high risk during pregnancy to have support systems in place. There should

be more training programs for healthcare providers to recognize and support women with

perinatal emotional disorders.

When PTSD goes undiagnosed and untreated the symptoms could last for years, or even

a lifetime. Symptoms can recur with the same or more intensity when triggered. The negative

impact of symptoms can drastically lower the quality of life for not only the woman but the

entire family unit. Families could choose to not have more children because the birth experience

was so traumatizing. Research shows that women that do not bond with their infants can lead to

the infant having poor relationships throughout their lifespan, creating a pattern of dysfunction

across generations. Women’s symptoms can have a negative impact on their partner’s quality of

life, even resulting in the deterioration or dissolving of the relationship. In the worse case

scenario, women can experience psychosis that could lead to self or infant harm.
The Negative Impact Of Post Traumatic Stress Disorder On The 4th Trimester 10

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