You may consider for the first time that a client/patient in your care is a survivor of abuse based on how she presents during labour and birth. She may be behaving in a way that is inconsistent with your clinical assessments, experiencing "pain out of proportion" and this may be due to past trauma. For instance, a woman may be expressing extreme pain early in labour not due to her "inability to cope" but because she is being triggered by the pain of remembering an earlier incident of violence or abuse.

For some women it can be the case that they are having a "body memory" of the abuse. They may say or do things that seem displaced, for instance she may say something like, "make him stop", when no one is touching her. She may express what seems to be an extreme need for control in the birthing room, wanting to know who is coming and going, and who is doing what, and when they are going to do it. These are normal behaviours for someone who has had their body violated. While her requests may seem excessive, they may be essential for her mental and physical well-being and should be accommodated whenever possible. While all women are entitled to fully informed choices (not just informed consent), it is particularly essential for a woman survivor to know why something is being suggested and to have her choice, if possible, of who provides the intervention.

There are some common fears and behaviours for women survivors in labour:

• unusual fear of IV's and needles
• recoiling when touched
• insistence on female caregivers
• obsession with cleanliness
• extensive sensitivity about body fluids on underpads, sheets and gowns
• not wanting to labour/push in certain positions (lying down, on hands and knees, squatting)
• fear of pushing
• extreme sensitivity about body exposure during labour and with breastfeeding
• intense gag reflex
• fear of the sensation in the vagina
• fear of being numb or not numb enough
• insistence on complete avoidance of pain management or complete pain management
• fear of being judged or criticized
• fear over their change in behaviour
• concern that they will lose control
• concern that others will see them vulnerable

Remember how important language can be in triggering a memory of abuse. Phrases such as "push like you are having a bowel movement" or "push my fingers out" are VERY distressing to women in labour who have been assaulted or violated. Be mindful at all times of how your words may be impacting the women in your care.

If a woman in your care has written a birth plan, please do her the courtesy of reading it. If she is not a survivor of abuse, it will do no harm to proceed with the compassion and patience required to support any woman who may not be responding to labour and birth as you would expect. If she does in fact have a history of abuse, there may be indicators of it in her plan that can assist you in providing her with the best care possible.

 

Here are some suggestions on how to assist sexual abuse survivors in labour through birth:

See past the behaviour

Remember, behaviour is the voice of the repressed or suppressed emotions... aggression or non-compliant behaviour can often be masking extreme fears and anxieties.

Always ask permission to touch, using non-threatening language

Remember that, as a survivor, there was a time in her life when her body was used against her will, without consent neither asked nor given. It is important that she be able to articulate her consent and decline touch when she is not feeling safe. As her care provider, it is your obligation to follow her lead and not pressure her into procedures that she is not absolutely comfortable with, or else you risk causing her further harm. She may feel safer if there is another person present during physical exams and be in a reclining position rather than lying down for pelvic/cervical assessments.

Where possible, strive for continuity of care

Woman who have survived abuse can have a difficult time trusting caregivers and may experience anxiety if they are exposed to changing hospital personnel throughout their labour and birth. Physical exams should be provided by the same nurse or doctor/midwife where possible and students kept to an absolute minimum.

Be aware of your language

Phases such as "good girl" are demeaning to a labouring woman and can remind her of a time when her abuser used this language. Also phrases such as "open your legs, feel me touch you, bend over, don't move, this will only hurt for a minute" may have sexually abusive connotations and can upset or trigger her.

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It is not uncommon for a woman to remember or recall a history of abuse for the first time during the postpartum period. It may be the sound of her baby's cries or the neediness of her baby that triggers her own memory of helplessness or violation. Sometimes women are able to keep their feelings repressed during pregnancy, only to have them surface when faced with the challenges of caring for a newborn. Feelings such as inadequacy, failure, worthlessness and shame can rise to the forefront for a mother who has experienced abuse, and often become exaggerated due to her fatigue and hormonal shifts.

She may make comments such as "I don't think my baby likes me", "I knew I wouldn't be a good mom", "he/she is just trying to make me mad". These comments may be indicators that she has experienced abuse in her past. Remember that sexual abuse profoundly alters a woman's sense of safety, boundaries and self-esteem.

A survivor of abuse may struggle with the following during postpartum:

• changing her baby's diaper
• bathing her baby
• feeding her baby
• touching her baby
• responding to the baby's cries
• allowing others to hold or touch her baby
• understanding normal newborn cues and behaviour
• postpartum depression

Here are some suggestions on how to assist sexual abuse survivors in postpartum:

Breastfeeding

During postpartum there are triggers associated with survivors having their breasts touched or exposed.

A survivor may feel that she will be unable to place her baby at her breast because of the physical and sometimes sexual feelings that a baby nursing can elicit. She will need your complete understanding, patience and problem-solving skills.

Provide her with alternatives, choices and suggestions for making these common concerns more comfortable for her. For instance, some women are able to nurse during the day but are unable to nurse at night. You could discuss with her ways to express her breast milk and bottle feed during the evening or ways to distract herself while nursing at night (watch television, keep the lights on).

The idea is not to portray an 'all or nothing' idea about breastfeeding but to be knowledgeable about all the ways in which one can combine breast- with bottle-feeding. Offering this information will optimize the possibility that she will feel empowered in whichever decision she makes around feeding her baby.

Newborn care

Some women are not comfortable cleaning their babies' genitals and may need some support around the difference between healthy touching and abusive touching. As she physically cares for her baby, a woman survivor may remember incidents of her abuse that she had repressed. She may feel shame, or fear that she may become abusive to her child. You can help by allowing her to express her fears and by normalizing her concerns.

- About Survivors of Childhood Sexual Abuse: page 1 - page 2 - (you are on page 3) -
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