Women who have previously given birth can have trauma related to the past pregnancy, birth and/or postpartum experience.

Among their concerns, women cite the following:

• unexpected outcomes for themselves and their babies, such as cesarean births
• hostile treatment from caregivers
• inadequate emotional or physical postpartum support from their partners, family and/or friends
• unexpected infant illnesses
• postpartum mood disorders.

Women can be concerned that these past circumstances may repeat or that current circumstances may bring up unresolved feelings related to these past events. These concerns need to be listened to, validated and normalized by caregivers.

Sometimes there are no answers available as to why a woman's birth went the way it did; however, in our experience, women often just want someone to help them "fill in the blanks." This can mean encouraging a woman to access her previous birth record(s) and reviewing it with her. It can mean allowing her to tell her birth story to you and listening for any inconsistencies or inaccuracies in her understanding of her experience. Remember, however, that her experience is her experience... you are not there to defend the actions of others, but to help clarify her concerns.

For other women, just offering some practical suggestions and information about how they might do things differently this time around, is helpful and appreciated. For instance, if a woman was induced before, she may want to negotiate more time before an induction is booked (if there are no clinical indicators otherwise), or may want more information about alternative methods of induction, such as homeopathics, sexual intercourse or nipple stimulation.

Trauma from a past birth experience... grieving the birth that wasn't

Often from the moment a woman becomes pregnant she envisions what giving birth will be like. She may connect with other mothers and seek out information related to the childbearing year. By the time a woman is nearing the end of her pregnancy she likely has developed some personal preferences around what she would like to have happen during her birth, and what she would like to avoid. For example, she may want pharmaceutical pain management or be planning a home birth; she may wish to have the support of a doula or she may wish to labour and birth solely with her partner present. She may have invested many hours in reading, researching, attending prenatal classes and exercising — all in an attempt to optimize her chances of having the birth she has planned for.

Regardless of how she has or hasn't prepared to labour and give birth, sometimes a woman may experience birth related grief and loss when her experience of giving birth differs from what her understanding, expectations or preferences were. Birth related grief and loss must be looked at from the perspective of the woman. While one woman may grieve the health of her body after a birth with lots of interventions, another woman may grieve the loss of her planned homebirth after she was transferred to the hospital.

Certainly there are varying degrees of grief or trauma women may experience, with some women showing signs of Post-Traumatic Spectrum/Stress Disorder.

Causes of post-birth trauma or grief can include the following:

• not understanding nor being fully informed of medical interventions
• poor treatment from staff or caregivers
• preterm labour
• birth involving forceps
• cesarean birth
• unhealthy outcome for baby
• apprehension or relinquishment of parental rights

These feelings are real and can have a profound impact on whether or not a woman will want to get pregnant again, how she may react to a subsequent pregnancy and how she may plan for her next birth. She may choose to change care givers, the place of birth, the support persons with her and the type of prenatal education she attends. She may view her body as unhealthy or incapable of giving birth to a healthy baby. Respect her choice to seek alternatives by offering her referrals that may assist her in moving through the trauma, such as a bereaved families support group if applicable.

Having a miscarriage is the loss not only of a pregnancy... it is the loss of a baby and the hopes and dreams associated with him/her. A woman may have all sorts of mixed feelings about a new pregnancy after a previous pregnancy resulted in miscarriage. These feelings can include ambivalence, fear, elation; and she may behave in ways that are perceived as hyper vigilant or controlling as she tries to cope with the realization that she could experience the loss again.

Her partner will naturally have his own feelings related to the pregnancy loss, and the dynamic between the two partners may be either helpful or damaging in processing the loss and moving forward with their current pregnancy. There may be feelings of blame, guilt or regret floating between the two of them and it may be helpful to offer referrals for counseling or grief support groups to assist them.

It is important for care givers to remember that every single woman responds in a different way to a pregnancy loss. While one woman may be devastated to have had a pregnancy loss, another woman may not experience the process as anything more than a heavy period. It is impossible to judge the intensity of this loss... and our challenge as care givers is to reach out to a woman and her family during the subsequent pregnancy in a way that is respectful of the previous loss, while assisting her in preparing for the current pregnancy.

Follow her lead. If she finds it difficult or can't talk about the upcoming birth, then don't push her. It may be too difficult for her to consider her options around her pregnancy if she is still afraid that she may miscarry the baby. Remain supportive and affirming of her choices. She may have previously wanted something very different for her labour and birth but as a result of her loss, may be looking at other options.

The grief a woman experiences after an abortion can be referred to as "forbidden grief". Caught up in the politics of abortion, many women are unable to openly grieve after an elective abortion or they may feel unworthy of being able to grieve at all. As a society we don't acknowledge abortion as a loss... we are quick to assume that because a woman made a choice to discontinue a pregnancy that she must have been at peace with the decision.

For lots of women it is a much more complex choice that has come at the end of a process of weighing out options. She may have been pressured into the decision by people in her life, or by the realities of her life circumstances. And while she may have felt certain that the decision was best for her at the time, this doesn't negate that she may have a mixture of feelings related to her choice. A subsequent pregnancy that she chooses to carry to term can bring previously suppressed feelings to the forefront if she has not had an opportunity to process her experience by talking with supportive people.

She is entitled to receive support in a non-judgmental way regarding her choice to terminate a previous pregnancy, in the interest of providing her with optimum care during her current pregnancy. If you are unable to support her in a non-biased manner, then you may not be the appropriate caregiver for her.

Remember that not all women who have chosen to terminate a pregnancy will have residual feelings related to their abortion. Some women may feel intense relief and gratitude that the choice was available for them, and are not in any need of processing their experience.

Here are some supportive techniques for care givers of pregnant women experiencing trauma from a previous pregnancy:

Listening

Be prepared to listen and resist the urge to become defensive of your actions or those of your colleagues. Likewise it is important not to add your "two-cents" into the discussion by criticizing the actions of others who were involved. However, you can say simpe things such as:

• "I can really hear how much you were hurt by the comment that John Doe made."
• "If you were to go back and tell John/Jane Doe how they impacted you, what would you most want them to know?"
• "If there is anything I can do to assist you in working through your past experience, please let me know. There are community services available and I can provide you with contact information"

While these may seem like basic statements, women often cite examples where those around them were insensitive or dismissive of their feelings. Comments such as "women only miscarry unhealthy babies" or "at least you were only [number of months] along in the pregnancy" are minimizing and silencing no matter what the intention behind them is. If the woman herself is using these phrases, it is appropriate to allow her to do so.

Often the best thing to say is "I am so sorry about... the loss of your baby... your past birth experience... the difficult time you are having. If you would like to talk, I am here to listen or I can refer you to another community support."

When someone shares an experience that has caused them trauma or left them feeling hurt and/or confused, your primary objective is to listen and validate their feelings. This doesn't mean that you necessarily agree with their recollection of events, but recognize that providing a woman and/or her partner with an outlet for their anger, resentment and hurt can allow them to move through the experience and contribute to the release of these feelings in a safe and healthy way.

Informing

Refer the parents to a support group and have a follow-up plan.

Only parents who have lost a child can understand the depth of this loss. Connecting a woman and her family with appropriate supports can be essential to assisting the healing process. Also, there is a concern about depression after the loss of a pregnancy or baby, family break-up is common, and substance involvement may also begin or increase for a family experiencing the loss of a pregnancy or death of an infant. Guilt, shame and resentment are normal emotions after a loss but if they fester without being given a voice, they can become incredibly damaging to a woman and her family.

Set a time to follow-up with the family and make sure that all referrals and other information are provided in a written form. When people are in a state of crisis they are unable to remember information given to them orally and will benefit from having the information written down to go over at a later date.